215 ILCS 134/87

(215 ILCS 134/87)

(This Section may contain text from a Public Act with a delayed effective date)

Sec. 87. General standards for use of utilization review criteria.

(a) Beginning January 1, 2026, all utilization review programs shall make medical necessity determinations in accordance with the requirements of this Section. No policy, contract, certificate, formulary, or evidence of coverage issued to any enrollee may contain terms or conditions to the contrary.

(b) All utilization review programs shall determine medical necessity by using the most recent treatment criteria developed by:

(1) an unaffiliated, nonprofit professional association for the relevant clinical specialty;

(2) a third-party entity that develops treatment criteria that: (i) are updated annually; (ii) are not paid for clinical care decision outcomes; (iii) do not offer different treatment criteria for the same health care service unless otherwise required by State or federal law; and (iv) are consistent with current generally accepted standards of care; or

(3) the Department of Healthcare and Family Services if the criteria are consistent with current generally accepted standards of care.

(c) For all level of care placement decisions, the utilization review program shall authorize placement at the level of care at or above the level ordered by the provider using the relevant treatment criteria as specified in subsection (b). If there is a disagreement between the health care plan and the provider or patient, the health care plan or utilization review program shall provide its complete assessment to the provider and the patient.

(d) If a utilization review program purchases or licenses utilization review criteria pursuant to this Section, the utilization review program shall, before using the criteria, verify and document that the criteria were developed in accordance with subsection (b).

(e) All health care plans and utilization review programs must:

(1) make an educational program on the chosen treatment criteria available to all staff and contracted entities performing utilization review;

(2) provide, at no cost, the treatment criteria and any related training material to providers and enrollees upon request; enrollees and treating providers shall be able to access treatment criteria at any point in time, including before an initial request for authorization;

(3) track, identify, and analyze how the treatment criteria are used to certify care, deny care, and support the appeals process;

(4) conduct interrater reliability testing to ensure consistency in utilization review decision-making; this testing shall cover all aspects of utilization review criteria as defined in Section 10;

(5) achieve interrater reliability pass rates of at least 90% and, if this threshold is not met, initiate remediation of poor interrater reliability within 3 business days after the finding and conduct interrater reliability testing for all new staff before they can conduct utilization review supervision; and

(6) maintain documentation of interrater reliability testing and any remediation and submit to the Department of Insurance, or, in the case of Medicaid managed care organizations, the Department of Healthcare and Family Services, the testing results de-identified of patient or employee personal information and a summary of remedial actions.

(f) Beginning January 1, 2026, no utilization review program or any policy, contract, certificate, evidence of coverage, or formulary shall impose step therapy requirements. Nothing in this subsection prohibits a health care plan, by contract, written policy, procedure, or any other agreement or course of conduct, from requiring a pharmacist to effect substitutions of prescription drugs consistent with Section 19.5 of the Pharmacy Practice Act, under which a pharmacist may substitute an interchangeable biologic for a prescribed biologic product, and Section 25 of the Pharmacy Practice Act, under which a pharmacist may select a generic drug determined to be therapeutically equivalent by the United States Food and Drug Administration and in accordance with the Illinois Food, Drug and Cosmetic Act. For health care plans operated or overseen by the Department of Healthcare and Family Services, including Medicaid managed care plans, the prohibition in this subsection does not apply to step therapy requirements for drugs that do not appear on the most recent Preferred Drug List published by the Department of Healthcare and Family Services.

(g) Except for subsection (f), this Section does not apply to utilization review concerning diagnosis, prevention, and treatment of mental, emotional, nervous, or substance use disorders or conditions, which shall be governed by Section 370c of the Illinois Insurance Code.

(h) Nothing in this Section supersedes or waives requirements provided under any other State or federal law or federal regulation that any coverage subject to this Section comply with specific utilization review criteria for a specific illness, level of care placement, injury, or condition or its symptoms and comorbidities.

(Source: P.A. 103-650, eff. 1-1-25.)