Full Text of HB4146 100th General Assembly
HB4146enr 100TH 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 Managed Care Reform and Patient Rights Act | 5 | | is amended by changing Section 25 as follows:
| 6 | | (215 ILCS 134/25)
| 7 | | Sec. 25. Transition of services.
| 8 | | (a) A health care plan shall provide for continuity of care | 9 | | for its
enrollees as follows:
| 10 | | (1) If an enrollee's physician leaves the health care | 11 | | plan's network
of
health care providers for reasons other | 12 | | than termination of a contract in
situations
involving | 13 | | imminent harm to a patient
or a final disciplinary action | 14 | | by a State
licensing board
and the physician
remains within | 15 | | the health care plan's service area, the health care plan
| 16 | | shall
permit the enrollee to continue an ongoing course of | 17 | | treatment with that
physician during a transitional | 18 | | period:
| 19 | | (A) of 90 days from the date of the notice of | 20 | | physician's
termination
from the health care plan to | 21 | | the enrollee of the physician's
disaffiliation from | 22 | | the health care plan if the enrollee has an ongoing | 23 | | course
of treatment; or
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| 1 | | (B) if the enrollee has entered the third trimester | 2 | | of pregnancy at the
time
of the physician's | 3 | | disaffiliation, that includes the
provision of | 4 | | post-partum care directly related to the delivery.
| 5 | | (2) Notwithstanding the provisions in item (1) of this | 6 | | subsection, such
care shall be
authorized by the health | 7 | | care plan during the transitional period only if
the
| 8 | | physician agrees:
| 9 | | (A) to continue to accept reimbursement from the | 10 | | health care plan
at the
rates applicable prior to the | 11 | | start of the transitional period;
| 12 | | (B) to adhere to the health care plan's quality | 13 | | assurance
requirements
and
to provide to the health | 14 | | care plan necessary medical information related
to
| 15 | | such care; and
| 16 | | (C) to otherwise adhere to the health care plan's | 17 | | policies and
procedures,
including but not limited to | 18 | | procedures regarding referrals and obtaining
| 19 | | preauthorizations for treatment.
| 20 | | (3) During an enrollee's plan year, a health care plan | 21 | | shall not remove a drug from its formulary or negatively | 22 | | change its preferred or cost-tier sharing unless, at least | 23 | | 60 days before making the formulary change, the health care | 24 | | plan: | 25 | | (A) provides general notification of the change in | 26 | | its formulary to current and prospective enrollees; |
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| 1 | | (B) directly notifies enrollees currently | 2 | | receiving coverage for the drug, including information | 3 | | on the specific drugs involved and the steps they may | 4 | | take to request coverage determinations and | 5 | | exceptions, including a statement that a certification | 6 | | of medical necessity by the enrollee's prescribing | 7 | | provider will result in continuation of coverage at the | 8 | | existing level; and | 9 | | (C) directly notifies by first class mail and | 10 | | through an electronic transmission, if available, the | 11 | | prescribing provider of all health care plan enrollees | 12 | | currently prescribed the drug affected by the proposed | 13 | | change; the notice shall include a one-page form by | 14 | | which the prescribing provider can notify the health | 15 | | care plan by first class mail that coverage of the drug | 16 | | for the enrollee is medically necessary. | 17 | | The notification in paragraph (C) may direct the | 18 | | prescribing provider to an electronic portal through which | 19 | | the prescribing provider may electronically file a | 20 | | certification to the health care plan that coverage of the | 21 | | drug for the enrollee is medically necessary. The | 22 | | prescribing provider may make a secure electronic | 23 | | signature beside the words "certification of medical | 24 | | necessity", and this certification shall authorize | 25 | | continuation of coverage for the drug. | 26 | | If the prescribing provider certifies to the health |
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| 1 | | care plan either in writing or electronically that the drug | 2 | | is medically necessary for the enrollee as provided in | 3 | | paragraph (C), a health care plan shall authorize coverage | 4 | | for the drug prescribed based solely on the prescribing | 5 | | provider's assertion that coverage is medically necessary, | 6 | | and the health care plan is prohibited from making | 7 | | modifications to the coverage related to the covered drug, | 8 | | including, but not limited to: | 9 | | (i) increasing the out-of-pocket costs for the | 10 | | covered drug; | 11 | | (ii) moving the covered drug to a more restrictive | 12 | | tier; or | 13 | | (iii) denying an enrollee coverage of the drug for | 14 | | which the enrollee has been previously approved for | 15 | | coverage by the health care plan. | 16 | | Nothing in this item (3) prevents a health care plan | 17 | | from removing a drug from its formulary or denying an | 18 | | enrollee coverage if the United States Food and Drug | 19 | | Administration has issued a statement about the drug that | 20 | | calls into question the clinical safety of the drug, the | 21 | | drug manufacturer has notified the United States Food and | 22 | | Drug Administration of a manufacturing discontinuance or | 23 | | potential discontinuance of the drug as required by Section | 24 | | 506C of the Federal Food, Drug, and Cosmetic Act, as | 25 | | codified in 21 U.S.C. 356c, or the drug manufacturer has | 26 | | removed the drug from the market. |
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| 1 | | Nothing in this item (3) prohibits a health care plan, | 2 | | by contract, written policy or procedure, or any other | 3 | | agreement or course of conduct, from requiring a pharmacist | 4 | | to effect substitutions of prescription drugs consistent | 5 | | with Section 19.5 of the Pharmacy Practice Act, under which | 6 | | a pharmacist may substitute an interchangeable biologic | 7 | | for a prescribed biologic product, and Section 25 of the | 8 | | Pharmacy Practice Act, under which a pharmacist may select | 9 | | a generic drug determined to be therapeutically equivalent | 10 | | by the United States Food and Drug Administration and in | 11 | | accordance with the Illinois Food, Drug and Cosmetic Act. | 12 | | This item (3) applies to a policy or contract that is | 13 | | amended, delivered, issued, or renewed on or after January | 14 | | 1, 2019. This item (3) does not apply to a health plan as | 15 | | defined in the State Employees Group Insurance Act of 1971 | 16 | | or medical assistance under Article V of the Illinois | 17 | | Public Aid Code. | 18 | | (b) A health care plan shall provide for continuity of care | 19 | | for new
enrollees as follows:
| 20 | | (1) If a new enrollee whose physician is not a member | 21 | | of the health care
plan's provider network, but is within | 22 | | the health care plan's service
area,
enrolls in the health | 23 | | care plan, the health care plan shall permit
the enrollee
| 24 | | to continue an ongoing course of treatment with the | 25 | | enrollee's current
physician during a transitional period:
| 26 | | (A) of 90 days from the
effective
date of |
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| 1 | | enrollment if
the enrollee has an ongoing course of | 2 | | treatment;
or
| 3 | | (B) if the enrollee has entered the third trimester | 4 | | of pregnancy at the
effective date of enrollment, that
| 5 | | includes the provision of post-partum care directly | 6 | | related to the delivery.
| 7 | | (2) If an enrollee elects to continue to receive care | 8 | | from such physician
pursuant to item (1) of this | 9 | | subsection, such care shall be authorized by the
health | 10 | | care plan for the transitional period only if the physician | 11 | | agrees:
| 12 | | (A) to accept reimbursement from the health care | 13 | | plan at rates
established
by the health care plan; such | 14 | | rates shall be
the level of reimbursement applicable to | 15 | | similar physicians within the health
care plan for such | 16 | | services;
| 17 | | (B) to adhere to the health care plan's quality | 18 | | assurance
requirements
and to provide to the health | 19 | | care plan necessary medical information
related to | 20 | | such care; and
| 21 | | (C) to otherwise adhere to the health care plan's | 22 | | policies and
procedures
including, but not limited to | 23 | | procedures regarding referrals and obtaining
| 24 | | preauthorization for treatment.
| 25 | | (c) In no event shall this Section be construed to require | 26 | | a health care
plan
to
provide coverage for benefits not |
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| 1 | | otherwise covered or to diminish or
impair preexisting | 2 | | condition limitations contained in the enrollee's
contract. In | 3 | | no event shall this Section be construed to prohibit the | 4 | | addition of prescription drugs to a health care plan's list of | 5 | | covered drugs during the coverage year.
| 6 | | (Source: P.A. 91-617, eff. 7-1-00.)
| 7 | | Section 99. Effective date. This Act takes effect upon | 8 | | becoming law.
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