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Public Act 103-0650 | ||||
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AN ACT concerning regulation. | ||||
Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly: | ||||
Article 1. | ||||
Section 1-1. This Act may be referred to as the Health Care | ||||
Protection Act. | ||||
Article 2. | ||||
Section 2-5. The Illinois Administrative Procedure Act is | ||||
amended by adding Section 5-45.55 as follows: | ||||
(5 ILCS 100/5-45.55 new) | ||||
Sec. 5-45.55. Emergency rulemaking; Network Adequacy and | ||||
Transparency Act. To provide for the expeditious and timely | ||||
implementation of the Network Adequacy and Transparency Act, | ||||
emergency rules implementing federal standards for provider | ||||
ratios, travel time and distance, and appointment wait times | ||||
if such standards apply to health insurance coverage regulated | ||||
by the Department of Insurance and are more stringent than the | ||||
State standards extant at the time the final federal standards | ||||
are published may be adopted in accordance with Section 5-45 | ||||
by the Department of Insurance. The adoption of emergency |
rules authorized by Section 5-45 and this Section is deemed to | ||
be necessary for the public interest, safety, and welfare. | ||
Section 2-10. The Network Adequacy and Transparency Act is | ||
amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and | ||
by adding Sections 35, 36, 40, 50, and 55 as follows: | ||
(215 ILCS 124/3) | ||
Sec. 3. Applicability of Act. This Act applies to an | ||
individual or group policy of accident and health insurance | ||
coverage with a network plan amended, delivered, issued, or | ||
renewed in this State on or after January 1, 2019. This Act | ||
does not apply to an individual or group policy for excepted | ||
benefits or short-term, limited-duration health insurance | ||
coverage dental or vision insurance or a limited health | ||
service organization with a network plan amended, delivered, | ||
issued, or renewed in this State on or after January 1, 2019 , | ||
except to the extent that federal law establishes network | ||
adequacy and transparency standards for stand-alone dental | ||
plans, which the Department shall enforce for plans amended, | ||
delivered, issued, or renewed on or after January 1, 2025 . | ||
(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.) | ||
(215 ILCS 124/5) | ||
Sec. 5. Definitions. In this Act: | ||
"Authorized representative" means a person to whom a |
beneficiary has given express written consent to represent the | ||
beneficiary; a person authorized by law to provide substituted | ||
consent for a beneficiary; or the beneficiary's treating | ||
provider only when the beneficiary or his or her family member | ||
is unable to provide consent. | ||
"Beneficiary" means an individual, an enrollee, an | ||
insured, a participant, or any other person entitled to | ||
reimbursement for covered expenses of or the discounting of | ||
provider fees for health care services under a program in | ||
which the beneficiary has an incentive to utilize the services | ||
of a provider that has entered into an agreement or | ||
arrangement with an issuer insurer . | ||
"Department" means the Department of Insurance. | ||
"Essential community provider" has the meaning ascribed to | ||
that term in 45 CFR 156.235. | ||
"Excepted benefits" has the meaning ascribed to that term | ||
in 42 U.S.C. 300gg-91(c) and implementing regulations. | ||
"Excepted benefits" includes individual, group, or blanket | ||
coverage. | ||
"Exchange" has the meaning ascribed to that term in 45 CFR | ||
155.20. | ||
"Director" means the Director of Insurance. | ||
"Family caregiver" means a relative, partner, friend, or | ||
neighbor who has a significant relationship with the patient | ||
and administers or assists the patient with activities of | ||
daily living, instrumental activities of daily living, or |
other medical or nursing tasks for the quality and welfare of | ||
that patient. | ||
"Group health plan" has the meaning ascribed to that term | ||
in Section 5 of the Illinois Health Insurance Portability and | ||
Accountability Act. | ||
"Health insurance coverage" has the meaning ascribed to | ||
that term in Section 5 of the Illinois Health Insurance | ||
Portability and Accountability Act. "Health insurance | ||
coverage" does not include any coverage or benefits under | ||
Medicare or under the medical assistance program established | ||
under Article V of the Illinois Public Aid Code. | ||
"Issuer" means a "health insurance issuer" as defined in | ||
Section 5 of the Illinois Health Insurance Portability and | ||
Accountability Act. | ||
"Insurer" means any entity that offers individual or group | ||
accident and health insurance, including, but not limited to, | ||
health maintenance organizations, preferred provider | ||
organizations, exclusive provider organizations, and other | ||
plan structures requiring network participation, excluding the | ||
medical assistance program under the Illinois Public Aid Code, | ||
the State employees group health insurance program, workers | ||
compensation insurance, and pharmacy benefit managers. | ||
"Material change" means a significant reduction in the | ||
number of providers available in a network plan, including, | ||
but not limited to, a reduction of 10% or more in a specific | ||
type of providers within any county , the removal of a major |
health system that causes a network to be significantly | ||
different within any county from the network when the | ||
beneficiary purchased the network plan, or any change that | ||
would cause the network to no longer satisfy the requirements | ||
of this Act or the Department's rules for network adequacy and | ||
transparency. | ||
"Network" means the group or groups of preferred providers | ||
providing services to a network plan. | ||
"Network plan" means an individual or group policy of | ||
accident and health insurance coverage that either requires a | ||
covered person to use or creates incentives, including | ||
financial incentives, for a covered person to use providers | ||
managed, owned, under contract with, or employed by the issuer | ||
or by a third party contracted to arrange, contract for, or | ||
administer such provider-related incentives for the issuer | ||
insurer . | ||
"Ongoing course of treatment" means (1) treatment for a | ||
life-threatening condition, which is a disease or condition | ||
for which likelihood of death is probable unless the course of | ||
the disease or condition is interrupted; (2) treatment for a | ||
serious acute condition, defined as a disease or condition | ||
requiring complex ongoing care that the covered person is | ||
currently receiving, such as chemotherapy, radiation therapy, | ||
or post-operative visits , or a serious and complex condition | ||
as defined under 42 U.S.C. 300gg-113(b)(2) ; (3) a course of | ||
treatment for a health condition that a treating provider |
attests that discontinuing care by that provider would worsen | ||
the condition or interfere with anticipated outcomes; or (4) | ||
the third trimester of pregnancy through the post-partum | ||
period ; (5) undergoing a course of institutional or inpatient | ||
care from the provider within the meaning of 42 U.S.C. | ||
300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective | ||
surgery from the provider, including receipt of preoperative | ||
or postoperative care from such provider with respect to such | ||
a surgery; (7) being determined to be terminally ill, as | ||
determined under 42 U.S.C. 1395x(dd)(3)(A), and receiving | ||
treatment for such illness from such provider; or (8) any | ||
other treatment of a condition or disease that requires | ||
repeated health care services pursuant to a plan of treatment | ||
by a provider because of the potential for changes in the | ||
therapeutic regimen or because of the potential for a | ||
recurrence of symptoms . | ||
"Preferred provider" means any provider who has entered, | ||
either directly or indirectly, into an agreement with an | ||
employer or risk-bearing entity relating to health care | ||
services that may be rendered to beneficiaries under a network | ||
plan. | ||
"Providers" means physicians licensed to practice medicine | ||
in all its branches, other health care professionals, | ||
hospitals, or other health care institutions or facilities | ||
that provide health care services. | ||
"Short-term, limited-duration insurance" means any type of |
accident and health insurance offered or provided within this | ||
State pursuant to a group or individual policy or individual | ||
certificate by a company, regardless of the situs state of the | ||
delivery of the policy, that has an expiration date specified | ||
in the contract that is fewer than 365 days after the original | ||
effective date. Regardless of the duration of coverage, | ||
"short-term, limited-duration insurance" does not include | ||
excepted benefits or any student health insurance coverage. | ||
"Stand-alone dental plan" has the meaning ascribed to that | ||
term in 45 CFR 156.400. | ||
"Telehealth" has the meaning given to that term in Section | ||
356z.22 of the Illinois Insurance Code. | ||
"Telemedicine" has the meaning given to that term in | ||
Section 49.5 of the Medical Practice Act of 1987. | ||
"Tiered network" means a network that identifies and | ||
groups some or all types of provider and facilities into | ||
specific groups to which different provider reimbursement, | ||
covered person cost-sharing or provider access requirements, | ||
or any combination thereof, apply for the same services. | ||
"Woman's principal health care provider" means a physician | ||
licensed to practice medicine in all of its branches | ||
specializing in obstetrics, gynecology, or family practice. | ||
(Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.) | ||
(215 ILCS 124/10) | ||
Sec. 10. Network adequacy. |
(a) Before issuing, delivering, or renewing a network | ||
plan, an issuer An insurer providing a network plan shall file | ||
a description of all of the following with the Director: | ||
(1) The written policies and procedures for adding | ||
providers to meet patient needs based on increases in the | ||
number of beneficiaries, changes in the | ||
patient-to-provider ratio, changes in medical and health | ||
care capabilities, and increased demand for services. | ||
(2) The written policies and procedures for making | ||
referrals within and outside the network. | ||
(3) The written policies and procedures on how the | ||
network plan will provide 24-hour, 7-day per week access | ||
to network-affiliated primary care, emergency services, | ||
and women's principal health care providers. | ||
An issuer insurer shall not prohibit a preferred provider | ||
from discussing any specific or all treatment options with | ||
beneficiaries irrespective of the insurer's position on those | ||
treatment options or from advocating on behalf of | ||
beneficiaries within the utilization review, grievance, or | ||
appeals processes established by the issuer insurer in | ||
accordance with any rights or remedies available under | ||
applicable State or federal law. | ||
(b) Before issuing, delivering, or renewing a network | ||
plan, an issuer Insurers must file for review a description of | ||
the services to be offered through a network plan. The | ||
description shall include all of the following: |
(1) A geographic map of the area proposed to be served | ||
by the plan by county service area and zip code, including | ||
marked locations for preferred providers. | ||
(2) As deemed necessary by the Department, the names, | ||
addresses, phone numbers, and specialties of the providers | ||
who have entered into preferred provider agreements under | ||
the network plan. | ||
(3) The number of beneficiaries anticipated to be | ||
covered by the network plan. | ||
(4) An Internet website and toll-free telephone number | ||
for beneficiaries and prospective beneficiaries to access | ||
current and accurate lists of preferred providers in each | ||
plan , additional information about the plan, as well as | ||
any other information required by Department rule. | ||
(5) A description of how health care services to be | ||
rendered under the network plan are reasonably accessible | ||
and available to beneficiaries. The description shall | ||
address all of the following: | ||
(A) the type of health care services to be | ||
provided by the network plan; | ||
(B) the ratio of physicians and other providers to | ||
beneficiaries, by specialty and including primary care | ||
physicians and facility-based physicians when | ||
applicable under the contract, necessary to meet the | ||
health care needs and service demands of the currently | ||
enrolled population; |
(C) the travel and distance standards for plan | ||
beneficiaries in county service areas; and | ||
(D) a description of how the use of telemedicine, | ||
telehealth, or mobile care services may be used to | ||
partially meet the network adequacy standards, if | ||
applicable. | ||
(6) A provision ensuring that whenever a beneficiary | ||
has made a good faith effort, as evidenced by accessing | ||
the provider directory, calling the network plan, and | ||
calling the provider, to utilize preferred providers for a | ||
covered service and it is determined the insurer does not | ||
have the appropriate preferred providers due to | ||
insufficient number, type, unreasonable travel distance or | ||
delay, or preferred providers refusing to provide a | ||
covered service because it is contrary to the conscience | ||
of the preferred providers, as protected by the Health | ||
Care Right of Conscience Act, the issuer insurer shall | ||
ensure, directly or indirectly, by terms contained in the | ||
payer contract, that the beneficiary will be provided the | ||
covered service at no greater cost to the beneficiary than | ||
if the service had been provided by a preferred provider. | ||
This paragraph (6) does not apply to: (A) a beneficiary | ||
who willfully chooses to access a non-preferred provider | ||
for health care services available through the panel of | ||
preferred providers, or (B) a beneficiary enrolled in a | ||
health maintenance organization. In these circumstances, |
the contractual requirements for non-preferred provider | ||
reimbursements shall apply unless Section 356z.3a of the | ||
Illinois Insurance Code requires otherwise. In no event | ||
shall a beneficiary who receives care at a participating | ||
health care facility be required to search for | ||
participating providers under the circumstances described | ||
in subsection (b) or (b-5) of Section 356z.3a of the | ||
Illinois Insurance Code except under the circumstances | ||
described in paragraph (2) of subsection (b-5). | ||
(7) A provision that the beneficiary shall receive | ||
emergency care coverage such that payment for this | ||
coverage is not dependent upon whether the emergency | ||
services are performed by a preferred or non-preferred | ||
provider and the coverage shall be at the same benefit | ||
level as if the service or treatment had been rendered by a | ||
preferred provider. For purposes of this paragraph (7), | ||
"the same benefit level" means that the beneficiary is | ||
provided the covered service at no greater cost to the | ||
beneficiary than if the service had been provided by a | ||
preferred provider. This provision shall be consistent | ||
with Section 356z.3a of the Illinois Insurance Code. | ||
(8) A limitation that, if the plan provides that the | ||
beneficiary will incur a penalty for failing to | ||
pre-certify inpatient hospital treatment, the penalty may | ||
not exceed $1,000 per occurrence in addition to the plan | ||
cost sharing provisions. |
(9) For a network plan to be offered through the | ||
Exchange in the individual or small group market, as well | ||
as any off-Exchange mirror of such a network plan, | ||
evidence that the network plan includes essential | ||
community providers in accordance with rules established | ||
by the Exchange that will operate in this State for the | ||
applicable plan year. | ||
(c) The issuer network plan shall demonstrate to the | ||
Director a minimum ratio of providers to plan beneficiaries as | ||
required by the Department for each network plan . | ||
(1) The minimum ratio of physicians or other providers | ||
to plan beneficiaries shall be established annually by the | ||
Department in consultation with the Department of Public | ||
Health based upon the guidance from the federal Centers | ||
for Medicare and Medicaid Services. The Department shall | ||
not establish ratios for vision or dental providers who | ||
provide services under dental-specific or vision-specific | ||
benefits , except to the extent provided under federal law | ||
for stand-alone dental plans . The Department shall | ||
consider establishing ratios for the following physicians | ||
or other providers: | ||
(A) Primary Care; | ||
(B) Pediatrics; | ||
(C) Cardiology; | ||
(D) Gastroenterology; | ||
(E) General Surgery; |
(F) Neurology; | ||
(G) OB/GYN; | ||
(H) Oncology/Radiation; | ||
(I) Ophthalmology; | ||
(J) Urology; | ||
(K) Behavioral Health; | ||
(L) Allergy/Immunology; | ||
(M) Chiropractic; | ||
(N) Dermatology; | ||
(O) Endocrinology; | ||
(P) Ears, Nose, and Throat (ENT)/Otolaryngology; | ||
(Q) Infectious Disease; | ||
(R) Nephrology; | ||
(S) Neurosurgery; | ||
(T) Orthopedic Surgery; | ||
(U) Physiatry/Rehabilitative; | ||
(V) Plastic Surgery; | ||
(W) Pulmonary; | ||
(X) Rheumatology; | ||
(Y) Anesthesiology; | ||
(Z) Pain Medicine; | ||
(AA) Pediatric Specialty Services; | ||
(BB) Outpatient Dialysis; and | ||
(CC) HIV. | ||
(2) The Director shall establish a process for the | ||
review of the adequacy of these standards, along with an |
assessment of additional specialties to be included in the | ||
list under this subsection (c). | ||
(3) Notwithstanding any other law or rule, the minimum | ||
ratio for each provider type shall be no less than any such | ||
ratio established for qualified health plans in | ||
Federally-Facilitated Exchanges by federal law or by the | ||
federal Centers for Medicare and Medicaid Services, even | ||
if the network plan is issued in the large group market or | ||
is otherwise not issued through an exchange. Federal | ||
standards for stand-alone dental plans shall only apply to | ||
such network plans. In the absence of an applicable | ||
Department rule, the federal standards shall apply for the | ||
time period specified in the federal law, regulation, or | ||
guidance. If the Centers for Medicare and Medicaid | ||
Services establish standards that are more stringent than | ||
the standards in effect under any Department rule, the | ||
Department may amend its rules to conform to the more | ||
stringent federal standards. | ||
(d) The network plan shall demonstrate to the Director | ||
maximum travel and distance standards and appointment wait | ||
time standards for plan beneficiaries, which shall be | ||
established annually by the Department in consultation with | ||
the Department of Public Health based upon the guidance from | ||
the federal Centers for Medicare and Medicaid Services. These | ||
standards shall consist of the maximum minutes or miles to be | ||
traveled by a plan beneficiary for each county type, such as |
large counties, metro counties, or rural counties as defined | ||
by Department rule. | ||
The maximum travel time and distance standards must | ||
include standards for each physician and other provider | ||
category listed for which ratios have been established. | ||
The Director shall establish a process for the review of | ||
the adequacy of these standards along with an assessment of | ||
additional specialties to be included in the list under this | ||
subsection (d). | ||
Notwithstanding any other law or Department rule, the | ||
maximum travel time and distance standards and appointment | ||
wait time standards shall be no greater than any such | ||
standards established for qualified health plans in | ||
Federally-Facilitated Exchanges by federal law or by the | ||
federal Centers for Medicare and Medicaid Services, even if | ||
the network plan is issued in the large group market or is | ||
otherwise not issued through an exchange. Federal standards | ||
for stand-alone dental plans shall only apply to such network | ||
plans. In the absence of an applicable Department rule, the | ||
federal standards shall apply for the time period specified in | ||
the federal law, regulation, or guidance. If the Centers for | ||
Medicare and Medicaid Services establish standards that are | ||
more stringent than the standards in effect under any | ||
Department rule, the Department may amend its rules to conform | ||
to the more stringent federal standards. | ||
If the federal area designations for the maximum time or |
distance or appointment wait time standards required are | ||
changed by the most recent Letter to Issuers in the | ||
Federally-facilitated Marketplaces, the Department shall post | ||
on its website notice of such changes and may amend its rules | ||
to conform to those designations if the Director deems | ||
appropriate. | ||
(d-5)(1) Every issuer insurer shall ensure that | ||
beneficiaries have timely and proximate access to treatment | ||
for mental, emotional, nervous, or substance use disorders or | ||
conditions in accordance with the provisions of paragraph (4) | ||
of subsection (a) of Section 370c of the Illinois Insurance | ||
Code. Issuers Insurers shall use a comparable process, | ||
strategy, evidentiary standard, and other factors in the | ||
development and application of the network adequacy standards | ||
for timely and proximate access to treatment for mental, | ||
emotional, nervous, or substance use disorders or conditions | ||
and those for the access to treatment for medical and surgical | ||
conditions. As such, the network adequacy standards for timely | ||
and proximate access shall equally be applied to treatment | ||
facilities and providers for mental, emotional, nervous, or | ||
substance use disorders or conditions and specialists | ||
providing medical or surgical benefits pursuant to the parity | ||
requirements of Section 370c.1 of the Illinois Insurance Code | ||
and the federal Paul Wellstone and Pete Domenici Mental Health | ||
Parity and Addiction Equity Act of 2008. Notwithstanding the | ||
foregoing, the network adequacy standards for timely and |
proximate access to treatment for mental, emotional, nervous, | ||
or substance use disorders or conditions shall, at a minimum, | ||
satisfy the following requirements: | ||
(A) For beneficiaries residing in the metropolitan | ||
counties of Cook, DuPage, Kane, Lake, McHenry, and Will, | ||
network adequacy standards for timely and proximate access | ||
to treatment for mental, emotional, nervous, or substance | ||
use disorders or conditions means a beneficiary shall not | ||
have to travel longer than 30 minutes or 30 miles from the | ||
beneficiary's residence to receive outpatient treatment | ||
for mental, emotional, nervous, or substance use disorders | ||
or conditions. Beneficiaries shall not be required to wait | ||
longer than 10 business days between requesting an initial | ||
appointment and being seen by the facility or provider of | ||
mental, emotional, nervous, or substance use disorders or | ||
conditions for outpatient treatment or to wait longer than | ||
20 business days between requesting a repeat or follow-up | ||
appointment and being seen by the facility or provider of | ||
mental, emotional, nervous, or substance use disorders or | ||
conditions for outpatient treatment; however, subject to | ||
the protections of paragraph (3) of this subsection, a | ||
network plan shall not be held responsible if the | ||
beneficiary or provider voluntarily chooses to schedule an | ||
appointment outside of these required time frames. | ||
(B) For beneficiaries residing in Illinois counties | ||
other than those counties listed in subparagraph (A) of |
this paragraph, network adequacy standards for timely and | ||
proximate access to treatment for mental, emotional, | ||
nervous, or substance use disorders or conditions means a | ||
beneficiary shall not have to travel longer than 60 | ||
minutes or 60 miles from the beneficiary's residence to | ||
receive outpatient treatment for mental, emotional, | ||
nervous, or substance use disorders or conditions. | ||
Beneficiaries shall not be required to wait longer than 10 | ||
business days between requesting an initial appointment | ||
and being seen by the facility or provider of mental, | ||
emotional, nervous, or substance use disorders or | ||
conditions for outpatient treatment or to wait longer than | ||
20 business days between requesting a repeat or follow-up | ||
appointment and being seen by the facility or provider of | ||
mental, emotional, nervous, or substance use disorders or | ||
conditions for outpatient treatment; however, subject to | ||
the protections of paragraph (3) of this subsection, a | ||
network plan shall not be held responsible if the | ||
beneficiary or provider voluntarily chooses to schedule an | ||
appointment outside of these required time frames. | ||
(2) For beneficiaries residing in all Illinois counties, | ||
network adequacy standards for timely and proximate access to | ||
treatment for mental, emotional, nervous, or substance use | ||
disorders or conditions means a beneficiary shall not have to | ||
travel longer than 60 minutes or 60 miles from the | ||
beneficiary's residence to receive inpatient or residential |
treatment for mental, emotional, nervous, or substance use | ||
disorders or conditions. | ||
(3) If there is no in-network facility or provider | ||
available for a beneficiary to receive timely and proximate | ||
access to treatment for mental, emotional, nervous, or | ||
substance use disorders or conditions in accordance with the | ||
network adequacy standards outlined in this subsection, the | ||
issuer insurer shall provide necessary exceptions to its | ||
network to ensure admission and treatment with a provider or | ||
at a treatment facility in accordance with the network | ||
adequacy standards in this subsection. | ||
(4) If the federal Centers for Medicare and Medicaid | ||
Services establishes or law requires more stringent standards | ||
for qualified health plans in the Federally-Facilitated | ||
Exchanges, the federal standards shall control for all network | ||
plans for the time period specified in the federal law, | ||
regulation, or guidance, even if the network plan is issued in | ||
the large group market, is issued through a different type of | ||
Exchange, or is otherwise not issued through an Exchange. | ||
(e) Except for network plans solely offered as a group | ||
health plan, these ratio and time and distance standards apply | ||
to the lowest cost-sharing tier of any tiered network. | ||
(f) The network plan may consider use of other health care | ||
service delivery options, such as telemedicine or telehealth, | ||
mobile clinics, and centers of excellence, or other ways of | ||
delivering care to partially meet the requirements set under |
this Section. | ||
(g) Except for the requirements set forth in subsection | ||
(d-5), issuers insurers who are not able to comply with the | ||
provider ratios and time and distance or appointment wait time | ||
standards established under this Act or federal law by the | ||
Department may request an exception to these requirements from | ||
the Department. The Department may grant an exception in the | ||
following circumstances: | ||
(1) if no providers or facilities meet the specific | ||
time and distance standard in a specific service area and | ||
the issuer insurer (i) discloses information on the | ||
distance and travel time points that beneficiaries would | ||
have to travel beyond the required criterion to reach the | ||
next closest contracted provider outside of the service | ||
area and (ii) provides contact information, including | ||
names, addresses, and phone numbers for the next closest | ||
contracted provider or facility; | ||
(2) if patterns of care in the service area do not | ||
support the need for the requested number of provider or | ||
facility type and the issuer insurer provides data on | ||
local patterns of care, such as claims data, referral | ||
patterns, or local provider interviews, indicating where | ||
the beneficiaries currently seek this type of care or | ||
where the physicians currently refer beneficiaries, or | ||
both; or | ||
(3) other circumstances deemed appropriate by the |
Department consistent with the requirements of this Act. | ||
(h) Issuers Insurers are required to report to the | ||
Director any material change to an approved network plan | ||
within 15 business days after the change occurs and any change | ||
that would result in failure to meet the requirements of this | ||
Act. The issuer shall submit a revised version of the portions | ||
of the network adequacy filing affected by the material | ||
change, as determined by the Director by rule, and the issuer | ||
shall attach versions with the changes indicated for each | ||
document that was revised from the previous version of the | ||
filing. Upon notice from the issuer insurer , the Director | ||
shall reevaluate the network plan's compliance with the | ||
network adequacy and transparency standards of this Act. For | ||
every day past 15 business days that the issuer fails to submit | ||
a revised network adequacy filing to the Director, the | ||
Director may order a fine of $5,000 per day. | ||
(i) If a network plan is inadequate under this Act with | ||
respect to a provider type in a county, and if the network plan | ||
does not have an approved exception for that provider type in | ||
that county pursuant to subsection (g), an issuer shall cover | ||
out-of-network claims for covered health care services | ||
received from that provider type within that county at the | ||
in-network benefit level and shall retroactively adjudicate | ||
and reimburse beneficiaries to achieve that objective if their | ||
claims were processed at the out-of-network level contrary to | ||
this subsection. Nothing in this subsection shall be construed |
to supersede Section 356z.3a of the Illinois Insurance Code. | ||
(j) If the Director determines that a network is | ||
inadequate in any county and no exception has been granted | ||
under subsection (g) and the issuer does not have a process in | ||
place to comply with subsection (d-5), the Director may | ||
prohibit the network plan from being issued or renewed within | ||
that county until the Director determines that the network is | ||
adequate apart from processes and exceptions described in | ||
subsections (d-5) and (g). Nothing in this subsection shall be | ||
construed to terminate any beneficiary's health insurance | ||
coverage under a network plan before the expiration of the | ||
beneficiary's policy period if the Director makes a | ||
determination under this subsection after the issuance or | ||
renewal of the beneficiary's policy or certificate because of | ||
a material change. Policies or certificates issued or renewed | ||
in violation of this subsection may subject the issuer to a | ||
civil penalty of $5,000 per policy. | ||
(k) For the Department to enforce any new or modified | ||
federal standard before the Department adopts the standard by | ||
rule, the Department must, no later than May 15 before the | ||
start of the plan year, give public notice to the affected | ||
health insurance issuers through a bulletin. | ||
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; | ||
102-1117, eff. 1-13-23.) | ||
(215 ILCS 124/15) |
Sec. 15. Notice of nonrenewal or termination. | ||
(a) A network plan must give at least 60 days' notice of | ||
nonrenewal or termination of a provider to the provider and to | ||
the beneficiaries served by the provider. The notice shall | ||
include a name and address to which a beneficiary or provider | ||
may direct comments and concerns regarding the nonrenewal or | ||
termination and the telephone number maintained by the | ||
Department for consumer complaints. Immediate written notice | ||
may be provided without 60 days' notice when a provider's | ||
license has been disciplined by a State licensing board or | ||
when the network plan reasonably believes direct imminent | ||
physical harm to patients under the provider's providers care | ||
may occur. The notice to the beneficiary shall provide the | ||
individual with an opportunity to notify the issuer of the | ||
individual's need for transitional care. | ||
(b) Primary care providers must notify active affected | ||
patients of nonrenewal or termination of the provider from the | ||
network plan, except in the case of incapacitation. | ||
(Source: P.A. 100-502, eff. 9-15-17.) | ||
(215 ILCS 124/20) | ||
Sec. 20. Transition of services. | ||
(a) A network plan shall provide for continuity of care | ||
for its beneficiaries as follows: | ||
(1) If a beneficiary's physician or hospital provider | ||
leaves the network plan's network of providers for reasons |
other than termination of a contract in situations | ||
involving imminent harm to a patient or a final | ||
disciplinary action by a State licensing board and the | ||
provider remains within the network plan's service area, | ||
if benefits provided under such network plan with respect | ||
to such provider or facility are terminated because of a | ||
change in the terms of the participation of such provider | ||
or facility in such plan, or if a contract between a group | ||
health plan and a health insurance issuer offering a | ||
network plan in connection with the group health plan is | ||
terminated and results in a loss of benefits provided | ||
under such plan with respect to such provider, then the | ||
network plan shall permit the beneficiary to continue an | ||
ongoing course of treatment with that provider during a | ||
transitional period for the following duration: | ||
(A) 90 days from the date of the notice to the | ||
beneficiary of the provider's disaffiliation from the | ||
network plan if the beneficiary has an ongoing course | ||
of treatment; or | ||
(B) if the beneficiary has entered the third | ||
trimester of pregnancy at the time of the provider's | ||
disaffiliation, a period that includes the provision | ||
of post-partum care directly related to the delivery. | ||
(2) Notwithstanding the provisions of paragraph (1) of | ||
this subsection (a), such care shall be authorized by the | ||
network plan during the transitional period in accordance |
with the following: | ||
(A) the provider receives continued reimbursement | ||
from the network plan at the rates and terms and | ||
conditions applicable under the terminated contract | ||
prior to the start of the transitional period; | ||
(B) the provider adheres to the network plan's | ||
quality assurance requirements, including provision to | ||
the network plan of necessary medical information | ||
related to such care; and | ||
(C) the provider otherwise adheres to the network | ||
plan's policies and procedures, including, but not | ||
limited to, procedures regarding referrals and | ||
obtaining preauthorizations for treatment. | ||
(3) The provisions of this Section governing health | ||
care provided during the transition period do not apply if | ||
the beneficiary has successfully transitioned to another | ||
provider participating in the network plan, if the | ||
beneficiary has already met or exceeded the benefit | ||
limitations of the plan, or if the care provided is not | ||
medically necessary. | ||
(b) A network plan shall provide for continuity of care | ||
for new beneficiaries as follows: | ||
(1) If a new beneficiary whose provider is not a | ||
member of the network plan's provider network, but is | ||
within the network plan's service area, enrolls in the | ||
network plan, the network plan shall permit the |
beneficiary to continue an ongoing course of treatment | ||
with the beneficiary's current physician during a | ||
transitional period: | ||
(A) of 90 days from the effective date of | ||
enrollment if the beneficiary has an ongoing course of | ||
treatment; or | ||
(B) if the beneficiary has entered the third | ||
trimester of pregnancy at the effective date of | ||
enrollment, that includes the provision of post-partum | ||
care directly related to the delivery. | ||
(2) If a beneficiary, or a beneficiary's authorized | ||
representative, elects in writing to continue to receive | ||
care from such provider pursuant to paragraph (1) of this | ||
subsection (b), such care shall be authorized by the | ||
network plan for the transitional period in accordance | ||
with the following: | ||
(A) the provider receives reimbursement from the | ||
network plan at rates established by the network plan; | ||
(B) the provider adheres to the network plan's | ||
quality assurance requirements, including provision to | ||
the network plan of necessary medical information | ||
related to such care; and | ||
(C) the provider otherwise adheres to the network | ||
plan's policies and procedures, including, but not | ||
limited to, procedures regarding referrals and | ||
obtaining preauthorization for treatment. |
(3) The provisions of this Section governing health | ||
care provided during the transition period do not apply if | ||
the beneficiary has successfully transitioned to another | ||
provider participating in the network plan, if the | ||
beneficiary has already met or exceeded the benefit | ||
limitations of the plan, or if the care provided is not | ||
medically necessary. | ||
(c) In no event shall this Section be construed to require | ||
a network plan to provide coverage for benefits not otherwise | ||
covered or to diminish or impair preexisting condition | ||
limitations contained in the beneficiary's contract. | ||
(d) A provider shall comply with the requirements of 42 | ||
U.S.C. 300gg-138. | ||
(Source: P.A. 100-502, eff. 9-15-17.) | ||
(215 ILCS 124/25) | ||
Sec. 25. Network transparency. | ||
(a) A network plan shall post electronically an | ||
up-to-date, accurate, and complete provider directory for each | ||
of its network plans, with the information and search | ||
functions, as described in this Section. | ||
(1) In making the directory available electronically, | ||
the network plans shall ensure that the general public is | ||
able to view all of the current providers for a plan | ||
through a clearly identifiable link or tab and without | ||
creating or accessing an account or entering a policy or |
contract number. | ||
(2) An issuer's failure to update a network plan's | ||
directory shall subject the issuer to a civil penalty of | ||
$5,000 per month. The network plan shall update the online | ||
provider directory at least monthly. Providers shall | ||
notify the network plan electronically or in writing | ||
within 10 business days of any changes to their | ||
information as listed in the provider directory, including | ||
the information required in subsections (b), (c), and (d) | ||
subparagraph (K) of paragraph (1) of subsection (b) . With | ||
regard to subparagraph (I) of paragraph (1) of subsection | ||
(b), the provider must give notice to the issuer within 20 | ||
business days of deciding to cease accepting new patients | ||
covered by the plan if the new patient limitation is | ||
expected to last 40 business days or longer. The network | ||
plan shall update its online provider directory in a | ||
manner consistent with the information provided by the | ||
provider within 2 10 business days after being notified of | ||
the change by the provider. Nothing in this paragraph (2) | ||
shall void any contractual relationship between the | ||
provider and the plan. | ||
(3) At least once every 90 days, the issuer shall | ||
self-audit each network plan's The network plan shall | ||
audit periodically at least 25% of its provider | ||
directories for accuracy, make any corrections necessary, | ||
and retain documentation of the audit. The issuer shall |
submit the self-audit and a summary to the Department, and | ||
the Department shall make the summary of each self-audit | ||
publicly available. The Department shall specify the | ||
requirements of the summary, which shall be statistical in | ||
nature except for a high-level narrative evaluating the | ||
impact of internal and external factors on the accuracy of | ||
the directory and the timeliness of updates. The network | ||
plan shall submit the audit to the Director upon request. | ||
As part of these self-audits audits , the network plan | ||
shall contact any provider in its network that has not | ||
submitted a claim to the plan or otherwise communicated | ||
his or her intent to continue participation in the plan's | ||
network. The self-audits shall comply with 42 U.S.C. | ||
300gg-115(a)(2), except that "provider directory | ||
information" shall include all information required to be | ||
included in a provider directory pursuant to this Act. | ||
(4) A network plan shall provide a print copy of a | ||
current provider directory or a print copy of the | ||
requested directory information upon request of a | ||
beneficiary or a prospective beneficiary. Except when an | ||
issuer's print copies use the same provider information as | ||
the electronic provider directory on each print copy's | ||
date of printing, print Print copies must be updated at | ||
least every 90 days quarterly and an errata that reflects | ||
changes in the provider network must be included in each | ||
update updated quarterly . |
(5) For each network plan, a network plan shall | ||
include, in plain language in both the electronic and | ||
print directory, the following general information: | ||
(A) in plain language, a description of the | ||
criteria the plan has used to build its provider | ||
network; | ||
(B) if applicable, in plain language, a | ||
description of the criteria the issuer insurer or | ||
network plan has used to create tiered networks; | ||
(C) if applicable, in plain language, how the | ||
network plan designates the different provider tiers | ||
or levels in the network and identifies for each | ||
specific provider, hospital, or other type of facility | ||
in the network which tier each is placed, for example, | ||
by name, symbols, or grouping, in order for a | ||
beneficiary-covered person or a prospective | ||
beneficiary-covered person to be able to identify the | ||
provider tier; and | ||
(D) if applicable, a notation that authorization | ||
or referral may be required to access some providers ; . | ||
(E) a telephone number and email address for a | ||
customer service representative to whom directory | ||
inaccuracies may be reported; and | ||
(F) a detailed description of the process to | ||
dispute charges for out-of-network providers, | ||
hospitals, or facilities that were incorrectly listed |
as in-network prior to the provision of care and a | ||
telephone number and email address to dispute such | ||
charges. | ||
(6) A network plan shall make it clear for both its | ||
electronic and print directories what provider directory | ||
applies to which network plan, such as including the | ||
specific name of the network plan as marketed and issued | ||
in this State. The network plan shall include in both its | ||
electronic and print directories a customer service email | ||
address and telephone number or electronic link that | ||
beneficiaries or the general public may use to notify the | ||
network plan of inaccurate provider directory information | ||
and contact information for the Department's Office of | ||
Consumer Health Insurance. | ||
(7) A provider directory, whether in electronic or | ||
print format, shall accommodate the communication needs of | ||
individuals with disabilities, and include a link to or | ||
information regarding available assistance for persons | ||
with limited English proficiency. | ||
(b) For each network plan, a network plan shall make | ||
available through an electronic provider directory the | ||
following information in a searchable format: | ||
(1) for health care professionals: | ||
(A) name; | ||
(B) gender; | ||
(C) participating office locations; |
(D) patient population served (such as pediatric, | ||
adult, elderly, or women) and specialty or | ||
subspecialty , if applicable; | ||
(E) medical group affiliations, if applicable; | ||
(F) facility affiliations, if applicable; | ||
(G) participating facility affiliations, if | ||
applicable; | ||
(H) languages spoken other than English, if | ||
applicable; | ||
(I) whether accepting new patients; | ||
(J) board certifications, if applicable; and | ||
(K) use of telehealth or telemedicine, including, | ||
but not limited to: | ||
(i) whether the provider offers the use of | ||
telehealth or telemedicine to deliver services to | ||
patients for whom it would be clinically | ||
appropriate; | ||
(ii) what modalities are used and what types | ||
of services may be provided via telehealth or | ||
telemedicine; and | ||
(iii) whether the provider has the ability and | ||
willingness to include in a telehealth or | ||
telemedicine encounter a family caregiver who is | ||
in a separate location than the patient if the | ||
patient wishes and provides his or her consent; | ||
(L) whether the health care professional accepts |
appointment requests from patients; and | ||
(M) the anticipated date the provider will leave | ||
the network, if applicable, which shall be included no | ||
more than 10 days after the issuer confirms that the | ||
provider is scheduled to leave the network; | ||
(2) for hospitals: | ||
(A) hospital name; | ||
(B) hospital type (such as acute, rehabilitation, | ||
children's, or cancer); | ||
(C) participating hospital location; and | ||
(D) hospital accreditation status; and | ||
(E) the anticipated date the hospital will leave | ||
the network, if applicable, which shall be included no | ||
more than 10 days after the issuer confirms the | ||
hospital is scheduled to leave the network; and | ||
(3) for facilities, other than hospitals, by type: | ||
(A) facility name; | ||
(B) facility type; | ||
(C) types of services performed; and | ||
(D) participating facility location or locations ; | ||
and . | ||
(E) the anticipated date the facility will leave | ||
the network, if applicable, which shall be included no | ||
more than 10 days after the issuer confirms the | ||
facility is scheduled to leave the network. | ||
(c) For the electronic provider directories, for each |
network plan, a network plan shall make available all of the | ||
following information in addition to the searchable | ||
information required in this Section: | ||
(1) for health care professionals: | ||
(A) contact information , including both a | ||
telephone number and digital contact information if | ||
the provider has supplied digital contact information ; | ||
and | ||
(B) languages spoken other than English by | ||
clinical staff, if applicable; | ||
(2) for hospitals, telephone number and digital | ||
contact information ; and | ||
(3) for facilities other than hospitals, telephone | ||
number. | ||
(d) The issuer insurer or network plan shall make | ||
available in print, upon request, the following provider | ||
directory information for the applicable network plan: | ||
(1) for health care professionals: | ||
(A) name; | ||
(B) contact information , including a telephone | ||
number and digital contact information if the provider | ||
has supplied digital contact information ; | ||
(C) participating office location or locations; | ||
(D) patient population (such as pediatric, adult, | ||
elderly, or women) and specialty or subspecialty , if | ||
applicable; |
(E) languages spoken other than English, if | ||
applicable; | ||
(F) whether accepting new patients; and | ||
(G) use of telehealth or telemedicine, including, | ||
but not limited to: | ||
(i) whether the provider offers the use of | ||
telehealth or telemedicine to deliver services to | ||
patients for whom it would be clinically | ||
appropriate; | ||
(ii) what modalities are used and what types | ||
of services may be provided via telehealth or | ||
telemedicine; and | ||
(iii) whether the provider has the ability and | ||
willingness to include in a telehealth or | ||
telemedicine encounter a family caregiver who is | ||
in a separate location than the patient if the | ||
patient wishes and provides his or her consent; | ||
and | ||
(H) whether the health care professional accepts | ||
appointment requests from patients. | ||
(2) for hospitals: | ||
(A) hospital name; | ||
(B) hospital type (such as acute, rehabilitation, | ||
children's, or cancer); and | ||
(C) participating hospital location , and telephone | ||
number , and digital contact information ; and |
(3) for facilities, other than hospitals, by type: | ||
(A) facility name; | ||
(B) facility type; | ||
(C) patient population (such as pediatric, adult, | ||
elderly, or women) served, if applicable, and types of | ||
services performed; and | ||
(D) participating facility location or locations , | ||
and telephone numbers , and digital contact information | ||
for each location . | ||
(e) The network plan shall include a disclosure in the | ||
print format provider directory that the information included | ||
in the directory is accurate as of the date of printing and | ||
that beneficiaries or prospective beneficiaries should consult | ||
the issuer's insurer's electronic provider directory on its | ||
website and contact the provider. The network plan shall also | ||
include a telephone number and email address in the print | ||
format provider directory for a customer service | ||
representative where the beneficiary can obtain current | ||
provider directory information or report provider directory | ||
inaccuracies. The printed provider directory shall include a | ||
detailed description of the process to dispute charges for | ||
out-of-network providers, hospitals, or facilities that were | ||
incorrectly listed as in-network prior to the provision of | ||
care and a telephone number and email address to dispute those | ||
charges . | ||
(f) The Director may conduct periodic audits of the |
accuracy of provider directories. A network plan shall not be | ||
subject to any fines or penalties for information required in | ||
this Section that a provider submits that is inaccurate or | ||
incomplete. | ||
(g) To the extent not otherwise provided in this Act, an | ||
issuer shall comply with the requirements of 42 U.S.C. | ||
300gg-115, except that "provider directory information" shall | ||
include all information required to be included in a provider | ||
directory pursuant to this Section. | ||
(h) If the issuer or the Department identifies a provider | ||
incorrectly listed in the provider directory, the issuer shall | ||
check each of the issuer's network plan provider directories | ||
for the provider within 2 business days to ascertain whether | ||
the provider is a preferred provider in that network plan and, | ||
if the provider is incorrectly listed in the provider | ||
directory, remove the provider from the provider directory | ||
without delay. | ||
(i) If the Director determines that an issuer violated | ||
this Section, the Director may assess a fine up to $5,000 per | ||
violation, except for inaccurate information given by a | ||
provider to the issuer. If an issuer, or any entity or person | ||
acting on the issuer's behalf, knew or reasonably should have | ||
known that a provider was incorrectly included in a provider | ||
directory, the Director may assess a fine of up to $25,000 per | ||
violation against the issuer. | ||
(j) This Section applies to network plans not otherwise |
exempt under Section 3, including stand-alone dental plans. | ||
(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.) | ||
(215 ILCS 124/30) | ||
Sec. 30. Administration and enforcement. | ||
(a) Issuers Insurers , as defined in this Act, have a | ||
continuing obligation to comply with the requirements of this | ||
Act. Other than the duties specifically created in this Act, | ||
nothing in this Act is intended to preclude, prevent, or | ||
require the adoption, modification, or termination of any | ||
utilization management, quality management, or claims | ||
processing methodologies of an issuer insurer . | ||
(b) Nothing in this Act precludes, prevents, or requires | ||
the adoption, modification, or termination of any network plan | ||
term, benefit, coverage or eligibility provision, or payment | ||
methodology. | ||
(c) The Director shall enforce the provisions of this Act | ||
pursuant to the enforcement powers granted to it by law. | ||
(d) The Department shall adopt rules to enforce compliance | ||
with this Act to the extent necessary. | ||
(e) In accordance with Section 5-45 of the Illinois | ||
Administrative Procedure Act, the Department may adopt | ||
emergency rules to implement federal standards for provider | ||
ratios, travel time and distance, and appointment wait times | ||
if such standards apply to health insurance coverage regulated | ||
by the Department and are more stringent than the State |
standards extant at the time the final federal standards are | ||
published. | ||
(Source: P.A. 100-502, eff. 9-15-17.) | ||
(215 ILCS 124/35 new) | ||
Sec. 35. Provider requirements. Providers shall comply | ||
with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations | ||
promulgated thereunder, as well as Section 20, paragraph (2) | ||
of subsection (a) of Section 25, subsections (h) and (j) of | ||
Section 25, and Section 36 of this Act, except that "provider | ||
directory information" includes all information required to be | ||
included in a provider directory pursuant to Section 25 of | ||
this Act. | ||
(215 ILCS 124/36 new) | ||
Sec. 36. Complaint of incorrect charges. | ||
(a) A beneficiary who, taking into account the | ||
reimbursement, if any, by the issuer, incurs a cost in excess | ||
of the in-network cost-sharing for a covered service from a | ||
provider, facility, or hospital that was listed as in-network | ||
in the plan's provider directory prior to or at the time of the | ||
provision of services may file a complaint with the | ||
Department. The Department shall investigate the complaint and | ||
determine if the provider was incorrectly included in the | ||
plan's provider directory when the beneficiary made the | ||
appointment or received the service. |
(b) Upon the Department's confirmation of the allegations | ||
in the complaint that the beneficiary incurred a cost in | ||
excess of the in-network cost-sharing for covered services | ||
provided by an incorrectly included provider when the | ||
appointment was made or service was provided, the issuer shall | ||
reimburse the beneficiary for all costs incurred in excess of | ||
the in-network cost-sharing. However, if the issuer has paid | ||
the claim to the provider directly, the issuer shall notify | ||
the beneficiary and the provider of the beneficiary's right to | ||
reimbursement from the provider for any payments in excess of | ||
the in-network cost-sharing amount pursuant to 42 U.S.C. | ||
300gg-139(b), and the issuer's notice shall specify the | ||
in-network cost-sharing amount for the covered services. The | ||
amounts paid by the beneficiary within the in-network | ||
cost-sharing amount shall apply towards the in-network | ||
deductible and out-of-pocket maximum, if any. | ||
(215 ILCS 124/40 new) | ||
Sec. 40. Confidentiality. | ||
(a) All records in the custody or possession of the | ||
Department are presumed to be open to public inspection or | ||
copying unless exempt from disclosure by Section 7 or 7.5 of | ||
the Freedom of Information Act. Except as otherwise provided | ||
in this Section or other applicable law, the filings required | ||
under this Act shall be open to public inspection or copying. | ||
(b) The following information shall not be deemed |
confidential: | ||
(1) actual or projected ratios of providers to | ||
beneficiaries; | ||
(2) actual or projected time and distance between | ||
network providers and beneficiaries or actual or projected | ||
waiting times for a beneficiary to see a network provider; | ||
(3) geographic maps of network providers; | ||
(4) requests for exceptions under subsection (g) of | ||
Section 10, except with respect to any discussion of | ||
ongoing or planned contractual negotiations with providers | ||
that the issuer requests to be treated as confidential; | ||
(5) provider directories and provider lists; | ||
(6) self-audit summaries required under paragraph (3) | ||
of subsection (a) of Section 25 of this Act; and | ||
(7) issuer or Department statements of determination | ||
as to whether a network plan has satisfied this Act's | ||
requirements regarding the information described in this | ||
subsection. | ||
(c) An issuer's work papers and reports on the results of a | ||
self-audit of its provider directories, including any | ||
communications between the issuer and the Department, shall | ||
remain confidential unless expressly waived by the issuer or | ||
unless deemed public information under federal law. | ||
(d) The filings required under Section 10 of this Act | ||
shall be confidential while they remain under the Department's | ||
review but shall become open to public inspection and copying |
upon completion of the review, except as provided in this | ||
Section or under other applicable law. | ||
(e) Nothing in this Section shall supersede the statutory | ||
requirement that work papers obtained during a market conduct | ||
examination be deemed confidential. | ||
(215 ILCS 124/50 new) | ||
Sec. 50. Funds for enforcement. Moneys from fines and | ||
penalties collected from issuers for violations of this Act | ||
shall be deposited into the Insurance Producer Administration | ||
Fund for appropriation by the General Assembly to the | ||
Department to be used for providing financial support of the | ||
Department's enforcement of this Act. | ||
(215 ILCS 124/55 new) | ||
Sec. 55. Uniform electronic provider directory information | ||
notification forms. | ||
(a) On or before January 1, 2026, the Department shall | ||
develop and publish a uniform electronic provider directory | ||
information form that issuers shall make available to | ||
onboarding, current, and former preferred providers to notify | ||
the issuer of the provider's currently accurate provider | ||
directory information under Section 25 of this Act and 42 | ||
U.S.C. 300gg-139. The form shall address information needed | ||
from newly onboarding preferred providers, updates to | ||
previously supplied provider directory information, reporting |
an inaccurate directory entry of previously supplied | ||
information, contract terminations, and differences in | ||
information for specific network plans offered by an issuer, | ||
such as whether the provider is a preferred provider for the | ||
network plan or is accepting new patients under that plan. The | ||
Department shall allow issuers to implement this form through | ||
either a PDF or a web portal that requests the same | ||
information. | ||
(b) Notwithstanding any other provision of law to the | ||
contrary, beginning 6 months after the Department publishes | ||
the uniform electronic provider directory information form and | ||
no later than July 1, 2026, every provider must use the uniform | ||
electronic provider directory information form to notify | ||
issuers of their provider directory information as required | ||
under Section 25 of this Act and 42 U.S.C. 300gg-139. Issuers | ||
shall accept this form as sufficient to update their provider | ||
directories. Issuers shall not accept paper or fax submissions | ||
of provider directory information from providers. | ||
(c) The Uniform Electronic Provider Directory Information | ||
Form Task Force is created. The purpose of this task force is | ||
to provide input and advice to the Department of Insurance in | ||
the development of a uniform electronic provider directory | ||
information form. The task force shall include at least the | ||
following individuals: | ||
(1) the Director of Insurance or a designee, as chair; | ||
(2) the Marketplace Director or a designee; |
(3) the Director of the Division of Professional | ||
Regulation or a designee; | ||
(4) the Director of Public Health or a designee; | ||
(5) the Secretary of Innovation and Technology or a | ||
designee; | ||
(6) the Director of Healthcare and Family Services or | ||
a designee; | ||
(7) the following individuals appointed by the | ||
Director: | ||
(A) one representative of a statewide association | ||
representing physicians; | ||
(B) one representative of a statewide association | ||
representing nurses; | ||
(C) one representative of a statewide organization | ||
representing a majority of Illinois hospitals; | ||
(D) one representative of a statewide organization | ||
representing Illinois pharmacies; | ||
(E) one representative of a statewide organization | ||
representing mental health care providers; | ||
(F) one representative of a statewide organization | ||
representing substance use disorder health care | ||
providers; | ||
(G) 2 representatives of health insurance issuers | ||
doing business in this State or issuer trade | ||
associations, at least one of which represents a | ||
State-domiciled mutual health insurance company, with |
a demonstrated expertise in the business of health | ||
insurance or health benefits administration; and | ||
(H) 2 representatives of a health insurance | ||
consumer advocacy group. | ||
(d) The Department shall convene the task force described | ||
in this Section no later than April 1, 2025. | ||
(e) The Department, in development of the uniform | ||
electronic provider directory information form, and the task | ||
force, in offering input, shall take into consideration the | ||
following: | ||
(1) readability and user experience; | ||
(2) interoperability; | ||
(3) existing regulations established by the federal | ||
Centers for Medicare and Medicaid Services, the Department | ||
of Insurance, the Department of Healthcare and Family | ||
Service, the Department of Financial and Professional | ||
Regulation, and the Department of Public Health; | ||
(4) potential opportunities to avoid duplication of | ||
data collection efforts, including, but not limited to, | ||
opportunities related to: | ||
(A) integrating any provider reporting required | ||
under Section 25 of this Act and 42 U.S.C. 300gg-139 | ||
with the provider reporting required under the Health | ||
Care Professional Credentials Data Collection Act; | ||
(B) furnishing information to any national | ||
provider directory established by the federal Centers |
for Medicare and Medicaid Services or another federal | ||
agency with jurisdiction over health care providers; | ||
and | ||
(C) furnishing information in compliance with the | ||
Patients' Right to Know Act; | ||
(5) compatibility with the Illinois Health Benefits | ||
Exchange; | ||
(6) provider licensing requirements and forms; and | ||
(7) information needed to classify a provider under | ||
any specialty type for which a network adequacy standard | ||
may be established under this Act when a specialty board | ||
certification or State license does not currently exist. | ||
Section 2-15. The Managed Care Reform and Patient Rights | ||
Act is amended by changing Sections 20 and 25 as follows: | ||
(215 ILCS 134/20) | ||
Sec. 20. Notice of nonrenewal or termination. A health | ||
care plan must give at least 60 days notice of nonrenewal or | ||
termination of a health care provider to the health care | ||
provider and to the enrollees served by the health care | ||
provider. The notice shall include a name and address to which | ||
an enrollee or health care provider may direct comments and | ||
concerns regarding the nonrenewal or termination. Immediate | ||
written notice may be provided without 60 days notice when a | ||
health care provider's license has been disciplined by a State |
licensing board. The notice to the enrollee shall provide the | ||
individual with an opportunity to notify the health care plan | ||
of the individual's need for transitional care. | ||
(Source: P.A. 91-617, eff. 1-1-00.) | ||
(215 ILCS 134/25) | ||
Sec. 25. Transition of services. | ||
(a) A health care plan shall provide for continuity of | ||
care for its enrollees as follows: | ||
(1) If an enrollee's health care provider physician | ||
leaves the health care plan's network of health care | ||
providers for reasons other than termination of a contract | ||
in situations involving imminent harm to a patient or a | ||
final disciplinary action by a State licensing board and | ||
the provider physician remains within the health care | ||
plan's service area, or if benefits provided under such | ||
health care plan with respect to such provider are | ||
terminated because of a change in the terms of the | ||
participation of such provider in such plan, or if a | ||
contract between a group health plan, as defined in | ||
Section 5 of the Illinois Health Insurance Portability and | ||
Accountability Act, and a health care plan offered in | ||
connection with the group health plan is terminated and | ||
results in a loss of benefits provided under such plan | ||
with respect to such provider, the health care plan shall | ||
permit the enrollee to continue an ongoing course of |
treatment with that provider physician during a | ||
transitional period: | ||
(A) of 90 days from the date of the notice of | ||
provider's physician's termination from the health | ||
care plan to the enrollee of the provider's | ||
physician's disaffiliation from the health care plan | ||
if the enrollee has an ongoing course of treatment; or | ||
(B) if the enrollee has entered the third | ||
trimester of pregnancy at the time of the provider's | ||
physician's disaffiliation, that includes the | ||
provision of post-partum care directly related to the | ||
delivery. | ||
(2) Notwithstanding the provisions in item (1) of this | ||
subsection, such care shall be authorized by the health | ||
care plan during the transitional period only if the | ||
provider physician agrees: | ||
(A) to continue to accept reimbursement from the | ||
health care plan at the rates applicable prior to the | ||
start of the transitional period; | ||
(B) to adhere to the health care plan's quality | ||
assurance requirements and to provide to the health | ||
care plan necessary medical information related to | ||
such care; and | ||
(C) to otherwise adhere to the health care plan's | ||
policies and procedures, including but not limited to | ||
procedures regarding referrals and obtaining |
preauthorizations for treatment. | ||
(3) During an enrollee's plan year, a health care plan | ||
shall not remove a drug from its formulary or negatively | ||
change its preferred or cost-tier sharing unless, at least | ||
60 days before making the formulary change, the health | ||
care plan: | ||
(A) provides general notification of the change in | ||
its formulary to current and prospective enrollees; | ||
(B) directly notifies enrollees currently | ||
receiving coverage for the drug, including information | ||
on the specific drugs involved and the steps they may | ||
take to request coverage determinations and | ||
exceptions, including a statement that a certification | ||
of medical necessity by the enrollee's prescribing | ||
provider will result in continuation of coverage at | ||
the existing level; and | ||
(C) directly notifies in writing by first class | ||
mail and through an electronic transmission , if | ||
available, the prescribing provider of all health care | ||
plan enrollees currently prescribed the drug affected | ||
by the proposed change; the notice shall include a | ||
one-page form by which the prescribing provider can | ||
notify the health care plan in writing or | ||
electronically by first class mail that coverage of | ||
the drug for the enrollee is medically necessary. | ||
The notification in paragraph (C) may direct the |
prescribing provider to an electronic portal through which | ||
the prescribing provider may electronically file a | ||
certification to the health care plan that coverage of the | ||
drug for the enrollee is medically necessary. The | ||
prescribing provider may make a secure electronic | ||
signature beside the words "certification of medical | ||
necessity", and this certification shall authorize | ||
continuation of coverage for the drug. | ||
If the prescribing provider certifies to the health | ||
care plan either in writing or electronically that the | ||
drug is medically necessary for the enrollee as provided | ||
in paragraph (C), a health care plan shall authorize | ||
coverage for the drug prescribed based solely on the | ||
prescribing provider's assertion that coverage is | ||
medically necessary, and the health care plan is | ||
prohibited from making modifications to the coverage | ||
related to the covered drug, including, but not limited | ||
to: | ||
(i) increasing the out-of-pocket costs for the | ||
covered drug; | ||
(ii) moving the covered drug to a more restrictive | ||
tier; or | ||
(iii) denying an enrollee coverage of the drug for | ||
which the enrollee has been previously approved for | ||
coverage by the health care plan. | ||
Nothing in this item (3) prevents a health care plan |
from removing a drug from its formulary or denying an | ||
enrollee coverage if the United States Food and Drug | ||
Administration has issued a statement about the drug that | ||
calls into question the clinical safety of the drug, the | ||
drug manufacturer has notified the United States Food and | ||
Drug Administration of a manufacturing discontinuance or | ||
potential discontinuance of the drug as required by | ||
Section 506C of the Federal Food, Drug, and Cosmetic Act, | ||
as codified in 21 U.S.C. 356c, or the drug manufacturer | ||
has removed the drug from the market. | ||
Nothing in this item (3) prohibits a health care plan, | ||
by contract, written policy or 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. | ||
This item (3) applies to a policy or contract that is | ||
amended, delivered, issued, or renewed on or after January | ||
1, 2019. This item (3) does not apply to a health plan as | ||
defined in the State Employees Group Insurance Act of 1971 |
or medical assistance under Article V of the Illinois | ||
Public Aid Code. | ||
(b) A health care plan shall provide for continuity of | ||
care for new enrollees as follows: | ||
(1) If a new enrollee whose physician is not a member | ||
of the health care plan's provider network, but is within | ||
the health care plan's service area, enrolls in the health | ||
care plan, the health care plan shall permit the enrollee | ||
to continue an ongoing course of treatment with the | ||
enrollee's current physician during a transitional period: | ||
(A) of 90 days from the effective date of | ||
enrollment if the enrollee has an ongoing course of | ||
treatment; or | ||
(B) if the enrollee has entered the third | ||
trimester of pregnancy at the effective date of | ||
enrollment, that includes the provision of post-partum | ||
care directly related to the delivery. | ||
(2) If an enrollee elects to continue to receive care | ||
from such physician pursuant to item (1) of this | ||
subsection, such care shall be authorized by the health | ||
care plan for the transitional period only if the | ||
physician agrees: | ||
(A) to accept reimbursement from the health care | ||
plan at rates established by the health care plan; | ||
such rates shall be the level of reimbursement | ||
applicable to similar physicians within the health |
care plan for such services; | ||
(B) to adhere to the health care plan's quality | ||
assurance requirements and to provide to the health | ||
care plan necessary medical information related to | ||
such care; and | ||
(C) to otherwise adhere to the health care plan's | ||
policies and procedures including, but not limited to | ||
procedures regarding referrals and obtaining | ||
preauthorization for treatment. | ||
(c) In no event shall this Section be construed to require | ||
a health care plan to provide coverage for benefits not | ||
otherwise covered or to diminish or impair preexisting | ||
condition limitations contained in the enrollee's contract. In | ||
no event shall this Section be construed to prohibit the | ||
addition of prescription drugs to a health care plan's list of | ||
covered drugs during the coverage year. | ||
(d) In this Section, "ongoing course of treatment" has the | ||
meaning ascribed to that term in Section 5 of the Network | ||
Adequacy and Transparency Act. | ||
(Source: P.A. 100-1052, eff. 8-24-18.) | ||
Article 3. | ||
Section 3-5. The Illinois Insurance Code is amended by | ||
changing Section 355 as follows: |
(215 ILCS 5/355) (from Ch. 73, par. 967) | ||
Sec. 355. Accident and health policies; provisions. | ||
(a) As used in this Section: | ||
"Inadequate rate" means a rate: | ||
(1) that is insufficient to sustain projected losses | ||
and expenses to which the rate applies; and | ||
(2) the continued use of which endangers the solvency | ||
of an insurer using that rate. | ||
"Large employer" has the meaning provided in the Illinois | ||
Health Insurance Portability and Accountability Act. | ||
"Plain language" has the meaning provided in the federal | ||
Plain Writing Act of 2010 and subsequent guidance documents, | ||
including the Federal Plain Language Guidelines. | ||
"Unreasonable rate increase" means a rate increase that | ||
the Director determines to be excessive, unjustified, or | ||
unfairly discriminatory in accordance with 45 CFR 154.205. | ||
(b) No policy of insurance against loss or damage from the | ||
sickness, or from the bodily injury or death of the insured by | ||
accident shall be issued or delivered to any person in this | ||
State until a copy of the form thereof and of the | ||
classification of risks and the premium rates pertaining | ||
thereto have been filed with the Director; nor shall it be so | ||
issued or delivered until the Director shall have approved | ||
such policy pursuant to the provisions of Section 143. If the | ||
Director disapproves the policy form, he or she shall make a | ||
written decision stating the respects in which such form does |
not comply with the requirements of law and shall deliver a | ||
copy thereof to the company and it shall be unlawful | ||
thereafter for any such company to issue any policy in such | ||
form. On and after January 1, 2025, any form filing submitted | ||
for large employer group accident and health insurance shall | ||
be automatically deemed approved within 90 days of the | ||
submission date unless the Director extends by not more than | ||
an additional 30 days the period within which the form shall be | ||
approved or disapproved by giving written notice to the | ||
insurer of such extension before the expiration of the 90 | ||
days. Any form in receipt of such an extension shall be | ||
automatically deemed approved within 120 days of the | ||
submission date. The Director may toll the filing due to a | ||
conflict in legal interpretation of federal or State law as | ||
long as the tolling is applied uniformly to all applicable | ||
forms, written notification is provided to the insurer prior | ||
to the tolling, the duration of the tolling is provided within | ||
the notice to the insurer, and justification for the tolling | ||
is posted to the Department's website. The Director may | ||
disapprove the filing if the insurer fails to respond to an | ||
objection or request for additional information within the | ||
timeframe identified for response. As used in this subsection, | ||
"large employer" has the meaning given in Section 5 of the | ||
federal Health Insurance Portability and Accountability Act. | ||
(c) For plan year 2026 and thereafter, premium rates for | ||
all individual and small group accident and health insurance |
policies must be filed with the Department for approval. | ||
Unreasonable rate increases or inadequate rates shall be | ||
modified or disapproved. For any plan year during which the | ||
Illinois Health Benefits Exchange operates as a full | ||
State-based exchange, the Department shall provide insurers at | ||
least 30 days' notice of the deadline to submit rate filings. | ||
(c-5) Unless prohibited under federal law, for plan year | ||
2026 and thereafter, each insurer proposing to offer a | ||
qualified health plan issued in the individual market through | ||
the Illinois Health Benefits Exchange must incorporate the | ||
following approach in its rate filing under this Section: | ||
(1) The rate filing must apply a cost-sharing | ||
reduction defunding adjustment factor within a range that: | ||
(A) is uniform across all insurers; | ||
(B) is consistent with the total adjustment | ||
expected to be needed to cover actual cost-sharing | ||
reduction costs across all silver plans on the | ||
Illinois Health Benefits Exchange statewide, provided | ||
that such costs are calculated assuming utilization by | ||
the State's full individual-market risk pool; and | ||
(C) assumes that the only on-Exchange silver plans | ||
that will be purchased are the 87% and 94% | ||
cost-sharing reduction variations. | ||
(2) The rate filing must apply an induced demand | ||
factor based on the following formula: (Plan Actuarial | ||
Value) 2 - (Plan Actuarial Value) + 1.24. |
In the annual notice to insurers described in subsection | ||
(c), the Department must include the specific numerical range | ||
calculated for the applicable plan year under paragraph (1) of | ||
this subsection (c-5) and the formula in paragraph (2) of this | ||
subsection (c-5). | ||
(d) For plan year 2025 and thereafter, the Department | ||
shall post all insurers' rate filings and summaries on the | ||
Department's website 5 business days after the rate filing | ||
deadline set by the Department in annual guidance. The rate | ||
filings and summaries posted to the Department's website shall | ||
exclude information that is proprietary or trade secret | ||
information protected under paragraph (g) of subsection (1) of | ||
Section 7 of the Freedom of Information Act or confidential or | ||
privileged under any applicable insurance law or rule. All | ||
summaries shall include a brief justification of any rate | ||
increase or decrease requested, including the number of | ||
individual members, the medical loss ratio, medical trend, | ||
administrative costs, and any other information required by | ||
rule. The plain writing summary shall include notification of | ||
the public comment period established in subsection (e). | ||
(e) The Department shall open a 30-day public comment | ||
period on the rate filings beginning on the date that all of | ||
the rate filings are posted on the Department's website. The | ||
Department shall post all of the comments received to the | ||
Department's website within 5 business days after the comment | ||
period ends. |
(f) After the close of the public comment period described | ||
in subsection (e), the Department, beginning for plan year | ||
2026, shall issue a decision to approve, disapprove, or modify | ||
a rate filing within 60 days. Any rate filing or any rates | ||
within a filing on which the Director does not issue a decision | ||
within 60 days shall automatically be deemed approved. The | ||
Director's decision shall take into account the actuarial | ||
justifications and public comments. The Department shall | ||
notify the insurer of the decision, make the decision | ||
available to the public by posting it on the Department's | ||
website, and include an explanation of the findings, actuarial | ||
justifications, and rationale that are the basis for the | ||
decision. Any company whose rate has been modified or | ||
disapproved shall be allowed to request a hearing within 10 | ||
days after the action taken. The action of the Director in | ||
disapproving a rate shall be subject to judicial review under | ||
the Administrative Review Law. | ||
(g) If, following the issuance of a decision but before | ||
the effective date of the premium rates approved by the | ||
decision, an event occurs that materially affects the | ||
Director's decision to approve, deny, or modify the rates, the | ||
Director may consider supplemental facts or data reasonably | ||
related to the event. | ||
(h) The Department shall adopt rules implementing the | ||
procedures described in subsections (d) through (g) by March | ||
31, 2024. |
(i) Subsection (a) and subsections (c) through (h) of this | ||
Section do not apply to grandfathered health plans as defined | ||
in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C. | ||
300gg-91; student health insurance coverage as defined in 45 | ||
CFR 147.145; the large group market as defined in Section 5 of | ||
the Illinois Health Insurance Portability and Accountability | ||
Act; or short-term, limited-duration health insurance coverage | ||
as defined in Section 5 of the Short-Term, Limited-Duration | ||
Health Insurance Coverage Act. For a filing of premium rates | ||
or classifications of risk for any of these types of coverage, | ||
the Director's initial review period shall not exceed 60 days | ||
to issue informal objections to the company that request | ||
additional clarification, explanation, substantiating | ||
documentation, or correction of concerns identified in the | ||
filing before the company implements the premium rates, | ||
classifications, or related rate-setting methodologies | ||
described in the filing, except that the Director may extend | ||
by not more than an additional 30 days the period of initial | ||
review by giving written notice to the company of such | ||
extension before the expiration of the initial 60-day period. | ||
Nothing in this subsection shall confer authority upon the | ||
Director to approve, modify, or disapprove rates where that | ||
authority is not provided by other law. Nothing in this | ||
subsection shall prohibit the Director from conducting any | ||
investigation, examination, hearing, or other formal | ||
administrative or enforcement proceeding with respect to a |
company's rate filing or implementation thereof under | ||
applicable law at any time, including after the period of | ||
initial review. | ||
(Source: P.A. 103-106, eff. 1-1-24 .) | ||
Section 3-10. The Illinois Health Benefits Exchange Law is | ||
amended by changing Section 5-5 as follows: | ||
(215 ILCS 122/5-5) | ||
Sec. 5-5. State health benefits exchange. It is declared | ||
that this State, beginning October 1, 2013, in accordance with | ||
Section 1311 of the federal Patient Protection and Affordable | ||
Care Act, shall establish a State health benefits exchange to | ||
be known as the Illinois Health Benefits Exchange in order to | ||
help individuals and small employers with no more than 50 | ||
employees shop for, select, and enroll in qualified, | ||
affordable private health plans that fit their needs at | ||
competitive prices. The Exchange shall separate coverage pools | ||
for individuals and small employers and shall supplement and | ||
not supplant any existing private health insurance market for | ||
individuals and small employers. The Department of Insurance | ||
shall operate the Illinois Health Benefits Exchange as a | ||
State-based exchange using the federal platform by plan year | ||
2025 and as a State-based exchange by plan year 2026. The | ||
Director of Insurance may require that all plans in the | ||
individual and small group markets, other than grandfathered |
health plans, be made available for comparison on the Illinois | ||
Health Benefits Exchange, but may not require that all plans | ||
in the individual and small group markets be purchased | ||
exclusively on the Illinois Health Benefits Exchange. Through | ||
the adoption of rules, the Director of Insurance may require | ||
that plans offered on the exchange conform with standardized | ||
plan designs that provide for standardized cost sharing for | ||
covered health services. Except when it is inconsistent with | ||
State law, the Department of Insurance shall enforce the | ||
coverage requirements under the federal Patient Protection and | ||
Affordable Care Act, including the coverage of all United | ||
States Preventive Services Task Force Grade A and B preventive | ||
services without cost sharing notwithstanding any federal | ||
overturning or repeal of 42 U.S.C. 300gg-13(a)(1), that apply | ||
to the individual and small group markets. Beginning for plan | ||
year 2026, if a health insurance issuer offers a product as | ||
defined under 45 CFR 144.103 at the gold or silver level | ||
through the Illinois Health Benefits Exchange, the issuer must | ||
offer that product at both the gold and silver levels. The | ||
Director of Insurance may elect to add a small business health | ||
options program to the Illinois Health Benefits Exchange to | ||
help small employers enroll their employees in qualified | ||
health plans in the small group market. The General Assembly | ||
shall appropriate funds to establish the Illinois Health | ||
Benefits Exchange. | ||
(Source: P.A. 103-103, eff. 6-27-23.) |
Article 4. | ||
Section 4-5. The Illinois Insurance Code is amended by | ||
changing Section 355 as follows: | ||
(215 ILCS 5/355) (from Ch. 73, par. 967) | ||
Sec. 355. Accident and health policies; provisions. | ||
(a) As used in this Section: | ||
"Inadequate rate" means a rate: | ||
(1) that is insufficient to sustain projected losses | ||
and expenses to which the rate applies; and | ||
(2) the continued use of which endangers the solvency | ||
of an insurer using that rate. | ||
"Large employer" has the meaning provided in the Illinois | ||
Health Insurance Portability and Accountability Act. | ||
"Plain language" has the meaning provided in the federal | ||
Plain Writing Act of 2010 and subsequent guidance documents, | ||
including the Federal Plain Language Guidelines. | ||
"Unreasonable rate increase" means a rate increase that | ||
the Director determines to be excessive, unjustified, or | ||
unfairly discriminatory in accordance with 45 CFR 154.205. | ||
(b) No policy of insurance against loss or damage from the | ||
sickness, or from the bodily injury or death of the insured by | ||
accident shall be issued or delivered to any person in this | ||
State until a copy of the form thereof and of the |
classification of risks and the premium rates pertaining | ||
thereto have been filed with the Director; nor shall it be so | ||
issued or delivered until the Director shall have approved | ||
such policy pursuant to the provisions of Section 143. If the | ||
Director disapproves the policy form, he or she shall make a | ||
written decision stating the respects in which such form does | ||
not comply with the requirements of law and shall deliver a | ||
copy thereof to the company and it shall be unlawful | ||
thereafter for any such company to issue any policy in such | ||
form. On and after January 1, 2025, any form filing submitted | ||
for large employer group accident and health insurance shall | ||
be automatically deemed approved within 90 days of the | ||
submission date unless the Director extends by not more than | ||
an additional 30 days the period within which the form shall be | ||
approved or disapproved by giving written notice to the | ||
insurer of such extension before the expiration of the 90 | ||
days. Any form in receipt of such an extension shall be | ||
automatically deemed approved within 120 days of the | ||
submission date. The Director may toll the filing due to a | ||
conflict in legal interpretation of federal or State law as | ||
long as the tolling is applied uniformly to all applicable | ||
forms, written notification is provided to the insurer prior | ||
to the tolling, the duration of the tolling is provided within | ||
the notice to the insurer, and justification for the tolling | ||
is posted to the Department's website. The Director may | ||
disapprove the filing if the insurer fails to respond to an |
objection or request for additional information within the | ||
timeframe identified for response. As used in this subsection, | ||
"large employer" has the meaning given in Section 5 of the | ||
federal Health Insurance Portability and Accountability Act. | ||
(c) For plan year 2026 and thereafter, premium rates for | ||
all individual and small group accident and health insurance | ||
policies must be filed with the Department for approval. | ||
Unreasonable rate increases or inadequate rates shall be | ||
modified or disapproved. For any plan year during which the | ||
Illinois Health Benefits Exchange operates as a full | ||
State-based exchange, the Department shall provide insurers at | ||
least 30 days' notice of the deadline to submit rate filings. | ||
(d) For plan year 2025 and thereafter, the Department | ||
shall post all insurers' rate filings and summaries on the | ||
Department's website 5 business days after the rate filing | ||
deadline set by the Department in annual guidance. The rate | ||
filings and summaries posted to the Department's website shall | ||
exclude information that is proprietary or trade secret | ||
information protected under paragraph (g) of subsection (1) of | ||
Section 7 of the Freedom of Information Act or confidential or | ||
privileged under any applicable insurance law or rule. All | ||
summaries shall include a brief justification of any rate | ||
increase or decrease requested, including the number of | ||
individual members, the medical loss ratio, medical trend, | ||
administrative costs, and any other information required by | ||
rule. The plain writing summary shall include notification of |
the public comment period established in subsection (e). | ||
(e) The Department shall open a 30-day public comment | ||
period on the rate filings beginning on the date that all of | ||
the rate filings are posted on the Department's website. The | ||
Department shall post all of the comments received to the | ||
Department's website within 5 business days after the comment | ||
period ends. | ||
(f) After the close of the public comment period described | ||
in subsection (e), the Department, beginning for plan year | ||
2026, shall issue a decision to approve, disapprove, or modify | ||
a rate filing within 60 days. Any rate filing or any rates | ||
within a filing on which the Director does not issue a decision | ||
within 60 days shall automatically be deemed approved. The | ||
Director's decision shall take into account the actuarial | ||
justifications and public comments. The Department shall | ||
notify the insurer of the decision, make the decision | ||
available to the public by posting it on the Department's | ||
website, and include an explanation of the findings, actuarial | ||
justifications, and rationale that are the basis for the | ||
decision. Any company whose rate has been modified or | ||
disapproved shall be allowed to request a hearing within 10 | ||
days after the action taken. The action of the Director in | ||
disapproving a rate shall be subject to judicial review under | ||
the Administrative Review Law. | ||
(g) If, following the issuance of a decision but before | ||
the effective date of the premium rates approved by the |
decision, an event occurs that materially affects the | ||
Director's decision to approve, deny, or modify the rates, the | ||
Director may consider supplemental facts or data reasonably | ||
related to the event. | ||
(h) The Department shall adopt rules implementing the | ||
procedures described in subsections (d) through (g) by March | ||
31, 2024. | ||
(i) Subsection (a) , and subsections (c) through (h) , and | ||
subsection (j) of this Section do not apply to grandfathered | ||
health plans as defined in 45 CFR 147.140; excepted benefits | ||
as defined in 42 U.S.C. 300gg-91; or student health insurance | ||
coverage as defined in 45 CFR 147.145 ; the large group market | ||
as defined in Section 5 of the Illinois Health Insurance | ||
Portability and Accountability Act; or short-term, | ||
limited-duration health insurance coverage as defined in | ||
Section 5 of the Short-Term, Limited-Duration Health Insurance | ||
Coverage Act . For a filing of premium rates or classifications | ||
of risk for any of these types of coverage, the Director's | ||
initial review period shall not exceed 60 days to issue | ||
informal objections to the company that request additional | ||
clarification, explanation, substantiating documentation, or | ||
correction of concerns identified in the filing before the | ||
company implements the premium rates, classifications, or | ||
related rate-setting methodologies described in the filing, | ||
except that the Director may extend by not more than an | ||
additional 30 days the period of initial review by giving |
written notice to the company of such extension before the | ||
expiration of the initial 60-day period. Nothing in this | ||
subsection shall confer authority upon the Director to | ||
approve, modify, or disapprove rates where that authority is | ||
not provided by other law. Nothing in this subsection shall | ||
prohibit the Director from conducting any investigation, | ||
examination, hearing, or other formal administrative or | ||
enforcement proceeding with respect to a company's rate filing | ||
or implementation thereof under applicable law at any time, | ||
including after the period of initial review. | ||
(j) Subsection (a) and subsections (c) through (h) do not | ||
apply to group policies issued in the large group market as | ||
defined in Section 5 of the Illinois Health Insurance | ||
Portability and Accountability Act. For large group policies | ||
issued, delivered, amended, or renewed on or after January 1, | ||
2026 that are not described in subsection (i), the premium | ||
rates and risk classifications, including any rate manuals and | ||
rules used to arrive at the rates, must be filed with the | ||
Department annually for approval at least 120 days before the | ||
rates are intended to take effect. | ||
(1) A rate filing shall be modified or disapproved if | ||
the premiums are unreasonable in relation to the benefits | ||
because the rates were not calculated in accordance with | ||
sound actuarial principles. | ||
(2) Within 60 days of receipt of the rate filing, the | ||
Director shall issue a decision to approve, disapprove, or |
modify the filing along with the reasons and actuarial | ||
justification for the decision. Any rate filing or rates | ||
within a filing on which the Director does not issue a | ||
decision within 60 days shall be automatically deemed | ||
approved. | ||
(3) Any company whose rate or rate filing has been | ||
modified or disapproved shall be allowed to request a | ||
hearing within 10 days after the action taken. The action | ||
of the Director in disapproving a rate or rate filing | ||
shall be subject to judicial review under the | ||
Administrative Review Law. | ||
(4) Nothing in this subsection requires a company to | ||
file a large group policy's final premium rates for prior | ||
approval if the company negotiates the final rates or rate | ||
adjustments with the plan sponsor or its administrator in | ||
accordance with the rate manual and rules of the currently | ||
approved rate filing for the policy. | ||
In this subsection, "administrator" and "plan sponsor" | ||
have the meaning given to those terms in 29 U.S.C. 1002(16). | ||
(Source: P.A. 103-106, eff. 1-1-24 .) | ||
Section 4-10. The Health Maintenance Organization Act is | ||
amended by changing Section 4-12 as follows: | ||
(215 ILCS 125/4-12) (from Ch. 111 1/2, par. 1409.5) | ||
Sec. 4-12. Changes in rate methodology and benefits, |
material modifications. A health maintenance organization | ||
shall file with the Director, prior to use, a notice of any | ||
change in rate methodology, or benefits and of any material | ||
modification of any matter or document furnished pursuant to | ||
Section 2-1, together with such supporting documents as are | ||
necessary to fully explain the change or modification. | ||
(a) Contract modifications described in subsections | ||
(c)(5), (c)(6) and (c)(7) of Section 2-1 shall include all | ||
form agreements between the organization and enrollees, | ||
providers, administrators of services and insurers of health | ||
maintenance organizations. | ||
(b) Material transactions or series of transactions other | ||
than those described in subsection (a) of this Section, the | ||
total annual value of which exceeds the greater of $100,000 or | ||
5% of net earned subscription revenue for the most current | ||
12-month period as determined from filed financial statements. | ||
(c) Any agreement between the organization and an insurer | ||
shall be subject to the provisions of the laws of this State | ||
regarding reinsurance as provided in Article XI of the | ||
Illinois Insurance Code. All reinsurance agreements must be | ||
filed. Approval of the Director is required for all agreements | ||
except the following: individual stop loss, aggregate excess, | ||
hospitalization benefits or out-of-area of the participating | ||
providers unless 20% or more of the organization's total risk | ||
is reinsured, in which case all reinsurance agreements require | ||
approval. |
(d) In addition to any applicable provisions of this Act, | ||
premium rate filings shall be subject to subsections (a) and | ||
(c) through (j) (i) of Section 355 of the Illinois Insurance | ||
Code. | ||
(Source: P.A. 103-106, eff. 1-1-24 .) | ||
Section 4-15. The Limited Health Service Organization Act | ||
is amended by changing Section 3006 as follows: | ||
(215 ILCS 130/3006) (from Ch. 73, par. 1503-6) | ||
Sec. 3006. Changes in rate methodology and benefits; | ||
material modifications; addition of limited health services. | ||
(a) A limited health service organization shall file with | ||
the Director prior to use, a notice of any change in rate | ||
methodology, charges , or benefits and of any material | ||
modification of any matter or document furnished pursuant to | ||
Section 2001, together with such supporting documents as are | ||
necessary to fully explain the change or modification. | ||
(1) Contract modifications described in paragraphs (5) | ||
and (6) of subsection (c) of Section 2001 shall include | ||
all agreements between the organization and enrollees, | ||
providers, administrators of services , and insurers of | ||
limited health services; also other material transactions | ||
or series of transactions, the total annual value of which | ||
exceeds the greater of $100,000 or 5% of net earned | ||
subscription revenue for the most current 12-month 12 |
month period as determined from filed financial | ||
statements. | ||
(2) Contract modification for reinsurance. Any | ||
agreement between the organization and an insurer shall be | ||
subject to the provisions of Article XI of the Illinois | ||
Insurance Code, as now or hereafter amended. All | ||
reinsurance agreements must be filed with the Director. | ||
Approval of the Director in required agreements must be | ||
filed. Approval of the director is required for all | ||
agreements except individual stop loss, aggregate excess, | ||
hospitalization benefits , or out-of-area of the | ||
participating providers, unless 20% or more of the | ||
organization's total risk is reinsured, in which case all | ||
reinsurance agreements shall require approval. | ||
(b) If a limited health service organization desires to | ||
add one or more additional limited health services, it shall | ||
file a notice with the Director and, at the same time, submit | ||
the information required by Section 2001 if different from | ||
that filed with the prepaid limited health service | ||
organization's application. Issuance of such an amended | ||
certificate of authority shall be subject to the conditions of | ||
Section 2002 of this Act. | ||
(c) In addition to any applicable provisions of this Act, | ||
premium rate filings shall be subject to subsection (i) and, | ||
for pharmaceutical policies, subsection (j) of Section 355 of | ||
the Illinois Insurance Code. |
(Source: P.A. 103-106, eff. 1-1-24; revised 1-2-24.) | ||
Article 6. | ||
Section 6-5. The Illinois Insurance Code is amended by | ||
changing Sections 155.36, 155.37, 356z.40, and 370c as | ||
follows: | ||
(215 ILCS 5/155.36) | ||
Sec. 155.36. Managed Care Reform and Patient Rights Act. | ||
Insurance companies that transact the kinds of insurance | ||
authorized under Class 1(b) or Class 2(a) of Section 4 of this | ||
Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65, | ||
70, and 85, and 87, subsection (d) of Section 30, and the | ||
definitions definition of the term "emergency medical | ||
condition" and any other term in Section 10 of the Managed Care | ||
Reform and Patient Rights Act that is used in the other | ||
Sections listed in this Section . | ||
(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.) | ||
(215 ILCS 5/155.37) | ||
Sec. 155.37. Drug formulary; notice. | ||
(a) Insurance companies that transact the kinds of | ||
insurance authorized under Class 1(b) or Class 2(a) of Section | ||
4 of this Code and provide coverage for prescription drugs | ||
through the use of a drug formulary must notify insureds of any |
change in the formulary. A company may comply with this | ||
Section by posting changes in the formulary on its website. | ||
(b) No later than October 1, 2025, insurance companies | ||
that use a drug formulary shall post the formulary on their | ||
websites in a manner that is searchable and accessible to the | ||
general public without requiring an individual to create any | ||
account. This formulary shall adhere to a template developed | ||
by the Department by March 31, 2025, which shall take into | ||
consideration existing requirements for reporting of | ||
information established by the federal Centers for Medicare | ||
and Medicaid Services as well as display of cost-sharing | ||
information. This template and all formularies also shall do | ||
all the following: | ||
(1) include information on cost-sharing tiers and | ||
utilization controls, such as prior authorization, for | ||
each covered drug; | ||
(2) indicate any drugs on the formulary that are | ||
preferred over other drugs on the formulary; | ||
(3) include information to educate insureds about the | ||
differences between drugs administered or provided under a | ||
policy's medical benefit and drugs covered under a drug | ||
benefit and how to obtain coverage information about drugs | ||
that are not covered under the drug benefit; | ||
(4) include information to educate insureds that | ||
policies that provide drug benefits are required to have a | ||
method for enrollees to obtain drugs not listed in the |
formulary if they are deemed medically necessary by a | ||
clinician under Section 45.1 of the Managed Care Reform | ||
and Patient Rights Act; | ||
(5) include information on which medications are | ||
covered, including both generic and brand name; and | ||
(6) include information on what tier of the plan's | ||
drug formulary each medication is in. | ||
(c) No formulary may establish a step therapy requirement | ||
as prohibited by Section 87 of the Managed Care Reform and | ||
Patient Rights Act. | ||
(Source: P.A. 92-440, eff. 8-17-01; 92-651, eff. 7-11-02.) | ||
(215 ILCS 5/356z.40) | ||
Sec. 356z.40. Pregnancy and postpartum coverage. | ||
(a) An individual or group policy of accident and health | ||
insurance or managed care plan amended, delivered, issued, or | ||
renewed on or after the effective date of this amendatory Act | ||
of the 102nd General Assembly shall provide coverage for | ||
pregnancy and newborn care in accordance with 42 U.S.C. | ||
18022(b) regarding essential health benefits. | ||
(b) Benefits under this Section shall be as follows: | ||
(1) An individual who has been identified as | ||
experiencing a high-risk pregnancy by the individual's | ||
treating provider shall have access to clinically | ||
appropriate case management programs. As used in this | ||
subsection, "case management" means a mechanism to |
coordinate and assure continuity of services, including, | ||
but not limited to, health services, social services, and | ||
educational services necessary for the individual. "Case | ||
management" involves individualized assessment of needs, | ||
planning of services, referral, monitoring, and advocacy | ||
to assist an individual in gaining access to appropriate | ||
services and closure when services are no longer required. | ||
"Case management" is an active and collaborative process | ||
involving a single qualified case manager, the individual, | ||
the individual's family, the providers, and the community. | ||
This includes close coordination and involvement with all | ||
service providers in the management plan for that | ||
individual or family, including assuring that the | ||
individual receives the services. As used in this | ||
subsection, "high-risk pregnancy" means a pregnancy in | ||
which the pregnant or postpartum individual or baby is at | ||
an increased risk for poor health or complications during | ||
pregnancy or childbirth, including, but not limited to, | ||
hypertension disorders, gestational diabetes, and | ||
hemorrhage. | ||
(2) An individual shall have access to medically | ||
necessary treatment of a mental, emotional, nervous, or | ||
substance use disorder or condition consistent with the | ||
requirements set forth in this Section and in Sections | ||
370c and 370c.1 of this Code. | ||
(3) The benefits provided for inpatient and outpatient |
services for the treatment of a mental, emotional, | ||
nervous, or substance use disorder or condition related to | ||
pregnancy or postpartum complications shall be provided if | ||
determined to be medically necessary, consistent with the | ||
requirements of Sections 370c and 370c.1 of this Code. The | ||
facility or provider shall notify the insurer of both the | ||
admission and the initial treatment plan within 48 hours | ||
after admission or initiation of treatment. Subject to the | ||
requirements of Sections 370c and 370c.1 of this Code, | ||
nothing Nothing in this paragraph shall prevent an insurer | ||
from applying concurrent and post-service utilization | ||
review of health care services, including review of | ||
medical necessity, case management, experimental and | ||
investigational treatments, managed care provisions, and | ||
other terms and conditions of the insurance policy. | ||
(4) The benefits for the first 48 hours of initiation | ||
of services for an inpatient admission, detoxification or | ||
withdrawal management program, or partial hospitalization | ||
admission for the treatment of a mental, emotional, | ||
nervous, or substance use disorder or condition related to | ||
pregnancy or postpartum complications shall be provided | ||
without post-service or concurrent review of medical | ||
necessity, as the medical necessity for the first 48 hours | ||
of such services shall be determined solely by the covered | ||
pregnant or postpartum individual's provider. Subject to | ||
Section 370c and 370c.1 of this Code, nothing Nothing in |
this paragraph shall prevent an insurer from applying | ||
concurrent and post-service utilization review, including | ||
the review of medical necessity, case management, | ||
experimental and investigational treatments, managed care | ||
provisions, and other terms and conditions of the | ||
insurance policy, of any inpatient admission, | ||
detoxification or withdrawal management program admission, | ||
or partial hospitalization admission services for the | ||
treatment of a mental, emotional, nervous, or substance | ||
use disorder or condition related to pregnancy or | ||
postpartum complications received 48 hours after the | ||
initiation of such services. If an insurer determines that | ||
the services are no longer medically necessary, then the | ||
covered person shall have the right to external review | ||
pursuant to the requirements of the Health Carrier | ||
External Review Act. | ||
(5) If an insurer determines that continued inpatient | ||
care, detoxification or withdrawal management, partial | ||
hospitalization, intensive outpatient treatment, or | ||
outpatient treatment in a facility is no longer medically | ||
necessary, the insurer shall, within 24 hours, provide | ||
written notice to the covered pregnant or postpartum | ||
individual and the covered pregnant or postpartum | ||
individual's provider of its decision and the right to | ||
file an expedited internal appeal of the determination. | ||
The insurer shall review and make a determination with |
respect to the internal appeal within 24 hours and | ||
communicate such determination to the covered pregnant or | ||
postpartum individual and the covered pregnant or | ||
postpartum individual's provider. If the determination is | ||
to uphold the denial, the covered pregnant or postpartum | ||
individual and the covered pregnant or postpartum | ||
individual's provider have the right to file an expedited | ||
external appeal. An independent utilization review | ||
organization shall make a determination within 72 hours. | ||
If the insurer's determination is upheld and it is | ||
determined that continued inpatient care, detoxification | ||
or withdrawal management, partial hospitalization, | ||
intensive outpatient treatment, or outpatient treatment is | ||
not medically necessary, the insurer shall remain | ||
responsible for providing benefits for the inpatient care, | ||
detoxification or withdrawal management, partial | ||
hospitalization, intensive outpatient treatment, or | ||
outpatient treatment through the day following the date | ||
the determination is made, and the covered pregnant or | ||
postpartum individual shall only be responsible for any | ||
applicable copayment, deductible, and coinsurance for the | ||
stay through that date as applicable under the policy. The | ||
covered pregnant or postpartum individual shall not be | ||
discharged or released from the inpatient facility, | ||
detoxification or withdrawal management, partial | ||
hospitalization, intensive outpatient treatment, or |
outpatient treatment until all internal appeals and | ||
independent utilization review organization appeals are | ||
exhausted. A decision to reverse an adverse determination | ||
shall comply with the Health Carrier External Review Act. | ||
(6) Except as otherwise stated in this subsection (b), | ||
the benefits and cost-sharing shall be provided to the | ||
same extent as for any other medical condition covered | ||
under the policy. | ||
(7) The benefits required by paragraphs (2) and (6) of | ||
this subsection (b) are to be provided to all covered | ||
pregnant or postpartum individuals with a diagnosis of a | ||
mental, emotional, nervous, or substance use disorder or | ||
condition. The presence of additional related or unrelated | ||
diagnoses shall not be a basis to reduce or deny the | ||
benefits required by this subsection (b). | ||
(Source: P.A. 102-665, eff. 10-8-21.) | ||
(215 ILCS 5/370c) (from Ch. 73, par. 982c) | ||
Sec. 370c. Mental and emotional disorders. | ||
(a)(1) On and after January 1, 2022 (the effective date of | ||
Public Act 102-579), every insurer that amends, delivers, | ||
issues, or renews group accident and health policies providing | ||
coverage for hospital or medical treatment or services for | ||
illness on an expense-incurred basis shall provide coverage | ||
for the medically necessary treatment of mental, emotional, | ||
nervous, or substance use disorders or conditions consistent |
with the parity requirements of Section 370c.1 of this Code. | ||
(2) Each insured that is covered for mental, emotional, | ||
nervous, or substance use disorders or conditions shall be | ||
free to select the physician licensed to practice medicine in | ||
all its branches, licensed clinical psychologist, licensed | ||
clinical social worker, licensed clinical professional | ||
counselor, licensed marriage and family therapist, licensed | ||
speech-language pathologist, or other licensed or certified | ||
professional at a program licensed pursuant to the Substance | ||
Use Disorder Act of his or her choice to treat such disorders, | ||
and the insurer shall pay the covered charges of such | ||
physician licensed to practice medicine in all its branches, | ||
licensed clinical psychologist, licensed clinical social | ||
worker, licensed clinical professional counselor, licensed | ||
marriage and family therapist, licensed speech-language | ||
pathologist, or other licensed or certified professional at a | ||
program licensed pursuant to the Substance Use Disorder Act up | ||
to the limits of coverage, provided (i) the disorder or | ||
condition treated is covered by the policy, and (ii) the | ||
physician, licensed psychologist, licensed clinical social | ||
worker, licensed clinical professional counselor, licensed | ||
marriage and family therapist, licensed speech-language | ||
pathologist, or other licensed or certified professional at a | ||
program licensed pursuant to the Substance Use Disorder Act is | ||
authorized to provide said services under the statutes of this | ||
State and in accordance with accepted principles of his or her |
profession. | ||
(3) Insofar as this Section applies solely to licensed | ||
clinical social workers, licensed clinical professional | ||
counselors, licensed marriage and family therapists, licensed | ||
speech-language pathologists, and other licensed or certified | ||
professionals at programs licensed pursuant to the Substance | ||
Use Disorder Act, those persons who may provide services to | ||
individuals shall do so after the licensed clinical social | ||
worker, licensed clinical professional counselor, licensed | ||
marriage and family therapist, licensed speech-language | ||
pathologist, or other licensed or certified professional at a | ||
program licensed pursuant to the Substance Use Disorder Act | ||
has informed the patient of the desirability of the patient | ||
conferring with the patient's primary care physician. | ||
(4) "Mental, emotional, nervous, or substance use disorder | ||
or condition" means a condition or disorder that involves a | ||
mental health condition or substance use disorder that falls | ||
under any of the diagnostic categories listed in the mental | ||
and behavioral disorders chapter of the current edition of the | ||
World Health Organization's International Classification of | ||
Disease or that is listed in the most recent version of the | ||
American Psychiatric Association's Diagnostic and Statistical | ||
Manual of Mental Disorders. "Mental, emotional, nervous, or | ||
substance use disorder or condition" includes any mental | ||
health condition that occurs during pregnancy or during the | ||
postpartum period and includes, but is not limited to, |
postpartum depression. | ||
(5) Medically necessary treatment and medical necessity | ||
determinations shall be interpreted and made in a manner that | ||
is consistent with and pursuant to subsections (h) through | ||
(t). | ||
(b)(1) (Blank). | ||
(2) (Blank). | ||
(2.5) (Blank). | ||
(3) Unless otherwise prohibited by federal law and | ||
consistent with the parity requirements of Section 370c.1 of | ||
this Code, the reimbursing insurer that amends, delivers, | ||
issues, or renews a group or individual policy of accident and | ||
health insurance, a qualified health plan offered through the | ||
health insurance marketplace, or a provider of treatment of | ||
mental, emotional, nervous, or substance use disorders or | ||
conditions shall furnish medical records or other necessary | ||
data that substantiate that initial or continued treatment is | ||
at all times medically necessary. An insurer shall provide a | ||
mechanism for the timely review by a provider holding the same | ||
license and practicing in the same specialty as the patient's | ||
provider, who is unaffiliated with the insurer, jointly | ||
selected by the patient (or the patient's next of kin or legal | ||
representative if the patient is unable to act for himself or | ||
herself), the patient's provider, and the insurer in the event | ||
of a dispute between the insurer and patient's provider | ||
regarding the medical necessity of a treatment proposed by a |
patient's provider. If the reviewing provider determines the | ||
treatment to be medically necessary, the insurer shall provide | ||
reimbursement for the treatment. Future contractual or | ||
employment actions by the insurer regarding the patient's | ||
provider may not be based on the provider's participation in | ||
this procedure. Nothing prevents the insured from agreeing in | ||
writing to continue treatment at his or her expense. When | ||
making a determination of the medical necessity for a | ||
treatment modality for mental, emotional, nervous, or | ||
substance use disorders or conditions, an insurer must make | ||
the determination in a manner that is consistent with the | ||
manner used to make that determination with respect to other | ||
diseases or illnesses covered under the policy, including an | ||
appeals process. Medical necessity determinations for | ||
substance use disorders shall be made in accordance with | ||
appropriate patient placement criteria established by the | ||
American Society of Addiction Medicine. No additional criteria | ||
may be used to make medical necessity determinations for | ||
substance use disorders. | ||
(4) A group health benefit plan amended, delivered, | ||
issued, or renewed on or after January 1, 2019 (the effective | ||
date of Public Act 100-1024) or an individual policy of | ||
accident and health insurance or a qualified health plan | ||
offered through the health insurance marketplace amended, | ||
delivered, issued, or renewed on or after January 1, 2019 (the | ||
effective date of Public Act 100-1024): |
(A) shall provide coverage based upon medical | ||
necessity for the treatment of a mental, emotional, | ||
nervous, or substance use disorder or condition consistent | ||
with the parity requirements of Section 370c.1 of this | ||
Code; provided, however, that in each calendar year | ||
coverage shall not be less than the following: | ||
(i) 45 days of inpatient treatment; and | ||
(ii) beginning on June 26, 2006 (the effective | ||
date of Public Act 94-921), 60 visits for outpatient | ||
treatment including group and individual outpatient | ||
treatment; and | ||
(iii) for plans or policies delivered, issued for | ||
delivery, renewed, or modified after January 1, 2007 | ||
(the effective date of Public Act 94-906), 20 | ||
additional outpatient visits for speech therapy for | ||
treatment of pervasive developmental disorders that | ||
will be in addition to speech therapy provided | ||
pursuant to item (ii) of this subparagraph (A); and | ||
(B) may not include a lifetime limit on the number of | ||
days of inpatient treatment or the number of outpatient | ||
visits covered under the plan. | ||
(C) (Blank). | ||
(5) An issuer of a group health benefit plan or an | ||
individual policy of accident and health insurance or a | ||
qualified health plan offered through the health insurance | ||
marketplace may not count toward the number of outpatient |
visits required to be covered under this Section an outpatient | ||
visit for the purpose of medication management and shall cover | ||
the outpatient visits under the same terms and conditions as | ||
it covers outpatient visits for the treatment of physical | ||
illness. | ||
(5.5) An individual or group health benefit plan amended, | ||
delivered, issued, or renewed on or after September 9, 2015 | ||
(the effective date of Public Act 99-480) shall offer coverage | ||
for medically necessary acute treatment services and medically | ||
necessary clinical stabilization services. The treating | ||
provider shall base all treatment recommendations and the | ||
health benefit plan shall base all medical necessity | ||
determinations for substance use disorders in accordance with | ||
the most current edition of the Treatment Criteria for | ||
Addictive, Substance-Related, and Co-Occurring Conditions | ||
established by the American Society of Addiction Medicine. The | ||
treating provider shall base all treatment recommendations and | ||
the health benefit plan shall base all medical necessity | ||
determinations for medication-assisted treatment in accordance | ||
with the most current Treatment Criteria for Addictive, | ||
Substance-Related, and Co-Occurring Conditions established by | ||
the American Society of Addiction Medicine. | ||
As used in this subsection: | ||
"Acute treatment services" means 24-hour medically | ||
supervised addiction treatment that provides evaluation and | ||
withdrawal management and may include biopsychosocial |
assessment, individual and group counseling, psychoeducational | ||
groups, and discharge planning. | ||
"Clinical stabilization services" means 24-hour treatment, | ||
usually following acute treatment services for substance | ||
abuse, which may include intensive education and counseling | ||
regarding the nature of addiction and its consequences, | ||
relapse prevention, outreach to families and significant | ||
others, and aftercare planning for individuals beginning to | ||
engage in recovery from addiction. | ||
(6) An issuer of a group health benefit plan may provide or | ||
offer coverage required under this Section through a managed | ||
care plan. | ||
(6.5) An individual or group health benefit plan amended, | ||
delivered, issued, or renewed on or after January 1, 2019 (the | ||
effective date of Public Act 100-1024): | ||
(A) shall not impose prior authorization requirements, | ||
other than those established under the Treatment Criteria | ||
for Addictive, Substance-Related, and Co-Occurring | ||
Conditions established by the American Society of | ||
Addiction Medicine, on a prescription medication approved | ||
by the United States Food and Drug Administration that is | ||
prescribed or administered for the treatment of substance | ||
use disorders; | ||
(B) shall not impose any step therapy requirements , | ||
other than those established under the Treatment Criteria | ||
for Addictive, Substance-Related, and Co-Occurring |
Conditions established by the American Society of | ||
Addiction Medicine, before authorizing coverage for a | ||
prescription medication approved by the United States Food | ||
and Drug Administration that is prescribed or administered | ||
for the treatment of substance use disorders ; | ||
(C) shall place all prescription medications approved | ||
by the United States Food and Drug Administration | ||
prescribed or administered for the treatment of substance | ||
use disorders on, for brand medications, the lowest tier | ||
of the drug formulary developed and maintained by the | ||
individual or group health benefit plan that covers brand | ||
medications and, for generic medications, the lowest tier | ||
of the drug formulary developed and maintained by the | ||
individual or group health benefit plan that covers | ||
generic medications; and | ||
(D) shall not exclude coverage for a prescription | ||
medication approved by the United States Food and Drug | ||
Administration for the treatment of substance use | ||
disorders and any associated counseling or wraparound | ||
services on the grounds that such medications and services | ||
were court ordered. | ||
(7) (Blank). | ||
(8) (Blank). | ||
(9) With respect to all mental, emotional, nervous, or | ||
substance use disorders or conditions, coverage for inpatient | ||
treatment shall include coverage for treatment in a |
residential treatment center certified or licensed by the | ||
Department of Public Health or the Department of Human | ||
Services. | ||
(c) This Section shall not be interpreted to require | ||
coverage for speech therapy or other habilitative services for | ||
those individuals covered under Section 356z.15 of this Code. | ||
(d) With respect to a group or individual policy of | ||
accident and health insurance or a qualified health plan | ||
offered through the health insurance marketplace, the | ||
Department and, with respect to medical assistance, the | ||
Department of Healthcare and Family Services shall each | ||
enforce the requirements of this Section and Sections 356z.23 | ||
and 370c.1 of this Code, the Paul Wellstone and Pete Domenici | ||
Mental Health Parity and Addiction Equity Act of 2008, 42 | ||
U.S.C. 18031(j), and any amendments to, and federal guidance | ||
or regulations issued under, those Acts, including, but not | ||
limited to, final regulations issued under the Paul Wellstone | ||
and Pete Domenici Mental Health Parity and Addiction Equity | ||
Act of 2008 and final regulations applying the Paul Wellstone | ||
and Pete Domenici Mental Health Parity and Addiction Equity | ||
Act of 2008 to Medicaid managed care organizations, the | ||
Children's Health Insurance Program, and alternative benefit | ||
plans. Specifically, the Department and the Department of | ||
Healthcare and Family Services shall take action: | ||
(1) proactively ensuring compliance by individual and | ||
group policies, including by requiring that insurers |
submit comparative analyses, as set forth in paragraph (6) | ||
of subsection (k) of Section 370c.1, demonstrating how | ||
they design and apply nonquantitative treatment | ||
limitations, both as written and in operation, for mental, | ||
emotional, nervous, or substance use disorder or condition | ||
benefits as compared to how they design and apply | ||
nonquantitative treatment limitations, as written and in | ||
operation, for medical and surgical benefits; | ||
(2) evaluating all consumer or provider complaints | ||
regarding mental, emotional, nervous, or substance use | ||
disorder or condition coverage for possible parity | ||
violations; | ||
(3) performing parity compliance market conduct | ||
examinations or, in the case of the Department of | ||
Healthcare and Family Services, parity compliance audits | ||
of individual and group plans and policies, including, but | ||
not limited to, reviews of: | ||
(A) nonquantitative treatment limitations, | ||
including, but not limited to, prior authorization | ||
requirements, concurrent review, retrospective review, | ||
step therapy, network admission standards, | ||
reimbursement rates, and geographic restrictions; | ||
(B) denials of authorization, payment, and | ||
coverage; and | ||
(C) other specific criteria as may be determined | ||
by the Department. |
The findings and the conclusions of the parity compliance | ||
market conduct examinations and audits shall be made public. | ||
The Director may adopt rules to effectuate any provisions | ||
of the Paul Wellstone and Pete Domenici Mental Health Parity | ||
and Addiction Equity Act of 2008 that relate to the business of | ||
insurance. | ||
(e) Availability of plan information. | ||
(1) The criteria for medical necessity determinations | ||
made under a group health plan, an individual policy of | ||
accident and health insurance, or a qualified health plan | ||
offered through the health insurance marketplace with | ||
respect to mental health or substance use disorder | ||
benefits (or health insurance coverage offered in | ||
connection with the plan with respect to such benefits) | ||
must be made available by the plan administrator (or the | ||
health insurance issuer offering such coverage) to any | ||
current or potential participant, beneficiary, or | ||
contracting provider upon request. | ||
(2) The reason for any denial under a group health | ||
benefit plan, an individual policy of accident and health | ||
insurance, or a qualified health plan offered through the | ||
health insurance marketplace (or health insurance coverage | ||
offered in connection with such plan or policy) of | ||
reimbursement or payment for services with respect to | ||
mental, emotional, nervous, or substance use disorders or | ||
conditions benefits in the case of any participant or |
beneficiary must be made available within a reasonable | ||
time and in a reasonable manner and in readily | ||
understandable language by the plan administrator (or the | ||
health insurance issuer offering such coverage) to the | ||
participant or beneficiary upon request. | ||
(f) As used in this Section, "group policy of accident and | ||
health insurance" and "group health benefit plan" includes (1) | ||
State-regulated employer-sponsored group health insurance | ||
plans written in Illinois or which purport to provide coverage | ||
for a resident of this State; and (2) State employee health | ||
plans. | ||
(g) (1) As used in this subsection: | ||
"Benefits", with respect to insurers, means the benefits | ||
provided for treatment services for inpatient and outpatient | ||
treatment of substance use disorders or conditions at American | ||
Society of Addiction Medicine levels of treatment 2.1 | ||
(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 | ||
(Clinically Managed Low-Intensity Residential), 3.3 | ||
(Clinically Managed Population-Specific High-Intensity | ||
Residential), 3.5 (Clinically Managed High-Intensity | ||
Residential), and 3.7 (Medically Monitored Intensive | ||
Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||
"Benefits", with respect to managed care organizations, | ||
means the benefits provided for treatment services for | ||
inpatient and outpatient treatment of substance use disorders | ||
or conditions at American Society of Addiction Medicine levels |
of treatment 2.1 (Intensive Outpatient), 2.5 (Partial | ||
Hospitalization), 3.5 (Clinically Managed High-Intensity | ||
Residential), and 3.7 (Medically Monitored Intensive | ||
Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||
"Substance use disorder treatment provider or facility" | ||
means a licensed physician, licensed psychologist, licensed | ||
psychiatrist, licensed advanced practice registered nurse, or | ||
licensed, certified, or otherwise State-approved facility or | ||
provider of substance use disorder treatment. | ||
(2) A group health insurance policy, an individual health | ||
benefit plan, or qualified health plan that is offered through | ||
the health insurance marketplace, small employer group health | ||
plan, and large employer group health plan that is amended, | ||
delivered, issued, executed, or renewed in this State, or | ||
approved for issuance or renewal in this State, on or after | ||
January 1, 2019 (the effective date of Public Act 100-1023) | ||
shall comply with the requirements of this Section and Section | ||
370c.1. The services for the treatment and the ongoing | ||
assessment of the patient's progress in treatment shall follow | ||
the requirements of 77 Ill. Adm. Code 2060. | ||
(3) Prior authorization shall not be utilized for the | ||
benefits under this subsection. The substance use disorder | ||
treatment provider or facility shall notify the insurer of the | ||
initiation of treatment. For an insurer that is not a managed | ||
care organization, the substance use disorder treatment | ||
provider or facility notification shall occur for the |
initiation of treatment of the covered person within 2 | ||
business days. For managed care organizations, the substance | ||
use disorder treatment provider or facility notification shall | ||
occur in accordance with the protocol set forth in the | ||
provider agreement for initiation of treatment within 24 | ||
hours. If the managed care organization is not capable of | ||
accepting the notification in accordance with the contractual | ||
protocol during the 24-hour period following admission, the | ||
substance use disorder treatment provider or facility shall | ||
have one additional business day to provide the notification | ||
to the appropriate managed care organization. Treatment plans | ||
shall be developed in accordance with the requirements and | ||
timeframes established in 77 Ill. Adm. Code 2060. If the | ||
substance use disorder treatment provider or facility fails to | ||
notify the insurer of the initiation of treatment in | ||
accordance with these provisions, the insurer may follow its | ||
normal prior authorization processes. | ||
(4) For an insurer that is not a managed care | ||
organization, if an insurer determines that benefits are no | ||
longer medically necessary, the insurer shall notify the | ||
covered person, the covered person's authorized | ||
representative, if any, and the covered person's health care | ||
provider in writing of the covered person's right to request | ||
an external review pursuant to the Health Carrier External | ||
Review Act. The notification shall occur within 24 hours | ||
following the adverse determination. |
Pursuant to the requirements of the Health Carrier | ||
External Review Act, the covered person or the covered | ||
person's authorized representative may request an expedited | ||
external review. An expedited external review may not occur if | ||
the substance use disorder treatment provider or facility | ||
determines that continued treatment is no longer medically | ||
necessary. | ||
If an expedited external review request meets the criteria | ||
of the Health Carrier External Review Act, an independent | ||
review organization shall make a final determination of | ||
medical necessity within 72 hours. If an independent review | ||
organization upholds an adverse determination, an insurer | ||
shall remain responsible to provide coverage of benefits | ||
through the day following the determination of the independent | ||
review organization. A decision to reverse an adverse | ||
determination shall comply with the Health Carrier External | ||
Review Act. | ||
(5) The substance use disorder treatment provider or | ||
facility shall provide the insurer with 7 business days' | ||
advance notice of the planned discharge of the patient from | ||
the substance use disorder treatment provider or facility and | ||
notice on the day that the patient is discharged from the | ||
substance use disorder treatment provider or facility. | ||
(6) The benefits required by this subsection shall be | ||
provided to all covered persons with a diagnosis of substance | ||
use disorder or conditions. The presence of additional related |
or unrelated diagnoses shall not be a basis to reduce or deny | ||
the benefits required by this subsection. | ||
(7) Nothing in this subsection shall be construed to | ||
require an insurer to provide coverage for any of the benefits | ||
in this subsection. | ||
(h) As used in this Section: | ||
"Generally accepted standards of mental, emotional, | ||
nervous, or substance use disorder or condition care" means | ||
standards of care and clinical practice that are generally | ||
recognized by health care providers practicing in relevant | ||
clinical specialties such as psychiatry, psychology, clinical | ||
sociology, social work, addiction medicine and counseling, and | ||
behavioral health treatment. Valid, evidence-based sources | ||
reflecting generally accepted standards of mental, emotional, | ||
nervous, or substance use disorder or condition care include | ||
peer-reviewed scientific studies and medical literature, | ||
recommendations of nonprofit health care provider professional | ||
associations and specialty societies, including, but not | ||
limited to, patient placement criteria and clinical practice | ||
guidelines, recommendations of federal government agencies, | ||
and drug labeling approved by the United States Food and Drug | ||
Administration. | ||
"Medically necessary treatment of mental, emotional, | ||
nervous, or substance use disorders or conditions" means a | ||
service or product addressing the specific needs of that | ||
patient, for the purpose of screening, preventing, diagnosing, |
managing, or treating an illness, injury, or condition or its | ||
symptoms and comorbidities, including minimizing the | ||
progression of an illness, injury, or condition or its | ||
symptoms and comorbidities in a manner that is all of the | ||
following: | ||
(1) in accordance with the generally accepted | ||
standards of mental, emotional, nervous, or substance use | ||
disorder or condition care; | ||
(2) clinically appropriate in terms of type, | ||
frequency, extent, site, and duration; and | ||
(3) not primarily for the economic benefit of the | ||
insurer, purchaser, or for the convenience of the patient, | ||
treating physician, or other health care provider. | ||
"Utilization review" means either of the following: | ||
(1) prospectively, retrospectively, or concurrently | ||
reviewing and approving, modifying, delaying, or denying, | ||
based in whole or in part on medical necessity, requests | ||
by health care providers, insureds, or their authorized | ||
representatives for coverage of health care services | ||
before, retrospectively, or concurrently with the | ||
provision of health care services to insureds. | ||
(2) evaluating the medical necessity, appropriateness, | ||
level of care, service intensity, efficacy, or efficiency | ||
of health care services, benefits, procedures, or | ||
settings, under any circumstances, to determine whether a | ||
health care service or benefit subject to a medical |
necessity coverage requirement in an insurance policy is | ||
covered as medically necessary for an insured. | ||
"Utilization review criteria" means patient placement | ||
criteria or any criteria, standards, protocols, or guidelines | ||
used by an insurer to conduct utilization review. | ||
(i)(1) Every insurer that amends, delivers, issues, or | ||
renews a group or individual policy of accident and health | ||
insurance or a qualified health plan offered through the | ||
health insurance marketplace in this State and Medicaid | ||
managed care organizations providing coverage for hospital or | ||
medical treatment on or after January 1, 2023 shall, pursuant | ||
to subsections (h) through (s), provide coverage for medically | ||
necessary treatment of mental, emotional, nervous, or | ||
substance use disorders or conditions. | ||
(2) An insurer shall not set a specific limit on the | ||
duration of benefits or coverage of medically necessary | ||
treatment of mental, emotional, nervous, or substance use | ||
disorders or conditions or limit coverage only to alleviation | ||
of the insured's current symptoms. | ||
(3) All utilization review conducted medical necessity | ||
determinations made by the insurer concerning diagnosis, | ||
prevention, and treatment service intensity, level of care | ||
placement, continued stay, and transfer or discharge of | ||
insureds diagnosed with mental, emotional, nervous, or | ||
substance use disorders or conditions shall be conducted in | ||
accordance with the requirements of subsections (k) through |
(w) (u) . | ||
(4) An insurer that authorizes a specific type of | ||
treatment by a provider pursuant to this Section shall not | ||
rescind or modify the authorization after that provider | ||
renders the health care service in good faith and pursuant to | ||
this authorization for any reason, including, but not limited | ||
to, the insurer's subsequent cancellation or modification of | ||
the insured's or policyholder's contract, or the insured's or | ||
policyholder's eligibility. Nothing in this Section shall | ||
require the insurer to cover a treatment when the | ||
authorization was granted based on a material | ||
misrepresentation by the insured, the policyholder, or the | ||
provider. Nothing in this Section shall require Medicaid | ||
managed care organizations to pay for services if the | ||
individual was not eligible for Medicaid at the time the | ||
service was rendered. Nothing in this Section shall require an | ||
insurer to pay for services if the individual was not the | ||
insurer's enrollee at the time services were rendered. As used | ||
in this paragraph, "material" means a fact or situation that | ||
is not merely technical in nature and results in or could | ||
result in a substantial change in the situation. | ||
(j) An insurer shall not limit benefits or coverage for | ||
medically necessary services on the basis that those services | ||
should be or could be covered by a public entitlement program, | ||
including, but not limited to, special education or an | ||
individualized education program, Medicaid, Medicare, |
Supplemental Security Income, or Social Security Disability | ||
Insurance, and shall not include or enforce a contract term | ||
that excludes otherwise covered benefits on the basis that | ||
those services should be or could be covered by a public | ||
entitlement program. Nothing in this subsection shall be | ||
construed to require an insurer to cover benefits that have | ||
been authorized and provided for a covered person by a public | ||
entitlement program. Medicaid managed care organizations are | ||
not subject to this subsection. | ||
(k) An insurer shall base any medical necessity | ||
determination or the utilization review criteria that the | ||
insurer, and any entity acting on the insurer's behalf, | ||
applies to determine the medical necessity of health care | ||
services and benefits for the diagnosis, prevention, and | ||
treatment of mental, emotional, nervous, or substance use | ||
disorders or conditions on current generally accepted | ||
standards of mental, emotional, nervous, or substance use | ||
disorder or condition care. All denials and appeals shall be | ||
reviewed by a professional with experience or expertise | ||
comparable to the provider requesting the authorization. | ||
(l) In conducting utilization review of all covered health | ||
care services for the diagnosis, prevention, and treatment of | ||
For medical necessity determinations relating to level of care | ||
placement, continued stay, and transfer or discharge of | ||
insureds diagnosed with mental, emotional, and nervous | ||
disorders or conditions, an insurer shall apply the patient |
placement criteria and guidelines set forth in the most recent | ||
version of the treatment criteria developed by an unaffiliated | ||
nonprofit professional association for the relevant clinical | ||
specialty or, for Medicaid managed care organizations, patient | ||
placement criteria and guidelines determined by the Department | ||
of Healthcare and Family Services that are consistent with | ||
generally accepted standards of mental, emotional, nervous or | ||
substance use disorder or condition care. Pursuant to | ||
subsection (b), in conducting utilization review of all | ||
covered services and benefits for the diagnosis, prevention, | ||
and treatment of substance use disorders an insurer shall use | ||
the most recent edition of the patient placement criteria | ||
established by the American Society of Addiction Medicine. | ||
(m) In conducting utilization review For medical necessity | ||
determinations relating to level of care placement, continued | ||
stay, and transfer , or discharge , or any other patient care | ||
decisions that are within the scope of the sources specified | ||
in subsection (l), an insurer shall not apply different, | ||
additional, conflicting, or more restrictive utilization | ||
review criteria than the criteria set forth in those sources. | ||
For all level of care placement decisions, the insurer shall | ||
authorize placement at the level of care consistent with the | ||
assessment of the insured using the relevant patient placement | ||
criteria as specified in subsection (l). If that level of | ||
placement is not available, the insurer shall authorize the | ||
next higher level of care. In the event of disagreement, the |
insurer shall provide full detail of its assessment using the | ||
relevant criteria as specified in subsection (l) to the | ||
provider of the service and the patient. | ||
Nothing in this subsection or subsection (l) prohibits an | ||
insurer from applying utilization review criteria that were | ||
developed in accordance with subsection (k) to health care | ||
services and benefits for mental, emotional, and nervous | ||
disorders or conditions that are not related to medical | ||
necessity determinations for level of care placement, | ||
continued stay, and transfer or discharge. If an insurer | ||
purchases or licenses utilization review criteria pursuant to | ||
this subsection, the insurer shall verify and document before | ||
use that the criteria were developed in accordance with | ||
subsection (k). | ||
(n) In conducting utilization review that is outside the | ||
scope of the criteria as specified in subsection (l) or | ||
relates to the advancements in technology or in the types or | ||
levels of care that are not addressed in the most recent | ||
versions of the sources specified in subsection (l), an | ||
insurer shall conduct utilization review in accordance with | ||
subsection (k). | ||
(o) This Section does not in any way limit the rights of a | ||
patient under the Medical Patient Rights Act. | ||
(p) This Section does not in any way limit early and | ||
periodic screening, diagnostic, and treatment benefits as | ||
defined under 42 U.S.C. 1396d(r). |
(q) To ensure the proper use of the criteria described in | ||
subsection (l), every insurer shall do all of the following: | ||
(1) Educate the insurer's staff, including any third | ||
parties contracted with the insurer to review claims, | ||
conduct utilization reviews, or make medical necessity | ||
determinations about the utilization review criteria. | ||
(2) Make the educational program available to other | ||
stakeholders, including the insurer's participating or | ||
contracted providers and potential participants, | ||
beneficiaries, or covered lives. The education program | ||
must be provided at least once a year, in-person or | ||
digitally, or recordings of the education program must be | ||
made available to the aforementioned stakeholders. | ||
(3) Provide, at no cost, the utilization review | ||
criteria and any training material or resources to | ||
providers and insured patients upon request. For | ||
utilization review criteria not concerning level of care | ||
placement, continued stay, and transfer , or discharge , or | ||
other patient care decisions used by the insurer pursuant | ||
to subsection (m), the insurer may place the criteria on a | ||
secure, password-protected website so long as the access | ||
requirements of the website do not unreasonably restrict | ||
access to insureds or their providers. No restrictions | ||
shall be placed upon the insured's or treating provider's | ||
access right to utilization review criteria obtained under | ||
this paragraph at any point in time, including before an |
initial request for authorization. | ||
(4) Track, identify, and analyze how the utilization | ||
review criteria are used to certify care, deny care, and | ||
support the appeals process. | ||
(5) Conduct interrater reliability testing to ensure | ||
consistency in utilization review decision making that | ||
covers how medical necessity decisions are made; this | ||
assessment shall cover all aspects of utilization review | ||
as defined in subsection (h). | ||
(6) Run interrater reliability reports about how the | ||
clinical guidelines are used in conjunction with the | ||
utilization review process and parity compliance | ||
activities. | ||
(7) Achieve interrater reliability pass rates of at | ||
least 90% and, if this threshold is not met, immediately | ||
provide for the remediation of poor interrater reliability | ||
and interrater reliability testing for all new staff | ||
before they can conduct utilization review without | ||
supervision. | ||
(8) Maintain documentation of interrater reliability | ||
testing and the remediation actions taken for those with | ||
pass rates lower than 90% 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 and a summary of remedial | ||
actions as part of parity compliance reporting set forth |
in subsection (k) of Section 370c.1. | ||
(r) This Section applies to all health care services and | ||
benefits for the diagnosis, prevention, and treatment of | ||
mental, emotional, nervous, or substance use disorders or | ||
conditions covered by an insurance policy, including | ||
prescription drugs. | ||
(s) This Section applies to an insurer that amends, | ||
delivers, issues, or renews a group or individual policy of | ||
accident and health insurance or a qualified health plan | ||
offered through the health insurance marketplace in this State | ||
providing coverage for hospital or medical treatment and | ||
conducts utilization review as defined in this Section, | ||
including Medicaid managed care organizations, and any entity | ||
or contracting provider that performs utilization review or | ||
utilization management functions on an insurer's behalf. | ||
(t) If the Director determines that an insurer has | ||
violated this Section, the Director may, after appropriate | ||
notice and opportunity for hearing, by order, assess a civil | ||
penalty between $1,000 and $5,000 for each violation. Moneys | ||
collected from penalties shall be deposited into the Parity | ||
Advancement Fund established in subsection (i) of Section | ||
370c.1. | ||
(u) An insurer shall not adopt, impose, or enforce terms | ||
in its policies or provider agreements, in writing or in | ||
operation, that undermine, alter, or conflict with the | ||
requirements of this Section. |
(v) The provisions of this Section are severable. If any | ||
provision of this Section or its application is held invalid, | ||
that invalidity shall not affect other provisions or | ||
applications that can be given effect without the invalid | ||
provision or application. | ||
(w) Beginning January 1, 2026, coverage for inpatient | ||
mental health treatment at participating hospitals shall | ||
comply with the following requirements: | ||
(1) Subject to paragraphs (2) and (3) of this | ||
subsection, no policy shall require prior authorization | ||
for admission for such treatment at any participating | ||
hospital. | ||
(2) Coverage provided under this subsection also shall | ||
not be subject to concurrent review for the first 72 | ||
hours, provided that the hospital must notify the insurer | ||
of both the admission and the initial treatment plan | ||
within 48 hours of admission. A discharge plan must be | ||
fully developed and continuity services prepared to meet | ||
the patient's needs and the patient's community preference | ||
upon release. Nothing in this paragraph supersedes a | ||
health maintenance organization's referral requirement for | ||
services from nonparticipating providers upon a patient's | ||
discharge from a hospital. | ||
(3) Treatment provided under this subsection may be | ||
reviewed retrospectively. If coverage is denied | ||
retrospectively, neither the insurer nor the participating |
hospital shall bill, and the insured shall not be liable, | ||
for any treatment under this subsection through the date | ||
the adverse determination is issued, other than any | ||
copayment, coinsurance, or deductible for the stay through | ||
that date as applicable under the policy. Coverage shall | ||
not be retrospectively denied for the first 72 hours of | ||
treatment at a participating hospital except: | ||
(A) upon reasonable determination that the | ||
inpatient mental health treatment was not provided; | ||
(B) upon determination that the patient receiving | ||
the treatment was not an insured, enrollee, or | ||
beneficiary under the policy; | ||
(C) upon material misrepresentation by the patient | ||
or health care provider. In this item (C), "material" | ||
means a fact or situation that is not merely technical | ||
in nature and results or could result in a substantial | ||
change in the situation; or | ||
(D) upon determination that a service was excluded | ||
under the terms of coverage. In that case, the | ||
limitation to billing for a copayment, coinsurance, or | ||
deductible shall not apply. | ||
(4) Nothing in this subsection shall be construed to | ||
require a policy to cover any health care service excluded | ||
under the terms of coverage. | ||
(x) Notwithstanding any provision of this Section, nothing | ||
shall require the medical assistance program under Article V |
of the Illinois Public Aid Code to violate any applicable | ||
federal laws, regulations, or grant requirements or any State | ||
or federal consent decrees. Nothing in subsection (w) shall | ||
prevent the Department of Healthcare and Family Services from | ||
requiring a health care provider to use specified level of | ||
care, admission, continued stay, or discharge criteria, | ||
including, but not limited to, those under Section 5-5.23 of | ||
the Illinois Public Aid Code, as long as the Department of | ||
Healthcare and Family Services does not require a health care | ||
provider to seek prior authorization or concurrent review from | ||
the Department of Healthcare and Family Services, a Medicaid | ||
managed care organization, or a utilization review | ||
organization under the circumstances expressly prohibited by | ||
subsection (w). Nothing in this Section prohibits a health | ||
plan, including a Medicaid managed care organization, from | ||
conducting reviews for fraud, waste, or abuse and reporting | ||
suspected fraud, waste, or abuse according to State and | ||
federal requirements. | ||
(y) Children's Mental Health. Nothing in this Section | ||
shall suspend the screening and assessment requirements for | ||
mental health services for children participating in the | ||
State's medical assistance program as required in Section | ||
5-5.23 of the Illinois Public Aid Code. | ||
(Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22; | ||
102-813, eff. 5-13-22; 103-426, eff. 8-4-23.) |
Section 6-10. The Managed Care Reform and Patient Rights | ||
Act is amended by changing Sections 10, 45.1, and 85 and by | ||
adding Section 87 as follows: | ||
(215 ILCS 134/10) | ||
Sec. 10. Definitions. In this Act: | ||
"Adverse determination" means a determination by a health | ||
care plan under Section 45 or by a utilization review program | ||
under Section 85 that a health care service is not medically | ||
necessary. | ||
"Clinical peer" means a health care professional who is in | ||
the same profession and the same or similar specialty as the | ||
health care provider who typically manages the medical | ||
condition, procedures, or treatment under review. | ||
"Department" means the Department of Insurance. | ||
"Emergency medical condition" means a medical condition | ||
manifesting itself by acute symptoms of sufficient severity, | ||
regardless of the final diagnosis given, such that a prudent | ||
layperson, who possesses an average knowledge of health and | ||
medicine, could reasonably expect the absence of immediate | ||
medical attention to result in: | ||
(1) placing the health of the individual (or, with | ||
respect to a pregnant woman, the health of the woman or her | ||
unborn child) in serious jeopardy; | ||
(2) serious impairment to bodily functions; | ||
(3) serious dysfunction of any bodily organ or part; |
(4) inadequately controlled pain; or | ||
(5) with respect to a pregnant woman who is having | ||
contractions: | ||
(A) inadequate time to complete a safe transfer to | ||
another hospital before delivery; or | ||
(B) a transfer to another hospital may pose a | ||
threat to the health or safety of the woman or unborn | ||
child. | ||
"Emergency medical screening examination" means a medical | ||
screening examination and evaluation by a physician licensed | ||
to practice medicine in all its branches, or to the extent | ||
permitted by applicable laws, by other appropriately licensed | ||
personnel under the supervision of or in collaboration with a | ||
physician licensed to practice medicine in all its branches to | ||
determine whether the need for emergency services exists. | ||
"Emergency services" means, with respect to an enrollee of | ||
a health care plan, transportation services, including but not | ||
limited to ambulance services, and covered inpatient and | ||
outpatient hospital services furnished by a provider qualified | ||
to furnish those services that are needed to evaluate or | ||
stabilize an emergency medical condition. "Emergency services" | ||
does not refer to post-stabilization medical services. | ||
"Enrollee" means any person and his or her dependents | ||
enrolled in or covered by a health care plan. | ||
"Generally accepted standards of care" means standards of | ||
care and clinical practice that are generally recognized by |
health care providers practicing in relevant clinical | ||
specialties for the illness, injury, or condition or its | ||
symptoms and comorbidities. Valid, evidence-based sources | ||
reflecting generally accepted standards of care include | ||
peer-reviewed scientific studies and medical literature, | ||
recommendations of nonprofit health care provider professional | ||
associations and specialty societies, including, but not | ||
limited to, patient placement criteria and clinical practice | ||
guidelines, recommendations of federal government agencies, | ||
and drug labeling approved by the United States Food and Drug | ||
Administration. | ||
"Health care plan" means a plan, including, but not | ||
limited to, a health maintenance organization, a managed care | ||
community network as defined in the Illinois Public Aid Code, | ||
or an accountable care entity as defined in the Illinois | ||
Public Aid Code that receives capitated payments to cover | ||
medical services from the Department of Healthcare and Family | ||
Services, that establishes, operates, or maintains a network | ||
of health care providers that has entered into an agreement | ||
with the plan to provide health care services to enrollees to | ||
whom the plan has the ultimate obligation to arrange for the | ||
provision of or payment for services through organizational | ||
arrangements for ongoing quality assurance, utilization review | ||
programs, or dispute resolution. Nothing in this definition | ||
shall be construed to mean that an independent practice | ||
association or a physician hospital organization that |
subcontracts with a health care plan is, for purposes of that | ||
subcontract, a health care plan. | ||
For purposes of this definition, "health care plan" shall | ||
not include the following: | ||
(1) indemnity health insurance policies including | ||
those using a contracted provider network; | ||
(2) health care plans that offer only dental or only | ||
vision coverage; | ||
(3) preferred provider administrators, as defined in | ||
Section 370g(g) of the Illinois Insurance Code; | ||
(4) employee or employer self-insured health benefit | ||
plans under the federal Employee Retirement Income | ||
Security Act of 1974; | ||
(5) health care provided pursuant to the Workers' | ||
Compensation Act or the Workers' Occupational Diseases | ||
Act; and | ||
(6) except with respect to subsections (a) and (b) of | ||
Section 65 and subsection (a-5) of Section 70, | ||
not-for-profit voluntary health services plans with health | ||
maintenance organization authority in existence as of | ||
January 1, 1999 that are affiliated with a union and that | ||
only extend coverage to union members and their | ||
dependents. | ||
"Health care professional" means a physician, a registered | ||
professional nurse, or other individual appropriately licensed | ||
or registered to provide health care services. |
"Health care provider" means any physician, hospital | ||
facility, facility licensed under the Nursing Home Care Act, | ||
long-term care facility as defined in Section 1-113 of the | ||
Nursing Home Care Act, or other person that is licensed or | ||
otherwise authorized to deliver health care services. Nothing | ||
in this Act shall be construed to define Independent Practice | ||
Associations or Physician-Hospital Organizations as health | ||
care providers. | ||
"Health care services" means any services included in the | ||
furnishing to any individual of medical care, or the | ||
hospitalization incident to the furnishing of such care, as | ||
well as the furnishing to any person of any and all other | ||
services for the purpose of preventing, alleviating, curing, | ||
or healing human illness or injury including behavioral | ||
health, mental health, home health, and pharmaceutical | ||
services and products. | ||
"Medical director" means a physician licensed in any state | ||
to practice medicine in all its branches appointed by a health | ||
care plan. | ||
"Medically necessary" means that a service or product | ||
addresses the specific needs of a patient for the purpose of | ||
screening, preventing, diagnosing, managing, or treating an | ||
illness, injury, or condition or its symptoms and | ||
comorbidities, including minimizing the progression of an | ||
illness, injury, or condition or its symptoms and | ||
comorbidities, in a manner that is all of the following: |
(1) in accordance with generally accepted standards of | ||
care; | ||
(2) clinically appropriate in terms of type, | ||
frequency, extent, site, and duration; and | ||
(3) not primarily for the economic benefit of the | ||
health care plan, purchaser, or utilization review | ||
organization, or for the convenience of the patient, | ||
treating physician, or other health care provider. | ||
"Person" means a corporation, association, partnership, | ||
limited liability company, sole proprietorship, or any other | ||
legal entity. | ||
"Physician" means a person licensed under the Medical | ||
Practice Act of 1987. | ||
"Post-stabilization medical services" means health care | ||
services provided to an enrollee that are furnished in a | ||
licensed hospital by a provider that is qualified to furnish | ||
such services, and determined to be medically necessary and | ||
directly related to the emergency medical condition following | ||
stabilization. | ||
"Stabilization" means, with respect to an emergency | ||
medical condition, to provide such medical treatment of the | ||
condition as may be necessary to assure, within reasonable | ||
medical probability, that no material deterioration of the | ||
condition is likely to result. | ||
"Step therapy requirement" means a utilization review or | ||
formulary requirement that specifies, as a condition of |
coverage under a health care plan, the order in which certain | ||
health care services must be used to treat or manage an | ||
enrollee's health condition. | ||
"Step therapy requirement" does not include: | ||
(1) utilization review to identify when a treatment or | ||
health care service is contraindicated or clinically | ||
appropriate or to limit quantity or dosage for an enrollee | ||
based on utilization review criteria consistent with | ||
generally accepted standards of care developed in | ||
accordance with Section 87 of this Act; | ||
(2) the removal of a drug from a formulary or changing | ||
the drug's preferred or cost-sharing tier to higher cost | ||
sharing; | ||
(3) use of the medical exceptions process under | ||
Section 45.1 of this Act; any decision during a medical | ||
exceptions process based on cost is step therapy and | ||
prohibited; | ||
(4) a requirement to obtain prior authorization for | ||
the requested treatment; or | ||
(5) for health care plans operated or overseen by the | ||
Department of Healthcare and Family Services, including | ||
Medicaid managed care plans, any utilization controls | ||
mandated by 42 CFR 456.703 or a preferred drug list as | ||
described in Section 5-30.14 of the Illinois Public Aid | ||
Code. | ||
"Utilization review" means the evaluation of the medical |
necessity, appropriateness, and efficiency of the use of | ||
health care services, procedures, and facilities . | ||
"Utilization review" includes either of the following: | ||
(1) prospectively, retrospectively, or concurrently | ||
reviewing and approving, modifying, delaying, or denying, | ||
based, in whole or in part, on medical necessity, requests | ||
by health care providers, enrollees, or their authorized | ||
representatives for coverage of health care services | ||
before, retrospectively, or concurrently with the | ||
provision of health care services to enrollees; or | ||
(2) evaluating the medical necessity, appropriateness, | ||
level of care, service intensity, efficacy, or efficiency | ||
of health care services, benefits, procedures, or | ||
settings, under any circumstances, to determine whether a | ||
health care service or benefit subject to a medical | ||
necessity coverage requirement in a health care plan is | ||
covered as medically necessary for an enrollee. | ||
"Utilization review criteria" means criteria, standards, | ||
protocols, or guidelines used by a utilization review program | ||
to conduct utilization review to ensure that a patient's care | ||
is aligned with generally accepted standards of care and | ||
consistent with State law . | ||
"Utilization review program" means a program established | ||
by a person to perform utilization review. | ||
(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.) |
(215 ILCS 134/45.1) | ||
Sec. 45.1. Medical exceptions procedures required. | ||
(a) Notwithstanding any other provision of law, on or | ||
after January 1, 2018 (the effective date of Public Act | ||
99-761), every insurer licensed in this State to sell a policy | ||
of group or individual accident and health insurance or a | ||
health benefits plan shall establish and maintain a medical | ||
exceptions process that allows covered persons or their | ||
authorized representatives to request any clinically | ||
appropriate prescription drug when (1) the drug is not covered | ||
based on the health benefit plan's formulary; (2) the health | ||
benefit plan is discontinuing coverage of the drug on the | ||
plan's formulary for reasons other than safety or other than | ||
because the prescription drug has been withdrawn from the | ||
market by the drug's manufacturer; (3) (blank) the | ||
prescription drug alternatives required to be used in | ||
accordance with a step therapy requirement (A) has been | ||
ineffective in the treatment of the enrollee's disease or | ||
medical condition or, based on both sound clinical evidence | ||
and medical and scientific evidence, the known relevant | ||
physical or mental characteristics of the enrollee, and the | ||
known characteristics of the drug regimen, is likely to be | ||
ineffective or adversely affect the drug's effectiveness or | ||
patient compliance or (B) has caused or, based on sound | ||
medical evidence, is likely to cause an adverse reaction or | ||
harm to the enrollee ; or (4) the number of doses available |
under a dose restriction for the prescription drug (A) has | ||
been ineffective in the treatment of the enrollee's disease or | ||
medical condition or (B) based on both sound clinical evidence | ||
and medical and scientific evidence, the known relevant | ||
physical and mental characteristics of the enrollee, and known | ||
characteristics of the drug regimen, is likely to be | ||
ineffective or adversely affect the drug's effective or | ||
patient compliance. | ||
(b) The health carrier's established medical exceptions | ||
procedures must require, at a minimum, the following: | ||
(1) Any request for approval of coverage made verbally | ||
or in writing (regardless of whether made using a paper or | ||
electronic form or some other writing) at any time shall | ||
be reviewed by appropriate health care professionals. | ||
(2) The health carrier must, within 72 hours after | ||
receipt of a request made under subsection (a) of this | ||
Section, either approve or deny the request. In the case | ||
of a denial, the health carrier shall provide the covered | ||
person or the covered person's authorized representative | ||
and the covered person's prescribing provider with the | ||
reason for the denial, an alternative covered medication, | ||
if applicable, and information regarding the procedure for | ||
submitting an appeal to the denial. A health carrier shall | ||
not use the authorization of alternative covered | ||
medications under this Section in a manner that | ||
effectively creates a step therapy requirement. |
(3) In the case of an expedited coverage | ||
determination, the health carrier must either approve or | ||
deny the request within 24 hours after receipt of the | ||
request. In the case of a denial, the health carrier shall | ||
provide the covered person or the covered person's | ||
authorized representative and the covered person's | ||
prescribing provider with the reason for the denial, an | ||
alternative covered medication, if applicable, and | ||
information regarding the procedure for submitting an | ||
appeal to the denial. | ||
(c) An off-formulary A step therapy requirement exception | ||
request shall not be denied be approved if: | ||
(1) the formulary required prescription drug is | ||
contraindicated; | ||
(2) the patient has tried the formulary required | ||
prescription drug while under the patient's current or | ||
previous health insurance or health benefit plan and the | ||
prescribing provider submits evidence of failure or | ||
intolerance; or | ||
(3) the patient is stable on a prescription drug | ||
selected by his or her health care provider for the | ||
medical condition under consideration while on a current | ||
or previous health insurance or health benefit plan. | ||
(d) Upon the granting of an exception request, the | ||
insurer, health plan, utilization review organization, or | ||
other entity shall authorize the coverage for the drug |
prescribed by the enrollee's treating health care provider, to | ||
the extent the prescribed drug is a covered drug under the | ||
policy or contract up to the quantity covered. | ||
(e) Any approval of a medical exception request made | ||
pursuant to this Section shall be honored for 12 months | ||
following the date of the approval or until renewal of the | ||
plan. | ||
(f) Notwithstanding any other provision of this Section, | ||
nothing in this Section shall be interpreted or implemented in | ||
a manner not consistent with the federal Patient Protection | ||
and Affordable Care Act (Public Law 111-148), as amended by | ||
the federal Health Care and Education Reconciliation Act of | ||
2010 (Public Law 111-152), and any amendments thereto, or | ||
regulations or guidance issued under those Acts. | ||
(g) Nothing in this Section shall require or authorize the | ||
State agency responsible for the administration of the medical | ||
assistance program established under the Illinois Public Aid | ||
Code to approve, supply, or cover prescription drugs pursuant | ||
to the procedure established in this Section. | ||
(Source: P.A. 103-154, eff. 6-30-23.) | ||
(215 ILCS 134/85) | ||
Sec. 85. Utilization review program registration. | ||
(a) No person may conduct a utilization review program in | ||
this State unless once every 2 years the person registers the | ||
utilization review program with the Department and certifies |
compliance with the Health Utilization Management Standards of | ||
the American Accreditation Healthcare Commission (URAC) | ||
sufficient to achieve American Accreditation Healthcare | ||
Commission (URAC) accreditation or submits evidence of | ||
accreditation by the American Accreditation Healthcare | ||
Commission (URAC) for its Health Utilization Management | ||
Standards. Nothing in this Act shall be construed to require a | ||
health care plan or its subcontractors to become American | ||
Accreditation Healthcare Commission (URAC) accredited. | ||
(b) In addition, the Director of the Department, in | ||
consultation with the Director of the Department of Public | ||
Health, may certify alternative utilization review standards | ||
of national accreditation organizations or entities in order | ||
for plans to comply with this Section. Any alternative | ||
utilization review standards shall meet or exceed those | ||
standards required under subsection (a). | ||
(b-5) The Department shall recognize the Accreditation | ||
Association for Ambulatory Health Care among the list of | ||
accreditors from which utilization organizations may receive | ||
accreditation and qualify for reduced registration and renewal | ||
fees. | ||
(c) The provisions of this Section do not apply to: | ||
(1) persons providing utilization review program | ||
services only to the federal government; | ||
(2) self-insured health plans under the federal | ||
Employee Retirement Income Security Act of 1974, however, |
this Section does apply to persons conducting a | ||
utilization review program on behalf of these health | ||
plans; | ||
(3) hospitals and medical groups performing | ||
utilization review activities for internal purposes unless | ||
the utilization review program is conducted for another | ||
person. | ||
Nothing in this Act prohibits a health care plan or other | ||
entity from contractually requiring an entity designated in | ||
item (3) of this subsection to adhere to the utilization | ||
review program requirements of this Act. | ||
(d) This registration shall include submission of all of | ||
the following information regarding utilization review program | ||
activities: | ||
(1) The name, address, and telephone number of the | ||
utilization review programs. | ||
(2) The organization and governing structure of the | ||
utilization review programs. | ||
(3) The number of lives for which utilization review | ||
is conducted by each utilization review program. | ||
(4) Hours of operation of each utilization review | ||
program. | ||
(5) Description of the grievance process for each | ||
utilization review program. | ||
(6) Number of covered lives for which utilization | ||
review was conducted for the previous calendar year for |
each utilization review program. | ||
(7) Written policies and procedures for protecting | ||
confidential information according to applicable State and | ||
federal laws for each utilization review program. | ||
(e) (1) A utilization review program shall have written | ||
procedures for assuring that patient-specific information | ||
obtained during the process of utilization review will be: | ||
(A) kept confidential in accordance with applicable | ||
State and federal laws; and | ||
(B) shared only with the enrollee, the enrollee's | ||
designee, the enrollee's health care provider, and those | ||
who are authorized by law to receive the information. | ||
Summary data shall not be considered confidential if it | ||
does not provide information to allow identification of | ||
individual patients or health care providers. | ||
(2) Only a clinical peer health care professional may | ||
make adverse determinations regarding the medical | ||
necessity of health care services during the course of | ||
utilization review. Either a health care professional or | ||
an accredited algorithmic automated process, or both in | ||
combination, may certify the medical necessity of a health | ||
care service in accordance with accreditation standards. | ||
Nothing in this subsection prohibits an accredited | ||
algorithmic automated process from being used to refer a | ||
case to a clinical peer for a potential adverse | ||
determination. |
(3) When making retrospective reviews, utilization | ||
review programs shall base reviews solely on the medical | ||
information available to the attending physician or | ||
ordering provider at the time the health care services | ||
were provided. | ||
(4) When making prospective, concurrent, and | ||
retrospective determinations, utilization review programs | ||
shall collect only information that is necessary to make | ||
the determination and shall not routinely require health | ||
care providers to numerically code diagnoses or procedures | ||
to be considered for certification, unless required under | ||
State or federal Medicare or Medicaid rules or | ||
regulations, but may request such code if available, or | ||
routinely request copies of medical records of all | ||
enrollees reviewed. During prospective or concurrent | ||
review, copies of medical records shall only be required | ||
when necessary to verify that the health care services | ||
subject to review are medically necessary. In these cases, | ||
only the necessary or relevant sections of the medical | ||
record shall be required. | ||
(f) If the Department finds that a utilization review | ||
program is not in compliance with this Section, the Department | ||
shall issue a corrective action plan and allow a reasonable | ||
amount of time for compliance with the plan. If the | ||
utilization review program does not come into compliance, the | ||
Department may issue a cease and desist order. Before issuing |
a cease and desist order under this Section, the Department | ||
shall provide the utilization review program with a written | ||
notice of the reasons for the order and allow a reasonable | ||
amount of time to supply additional information demonstrating | ||
compliance with requirements of this Section and to request a | ||
hearing. The hearing notice shall be sent by certified mail, | ||
return receipt requested, and the hearing shall be conducted | ||
in accordance with the Illinois Administrative Procedure Act. | ||
(g) A utilization review program subject to a corrective | ||
action may continue to conduct business until a final decision | ||
has been issued by the Department. | ||
(h) Any adverse determination made by a health care plan | ||
or its subcontractors may be appealed in accordance with | ||
subsection (f) of Section 45. | ||
(i) The Director may by rule establish a registration fee | ||
for each person conducting a utilization review program. All | ||
fees paid to and collected by the Director under this Section | ||
shall be deposited into the Insurance Producer Administration | ||
Fund. | ||
(Source: P.A. 99-111, eff. 1-1-16 .) | ||
(215 ILCS 134/87 new) | ||
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. | ||
Section 6-15. The Health Carrier External Review Act is | ||
amended by changing Section 10 as follows: | ||
(215 ILCS 180/10) | ||
Sec. 10. Definitions. For the purposes of this Act: | ||
"Adverse determination" means: | ||
(1) a determination by a health carrier or its | ||
designee utilization review organization that, based upon | ||
the information provided, a request for a benefit under | ||
the health carrier's health benefit plan upon application | ||
of any utilization review technique does not meet the |
health carrier's requirements for medical necessity, | ||
appropriateness, health care setting, level of care, or | ||
effectiveness or is determined to be experimental or | ||
investigational and the requested benefit is therefore | ||
denied, reduced, or terminated or payment is not provided | ||
or made, in whole or in part, for the benefit; | ||
(2) the denial, reduction, or termination of or | ||
failure to provide or make payment, in whole or in part, | ||
for a benefit based on a determination by a health carrier | ||
or its designee utilization review organization that a | ||
preexisting condition was present before the effective | ||
date of coverage; or | ||
(3) a rescission of coverage determination, which does | ||
not include a cancellation or discontinuance of coverage | ||
that is attributable to a failure to timely pay required | ||
premiums or contributions towards the cost of coverage. | ||
"Authorized representative" means: | ||
(1) a person to whom a covered person has given | ||
express written consent to represent the covered person | ||
for purposes of this Law; | ||
(2) a person authorized by law to provide substituted | ||
consent for a covered person; | ||
(3) a family member of the covered person or the | ||
covered person's treating health care professional when | ||
the covered person is unable to provide consent; | ||
(4) a health care provider when the covered person's |
health benefit plan requires that a request for a benefit | ||
under the plan be initiated by the health care provider; | ||
or | ||
(5) in the case of an urgent care request, a health | ||
care provider with knowledge of the covered person's | ||
medical condition. | ||
"Best evidence" means evidence based on: | ||
(1) randomized clinical trials; | ||
(2) if randomized clinical trials are not available, | ||
then cohort studies or case-control studies; | ||
(3) if items (1) and (2) are not available, then | ||
case-series; or | ||
(4) if items (1), (2), and (3) are not available, then | ||
expert opinion. | ||
"Case-series" means an evaluation of a series of patients | ||
with a particular outcome, without the use of a control group. | ||
"Clinical review criteria" means the written screening | ||
procedures, decision abstracts, clinical protocols, and | ||
practice guidelines used by a health carrier to determine the | ||
necessity and appropriateness of health care services. | ||
"Clinical review criteria" includes all utilization review | ||
criteria as defined in Section 10 of the Managed Care Reform | ||
and Patient Rights Act. | ||
"Cohort study" means a prospective evaluation of 2 groups | ||
of patients with only one group of patients receiving specific | ||
intervention. |
"Concurrent review" means a review conducted during a | ||
patient's stay or course of treatment in a facility, the | ||
office of a health care professional, or other inpatient or | ||
outpatient health care setting. | ||
"Covered benefits" or "benefits" means those health care | ||
services to which a covered person is entitled under the terms | ||
of a health benefit plan. | ||
"Covered person" means a policyholder, subscriber, | ||
enrollee, or other individual participating in a health | ||
benefit plan. | ||
"Director" means the Director of the Department of | ||
Insurance. | ||
"Emergency medical condition" means a medical condition | ||
manifesting itself by acute symptoms of sufficient severity, | ||
including, but not limited to, severe pain, such that a | ||
prudent layperson who possesses an average knowledge of health | ||
and medicine could reasonably expect the absence of immediate | ||
medical attention to result in: | ||
(1) placing the health of the individual or, with | ||
respect to a pregnant woman, the health of the woman or her | ||
unborn child, in serious jeopardy; | ||
(2) serious impairment to bodily functions; or | ||
(3) serious dysfunction of any bodily organ or part. | ||
"Emergency services" means health care items and services | ||
furnished or required to evaluate and treat an emergency | ||
medical condition. |
"Evidence-based standard" means the conscientious, | ||
explicit, and judicious use of the current best evidence based | ||
on an overall systematic review of the research in making | ||
decisions about the care of individual patients. | ||
"Expert opinion" means a belief or an interpretation by | ||
specialists with experience in a specific area about the | ||
scientific evidence pertaining to a particular service, | ||
intervention, or therapy. | ||
"Facility" means an institution providing health care | ||
services or a health care setting. | ||
"Final adverse determination" means an adverse | ||
determination involving a covered benefit that has been upheld | ||
by a health carrier, or its designee utilization review | ||
organization, at the completion of the health carrier's | ||
internal grievance process procedures as set forth by the | ||
Managed Care Reform and Patient Rights Act. | ||
"Health benefit plan" means a policy, contract, | ||
certificate, plan, or agreement offered or issued by a health | ||
carrier to provide, deliver, arrange for, pay for, or | ||
reimburse any of the costs of health care services. | ||
"Health care provider" or "provider" means a physician, | ||
hospital facility, or other health care practitioner licensed, | ||
accredited, or certified to perform specified health care | ||
services consistent with State law, responsible for | ||
recommending health care services on behalf of a covered | ||
person. |
"Health care services" means services for the diagnosis, | ||
prevention, treatment, cure, or relief of a health condition, | ||
illness, injury, or disease. | ||
"Health carrier" means an entity subject to the insurance | ||
laws and regulations of this State, or subject to the | ||
jurisdiction of the Director, that contracts or offers to | ||
contract to provide, deliver, arrange for, pay for, or | ||
reimburse any of the costs of health care services, including | ||
a sickness and accident insurance company, a health | ||
maintenance organization, or any other entity providing a plan | ||
of health insurance, health benefits, or health care services. | ||
"Health carrier" also means Limited Health Service | ||
Organizations (LHSO) and Voluntary Health Service Plans. | ||
"Health information" means information or data, whether | ||
oral or recorded in any form or medium, and personal facts or | ||
information about events or relationships that relate to: | ||
(1) the past, present, or future physical, mental, or | ||
behavioral health or condition of an individual or a | ||
member of the individual's family; | ||
(2) the provision of health care services to an | ||
individual; or | ||
(3) payment for the provision of health care services | ||
to an individual. | ||
"Independent review organization" means an entity that | ||
conducts independent external reviews of adverse | ||
determinations and final adverse determinations. |
"Medical or scientific evidence" means evidence found in | ||
the following sources: | ||
(1) peer-reviewed scientific studies published in or | ||
accepted for publication by medical journals that meet | ||
nationally recognized requirements for scientific | ||
manuscripts and that submit most of their published | ||
articles for review by experts who are not part of the | ||
editorial staff; | ||
(2) peer-reviewed medical literature, including | ||
literature relating to therapies reviewed and approved by | ||
a qualified institutional review board, biomedical | ||
compendia, and other medical literature that meet the | ||
criteria of the National Institutes of Health's Library of | ||
Medicine for indexing in Index Medicus (Medline) and | ||
Elsevier Science Ltd. for indexing in Excerpta Medicus | ||
(EMBASE); | ||
(3) medical journals recognized by the Secretary of | ||
Health and Human Services under Section 1861(t)(2) of the | ||
federal Social Security Act; | ||
(4) the following standard reference compendia: | ||
(a) The American Hospital Formulary Service-Drug | ||
Information; | ||
(b) Drug Facts and Comparisons; | ||
(c) The American Dental Association Accepted | ||
Dental Therapeutics; and | ||
(d) The United States Pharmacopoeia-Drug |
Information; | ||
(5) findings, studies, or research conducted by or | ||
under the auspices of federal government agencies and | ||
nationally recognized federal research institutes, | ||
including: | ||
(a) the federal Agency for Healthcare Research and | ||
Quality; | ||
(b) the National Institutes of Health; | ||
(c) the National Cancer Institute; | ||
(d) the National Academy of Sciences; | ||
(e) the Centers for Medicare & Medicaid Services; | ||
(f) the federal Food and Drug Administration; and | ||
(g) any national board recognized by the National | ||
Institutes of Health for the purpose of evaluating the | ||
medical value of health care services; or | ||
(6) any other medical or scientific evidence that is | ||
comparable to the sources listed in items (1) through (5). | ||
"Person" means an individual, a corporation, a | ||
partnership, an association, a joint venture, a joint stock | ||
company, a trust, an unincorporated organization, any similar | ||
entity, or any combination of the foregoing. | ||
"Prospective review" means a review conducted prior to an | ||
admission or the provision of a health care service or a course | ||
of treatment in accordance with a health carrier's requirement | ||
that the health care service or course of treatment, in whole | ||
or in part, be approved prior to its provision. |
"Protected health information" means health information | ||
(i) that identifies an individual who is the subject of the | ||
information; or (ii) with respect to which there is a | ||
reasonable basis to believe that the information could be used | ||
to identify an individual. | ||
"Randomized clinical trial" means a controlled prospective | ||
study of patients that have been randomized into an | ||
experimental group and a control group at the beginning of the | ||
study with only the experimental group of patients receiving a | ||
specific intervention, which includes study of the groups for | ||
variables and anticipated outcomes over time. | ||
"Retrospective review" means any review of a request for a | ||
benefit that is not a concurrent or prospective review | ||
request. "Retrospective review" does not include the review of | ||
a claim that is limited to veracity of documentation or | ||
accuracy of coding. | ||
"Utilization review" has the meaning provided by the | ||
Managed Care Reform and Patient Rights Act. | ||
"Utilization review organization" means a utilization | ||
review program as defined in the Managed Care Reform and | ||
Patient Rights Act. | ||
(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12; | ||
98-756, eff. 7-16-14.) | ||
Section 6-20. The Prior Authorization Reform Act is | ||
amended by changing Sections 15 and 20 as follows: |
(215 ILCS 200/15) | ||
Sec. 15. Definitions. As used in this Act: | ||
"Adverse determination" has the meaning given to that term | ||
in Section 10 of the Health Carrier External Review Act. | ||
"Appeal" means a formal request, either orally or in | ||
writing, to reconsider an adverse determination. | ||
"Approval" means a determination by a health insurance | ||
issuer or its contracted utilization review organization that | ||
a health care service has been reviewed and, based on the | ||
information provided, satisfies the health insurance issuer's | ||
or its contracted utilization review organization's | ||
requirements for medical necessity and appropriateness. | ||
"Clinical review criteria" has the meaning given to that | ||
term in Section 10 of the Health Carrier External Review Act. | ||
"Department" means the Department of Insurance. | ||
"Emergency medical condition" has the meaning given to | ||
that term in Section 10 of the Managed Care Reform and Patient | ||
Rights Act. | ||
"Emergency services" has the meaning given to that term in | ||
federal health insurance reform requirements for the group and | ||
individual health insurance markets, 45 CFR 147.138. | ||
"Enrollee" has the meaning given to that term in Section | ||
10 of the Managed Care Reform and Patient Rights Act. | ||
"Health care professional" has the meaning given to that | ||
term in Section 10 of the Managed Care Reform and Patient |
Rights Act. | ||
"Health care provider" has the meaning given to that term | ||
in Section 10 of the Managed Care Reform and Patient Rights | ||
Act, except that facilities licensed under the Nursing Home | ||
Care Act and long-term care facilities as defined in Section | ||
1-113 of the Nursing Home Care Act are excluded from this Act. | ||
"Health care service" means any services or level of | ||
services included in the furnishing to an individual of | ||
medical care or the hospitalization incident to the furnishing | ||
of such care, as well as the furnishing to any person of any | ||
other services for the purpose of preventing, alleviating, | ||
curing, or healing human illness or injury, including | ||
behavioral health, mental health, home health, and | ||
pharmaceutical services and products. | ||
"Health insurance issuer" has the meaning given to that | ||
term in Section 5 of the Illinois Health Insurance Portability | ||
and Accountability Act. | ||
"Medically necessary" has the meaning given to that term | ||
in Section 10 of the Managed Care Reform and Patient Rights | ||
Act. means a health care professional exercising prudent | ||
clinical judgment would provide care to a patient for the | ||
purpose of preventing, diagnosing, or treating an illness, | ||
injury, disease, or its symptoms and that are: (i) in | ||
accordance with generally accepted standards of medical | ||
practice; (ii) clinically appropriate in terms of type, | ||
frequency, extent, site, and duration and are considered |
effective for the patient's illness, injury, or disease; and | ||
(iii) not primarily for the convenience of the patient, | ||
treating physician, other health care professional, caregiver, | ||
family member, or other interested party, but focused on what | ||
is best for the patient's health outcome. | ||
"Physician" means a person licensed under the Medical | ||
Practice Act of 1987 or licensed under the laws of another | ||
state to practice medicine in all its branches. | ||
"Prior authorization" means the process by which health | ||
insurance issuers or their contracted utilization review | ||
organizations determine the medical necessity and medical | ||
appropriateness of otherwise covered health care services | ||
before the rendering of such health care services. "Prior | ||
authorization" includes any health insurance issuer's or its | ||
contracted utilization review organization's requirement that | ||
an enrollee, health care professional, or health care provider | ||
notify the health insurance issuer or its contracted | ||
utilization review organization before, at the time of, or | ||
concurrent to providing a health care service. | ||
"Urgent health care service" means a health care service | ||
with respect to which the application of the time periods for | ||
making a non-expedited prior authorization that in the opinion | ||
of a health care professional with knowledge of the enrollee's | ||
medical condition: | ||
(1) could seriously jeopardize the life or health of | ||
the enrollee or the ability of the enrollee to regain |
maximum function; or | ||
(2) could subject the enrollee to severe pain that | ||
cannot be adequately managed without the care or treatment | ||
that is the subject of the utilization review. | ||
"Urgent health care service" does not include emergency | ||
services. | ||
"Utilization review organization" has the meaning given to | ||
that term in 50 Ill. Adm. Code 4520.30. | ||
(Source: P.A. 102-409, eff. 1-1-22 .) | ||
(215 ILCS 200/20) | ||
Sec. 20. Disclosure and review of prior authorization | ||
requirements. | ||
(a) A health insurance issuer shall maintain a complete | ||
list of services for which prior authorization is required, | ||
including for all services where prior authorization is | ||
performed by an entity under contract with the health | ||
insurance issuer. The health insurance issuer shall publish | ||
this list on its public website without requiring a member of | ||
the general public to create any account or enter any | ||
credentials to access it. The list described in this | ||
subsection is not required to contain the clinical review | ||
criteria applicable to these services. | ||
(b) A health insurance issuer shall make any current prior | ||
authorization requirements and restrictions, including the | ||
written clinical review criteria, readily accessible and |
conspicuously posted on its website to enrollees, health care | ||
professionals, and health care providers. Content published by | ||
a third party and licensed for use by a health insurance issuer | ||
or its contracted utilization review organization may be made | ||
available through the health insurance issuer's or its | ||
contracted utilization review organization's secure, | ||
password-protected website so long as the access requirements | ||
of the website do not unreasonably restrict access. | ||
Requirements shall be described in detail, written in easily | ||
understandable language, and readily available to the health | ||
care professional and health care provider at the point of | ||
care. The website shall indicate for each service subject to | ||
prior authorization: | ||
(1) when prior authorization became required for | ||
policies issued or delivered in Illinois, including the | ||
effective date or dates and the termination date or dates, | ||
if applicable, in Illinois; | ||
(2) the date the Illinois-specific requirement was | ||
listed on the health insurance issuer's or its contracted | ||
utilization review organization's website; | ||
(3) where applicable, the date that prior | ||
authorization was removed for Illinois; and | ||
(4) where applicable, access to a standardized | ||
electronic prior authorization request transaction | ||
process. | ||
(c) The clinical review criteria must: |
(1) be based on nationally recognized, generally | ||
accepted standards except where State law provides its own | ||
standard; | ||
(2) be developed in accordance with the current | ||
standards of a national medical accreditation entity; | ||
(3) ensure quality of care and access to needed health | ||
care services; | ||
(4) be evidence-based; | ||
(5) be sufficiently flexible to allow deviations from | ||
norms when justified on a case-by-case basis; and | ||
(6) be evaluated and updated, if necessary, at least | ||
annually. | ||
(d) A health insurance issuer shall not deny a claim for | ||
failure to obtain prior authorization if the prior | ||
authorization requirement was not in effect on the date of | ||
service on the claim. | ||
(e) A health insurance issuer or its contracted | ||
utilization review organization shall not deem as incidental | ||
or deny supplies or health care services that are routinely | ||
used as part of a health care service when: | ||
(1) an associated health care service has received | ||
prior authorization; or | ||
(2) prior authorization for the health care service is | ||
not required. | ||
(f) If a health insurance issuer intends either to | ||
implement a new prior authorization requirement or restriction |
or amend an existing requirement or restriction, the health | ||
insurance issuer shall provide contracted health care | ||
professionals and contracted health care providers of | ||
enrollees written notice of the new or amended requirement or | ||
amendment no less than 60 days before the requirement or | ||
restriction is implemented. The written notice may be provided | ||
in an electronic format, including email or facsimile, if the | ||
health care professional or health care provider has agreed in | ||
advance to receive notices electronically. The health | ||
insurance issuer shall ensure that the new or amended | ||
requirement is not implemented unless the health insurance | ||
issuer's or its contracted utilization review organization's | ||
website has been updated to reflect the new or amended | ||
requirement or restriction. | ||
(g) Entities using prior authorization shall make | ||
statistics available regarding prior authorization approvals | ||
and denials on their website in a readily accessible format. | ||
The statistics must be updated annually and include all of the | ||
following information: | ||
(1) a list of all health care services, including | ||
medications, that are subject to prior authorization; | ||
(2) the total number of prior authorization requests | ||
received; | ||
(3) the number of prior authorization requests denied | ||
during the previous plan year by the health insurance | ||
issuer or its contracted utilization review organization |
with respect to each service described in paragraph (1) | ||
and the top 5 reasons for denial; | ||
(4) the number of requests described in paragraph (3) | ||
that were appealed, the number of the appealed requests | ||
that upheld the adverse determination, and the number of | ||
appealed requests that reversed the adverse determination; | ||
(5) the average time between submission and response; | ||
and | ||
(6) any other information as the Director determines | ||
appropriate. | ||
(Source: P.A. 102-409, eff. 1-1-22 .) | ||
Section 6-25. The Illinois Public Aid Code is amended by | ||
changing Section 5-16.12 as follows: | ||
(305 ILCS 5/5-16.12) | ||
Sec. 5-16.12. Managed Care Reform and Patient Rights Act. | ||
The medical assistance program and other programs administered | ||
by the Department are subject to the provisions of the Managed | ||
Care Reform and Patient Rights Act. The Department may adopt | ||
rules to implement those provisions. These rules shall require | ||
compliance with that Act in the medical assistance managed | ||
care programs and other programs administered by the | ||
Department. The medical assistance fee-for-service program is | ||
not subject to the provisions of the Managed Care Reform and | ||
Patient Rights Act , except for Sections 85 and 87 of the |
Managed Care Reform and Patient Rights Act and for any | ||
definition in Section 10 of the Managed Care Reform and | ||
Patient Rights Act that applies to Sections 85 and 87 of the | ||
Managed Care Reform and Patient Rights Act . | ||
Nothing in the Managed Care Reform and Patient Rights Act | ||
shall be construed to mean that the Department is a health care | ||
plan as defined in that Act simply because the Department | ||
enters into contractual relationships with health care plans ; | ||
provided that this clause shall not defeat the applicability | ||
of Sections 10, 85, and 87 of the Managed Care Reform and | ||
Patient Rights Act to the fee-for-service program . | ||
(Source: P.A. 91-617, eff. 1-1-00.) | ||
Article 99. | ||
Section 99-95. No acceleration or delay. Where this Act | ||
makes changes in a statute that is represented in this Act by | ||
text that is not yet or no longer in effect (for example, a | ||
Section represented by multiple versions), the use of that | ||
text does not accelerate or delay the taking effect of (i) the | ||
changes made by this Act or (ii) provisions derived from any | ||
other Public Act. | ||
Section 99-99. Effective date. This Act takes effect | ||
January 1, 2025, except that the changes to Section 45.1 of the | ||
Managed Care Reform and Patient Rights Act take effect January | ||
1, 2026. |