Rep. Bob Morgan

Filed: 3/14/2024

 

 


 

 


 
10300HB2472ham001LRB103 28761 RPS 70817 a

1
AMENDMENT TO HOUSE BILL 2472

2    AMENDMENT NO. ______. Amend House Bill 2472 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Sections 143.31, 155.36, 315.6, and 370s as follows:
 
6    (215 ILCS 5/143.31)
7    Sec. 143.31. Uniform medical claim and billing forms.
8    (a) The Director shall prescribe by rule, after
9consultation with providers of health care or treatment,
10insurers, hospital, medical, and dental service corporations,
11and other prepayment organizations, insurance claim and
12billing forms that the Director determines will provide for
13uniformity and simplicity in insurance claims handling. The
14claim forms shall include, but need not be limited to,
15information regarding the medical diagnosis, treatment, and
16prognosis of the patient, together with the details of charges

 

 

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1incident to the providing of care, treatment, or services,
2sufficient for the purpose of meeting the proof requirements
3of an insurance policy or a hospital, medical, or dental
4service contract.
5    (b) An insurer or a provider of health care treatment may
6not refuse to accept a claim or bill submitted on duly
7promulgated uniform claim and billing forms. An insurer,
8however, may accept claims and bills submitted on any other
9form.
10    (c) After receipt and adjudication or readjudication of
11any claim or bill with all required documentation from an
12insured or provider, or a notification under 42 U.S.C.
13300gg-136, an accident Accident and health insurer shall send
14explanation of benefits paid statements or claims summary
15statements sent to an insured by the accident and health
16insurer shall be in a format and written in a manner that
17promotes understanding by the insured by setting forth all of
18the following:
19        (1) The total dollar amount submitted to the insurer
20    for payment.
21        (2) Any reduction in the amount paid due to the
22    application of any co-payment, coinsurance, or deductible,
23    along with an explanation of the amount of the co-payment,
24    coinsurance, or deductible applied under the insured's
25    policy.
26        (3) Any reduction in the amount paid due to the

 

 

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1    application of any other policy limitation, penalty, or
2    exclusion set forth in the insured's policy, along with an
3    explanation thereof.
4        (4) The total dollar amount paid.
5        (5) The total dollar amount remaining unpaid.
6        (6) If applicable under 42 U.S.C. 300gg-111 or 42
7    U.S.C. 300gg-115, other information required for any
8    explanation of benefits described in either of those
9    Sections.
10    (d) The Director may issue an order directing an accident
11and health insurer to comply with subsection (c).
12    (e) An accident and health insurer does not violate
13subsection (c) by using a document that the accident and
14health insurer is required to use by the federal government or
15the State.
16    (f) The adoption of uniform claim forms and uniform
17billing forms by the Director under this Section does not
18preclude an insurer, hospital, medical, or dental service
19corporation, or other prepayment organization from obtaining
20any necessary additional information regarding a claim from
21the claimant, provider of health care or treatment, or
22certifier of coverage, as may be required.
23    (g) On and after January 1, 1996 when billing insurers or
24otherwise filing insurance claims with insurers subject to
25this Section, providers of health care or treatment, medical
26services, dental services, pharmaceutical services, or medical

 

 

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1equipment must use the uniform claim and billing forms adopted
2by the Director under this Section.
3(Source: P.A. 91-357, eff. 7-29-99.)
 
4    (215 ILCS 5/155.36)
5    Sec. 155.36. Managed Care Reform and Patient Rights Act.
6Insurance companies that transact the kinds of insurance
7authorized under Class 1(b) or Class 2(a) of Section 4 of this
8Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65,
970, and 85, subsection (d) of Section 30, and the definition of
10the term "emergency medical condition" in Section 10 of the
11Managed Care Reform and Patient Rights Act. Except as provided
12by Section 85 of the Managed Care Reform and Patient Rights
13Act, no law or rule shall be construed to exempt any
14utilization review program from the requirements of Section 85
15of the Managed Care Reform and Patient Rights Act with respect
16to any insurance described in this Section.
17(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
18    (215 ILCS 5/315.6)  (from Ch. 73, par. 927.6)
19    (Section scheduled to be repealed on January 1, 2027)
20    Sec. 315.6. Application of other Code provisions. Unless
21otherwise provided in this amendatory Act, every fraternal
22benefit society shall be governed by this amendatory Act and
23shall be exempt from all other provisions of the insurance
24laws of this State not only in governmental relations with the

 

 

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1State but for every other purpose, except for those provisions
2specified in this amendatory Act and except as follows:
3        (a) Sections 1, 2, 2.1, 3.1, 117, 118, 132, 132.1,
4    132.2, 132.3, 132.4, 132.5, 132.6, 132.7, 133, 134, 136,
5    138, 139, 140, 141, 141.01, 141.1, 141.2, 141.3, 143,
6    143.31, 143c, 144.1, 147, 148, 149, 150, 151, 152, 153,
7    154.5, 154.6, 154.7, 154.8, 155, 155.04, 155.05, 155.06,
8    155.07, 155.08 and 408 of this Code; and
9        (b) Articles VIII 1/2, XII, XII 1/2, XIII, XXIV, and
10    XXVIII of this Code.
11(Source: P.A. 98-814, eff. 1-1-15.)
 
12    (215 ILCS 5/370s)
13    Sec. 370s. Managed Care Reform and Patient Rights Act. All
14administrators shall comply with Sections 55 and 85 of the
15Managed Care Reform and Patient Rights Act. Except as provided
16by Section 85 of the Managed Care Reform and Patient Rights
17Act, no law or rule shall be construed to exempt any
18utilization review program from the requirements of Section 85
19of the Managed Care Reform and Patient Rights Act with respect
20to any insured or beneficiary described in this Article.
21(Source: P.A. 91-617, eff. 1-1-00.)
 
22    Section 10. The Dental Service Plan Act is amended by
23changing Section 25 as follows:
 

 

 

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1    (215 ILCS 110/25)  (from Ch. 32, par. 690.25)
2    Sec. 25. Application of Insurance Code provisions. Dental
3service plan corporations and all persons interested therein
4or dealing therewith shall be subject to the provisions of
5Articles IIA, XI, and XII 1/2 and Sections 3.1, 133, 136, 139,
6140, 143, 143.31, 143c, 149, 155.49, 355.2, 355.3, 367.2, 401,
7401.1, 402, 403, 403A, 408, 408.2, and 412, and subsection
8(15) of Section 367 of the Illinois Insurance Code.
9(Source: P.A. 103-426, eff. 8-4-23.)
 
10    Section 15. The Network Adequacy and Transparency Act is
11amended by changing Section 10 as follows:
 
12    (215 ILCS 124/10)
13    Sec. 10. Network adequacy.
14    (a) An insurer providing a network plan shall file a
15description of all of the following with the Director:
16        (1) The written policies and procedures for adding
17    providers to meet patient needs based on increases in the
18    number of beneficiaries, changes in the
19    patient-to-provider ratio, changes in medical and health
20    care capabilities, and increased demand for services.
21        (2) The written policies and procedures for making
22    referrals within and outside the network.
23        (3) The written policies and procedures on how the
24    network plan will provide 24-hour, 7-day per week access

 

 

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1    to network-affiliated primary care, emergency services,
2    and women's principal health care providers.
3    An insurer shall not prohibit a preferred provider from
4discussing any specific or all treatment options with
5beneficiaries irrespective of the insurer's position on those
6treatment options or from advocating on behalf of
7beneficiaries within the utilization review, grievance, or
8appeals processes established by the insurer in accordance
9with any rights or remedies available under applicable State
10or federal law.
11    (b) Insurers must file for review a description of the
12services to be offered through a network plan. The description
13shall include all of the following:
14        (1) A geographic map of the area proposed to be served
15    by the plan by county service area and zip code, including
16    marked locations for preferred providers.
17        (2) As deemed necessary by the Department, the names,
18    addresses, phone numbers, and specialties of the providers
19    who have entered into preferred provider agreements under
20    the network plan.
21        (3) The number of beneficiaries anticipated to be
22    covered by the network plan.
23        (4) An Internet website and toll-free telephone number
24    for beneficiaries and prospective beneficiaries to access
25    current and accurate lists of preferred providers,
26    additional information about the plan, as well as any

 

 

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1    other information required by Department rule.
2        (5) A description of how health care services to be
3    rendered under the network plan are reasonably accessible
4    and available to beneficiaries. The description shall
5    address all of the following:
6            (A) the type of health care services to be
7        provided by the network plan;
8            (B) the ratio of physicians and other providers to
9        beneficiaries, by specialty and including primary care
10        physicians and facility-based physicians when
11        applicable under the contract, necessary to meet the
12        health care needs and service demands of the currently
13        enrolled population;
14            (C) the travel and distance standards for plan
15        beneficiaries in county service areas; and
16            (D) a description of how the use of telemedicine,
17        telehealth, or mobile care services may be used to
18        partially meet the network adequacy standards, if
19        applicable.
20        (6) A provision ensuring that whenever a beneficiary
21    has made a good faith effort, as evidenced by accessing
22    the provider directory, calling the network plan, and
23    calling the provider, to utilize preferred providers for a
24    covered service and it is determined the insurer does not
25    have the appropriate preferred providers due to
26    insufficient number, type, unreasonable travel distance or

 

 

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1    delay, or preferred providers refusing to provide a
2    covered service because it is contrary to the conscience
3    of the preferred providers, as protected by the Health
4    Care Right of Conscience Act, the insurer shall ensure,
5    directly or indirectly, by terms contained in the payer
6    contract, that the beneficiary will be provided the
7    covered service at no greater cost to the beneficiary than
8    if the service had been provided by a preferred provider.
9    This paragraph (6) does not apply to: (A) a beneficiary
10    who willfully chooses to access a non-preferred provider
11    for health care services available through the panel of
12    preferred providers, or (B) a beneficiary enrolled in a
13    health maintenance organization. In these circumstances,
14    the contractual requirements for non-preferred provider
15    reimbursements shall apply unless Section 356z.3a of the
16    Illinois Insurance Code requires otherwise. In no event
17    shall a beneficiary who receives care at a participating
18    health care facility be required to search for
19    participating providers under the circumstances described
20    in subsection (b) or (b-5) of Section 356z.3a of the
21    Illinois Insurance Code except under the circumstances
22    described in paragraph (2) of subsection (b-5).
23        (7) A provision that the beneficiary shall receive
24    emergency care coverage such that payment for this
25    coverage is not dependent upon whether the emergency
26    services are performed by a preferred or non-preferred

 

 

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1    provider and the coverage shall be at the same benefit
2    level as if the service or treatment had been rendered by a
3    preferred provider. For purposes of this paragraph (7),
4    "the same benefit level" means that the beneficiary is
5    provided the covered service at no greater cost to the
6    beneficiary than if the service had been provided by a
7    preferred provider. This provision shall be consistent
8    with Section 356z.3a of the Illinois Insurance Code.
9        (8) A limitation that complies with subsections (d)
10    and (e) of Section 55 of the Prior Authorization Reform
11    Act , if the plan provides that the beneficiary will incur
12    a penalty for failing to pre-certify inpatient hospital
13    treatment, the penalty may not exceed $1,000 per
14    occurrence in addition to the plan cost sharing
15    provisions.
16    (c) The network plan shall demonstrate to the Director a
17minimum ratio of providers to plan beneficiaries as required
18by the Department.
19        (1) The ratio of physicians or other providers to plan
20    beneficiaries shall be established annually by the
21    Department in consultation with the Department of Public
22    Health based upon the guidance from the federal Centers
23    for Medicare and Medicaid Services. The Department shall
24    not establish ratios for vision or dental providers who
25    provide services under dental-specific or vision-specific
26    benefits. The Department shall consider establishing

 

 

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1    ratios for the following physicians or other providers:
2            (A) Primary Care;
3            (B) Pediatrics;
4            (C) Cardiology;
5            (D) Gastroenterology;
6            (E) General Surgery;
7            (F) Neurology;
8            (G) OB/GYN;
9            (H) Oncology/Radiation;
10            (I) Ophthalmology;
11            (J) Urology;
12            (K) Behavioral Health;
13            (L) Allergy/Immunology;
14            (M) Chiropractic;
15            (N) Dermatology;
16            (O) Endocrinology;
17            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
18            (Q) Infectious Disease;
19            (R) Nephrology;
20            (S) Neurosurgery;
21            (T) Orthopedic Surgery;
22            (U) Physiatry/Rehabilitative;
23            (V) Plastic Surgery;
24            (W) Pulmonary;
25            (X) Rheumatology;
26            (Y) Anesthesiology;

 

 

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1            (Z) Pain Medicine;
2            (AA) Pediatric Specialty Services;
3            (BB) Outpatient Dialysis; and
4            (CC) HIV.
5        (2) The Director shall establish a process for the
6    review of the adequacy of these standards, along with an
7    assessment of additional specialties to be included in the
8    list under this subsection (c).
9    (d) The network plan shall demonstrate to the Director
10maximum travel and distance standards for plan beneficiaries,
11which shall be established annually by the Department in
12consultation with the Department of Public Health based upon
13the guidance from the federal Centers for Medicare and
14Medicaid Services. These standards shall consist of the
15maximum minutes or miles to be traveled by a plan beneficiary
16for each county type, such as large counties, metro counties,
17or rural counties as defined by Department rule.
18    The maximum travel time and distance standards must
19include standards for each physician and other provider
20category listed for which ratios have been established.
21    The Director shall establish a process for the review of
22the adequacy of these standards along with an assessment of
23additional specialties to be included in the list under this
24subsection (d).
25    (d-5)(1) Every insurer shall ensure that beneficiaries
26have timely and proximate access to treatment for mental,

 

 

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1emotional, nervous, or substance use disorders or conditions
2in accordance with the provisions of paragraph (4) of
3subsection (a) of Section 370c of the Illinois Insurance Code.
4Insurers shall use a comparable process, strategy, evidentiary
5standard, and other factors in the development and application
6of the network adequacy standards for timely and proximate
7access to treatment for mental, emotional, nervous, or
8substance use disorders or conditions and those for the access
9to treatment for medical and surgical conditions. As such, the
10network adequacy standards for timely and proximate access
11shall equally be applied to treatment facilities and providers
12for mental, emotional, nervous, or substance use disorders or
13conditions and specialists providing medical or surgical
14benefits pursuant to the parity requirements of Section 370c.1
15of the Illinois Insurance Code and the federal Paul Wellstone
16and Pete Domenici Mental Health Parity and Addiction Equity
17Act of 2008. Notwithstanding the foregoing, the network
18adequacy standards for timely and proximate access to
19treatment for mental, emotional, nervous, or substance use
20disorders or conditions shall, at a minimum, satisfy the
21following requirements:
22        (A) For beneficiaries residing in the metropolitan
23    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
24    network adequacy standards for timely and proximate access
25    to treatment for mental, emotional, nervous, or substance
26    use disorders or conditions means a beneficiary shall not

 

 

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1    have to travel longer than 30 minutes or 30 miles from the
2    beneficiary's residence to receive outpatient treatment
3    for mental, emotional, nervous, or substance use disorders
4    or conditions. Beneficiaries shall not be required to wait
5    longer than 10 business days between requesting an initial
6    appointment and being seen by the facility or provider of
7    mental, emotional, nervous, or substance use disorders or
8    conditions for outpatient treatment or to wait longer than
9    20 business days between requesting a repeat or follow-up
10    appointment and being seen by the facility or provider of
11    mental, emotional, nervous, or substance use disorders or
12    conditions for outpatient treatment; however, subject to
13    the protections of paragraph (3) of this subsection, a
14    network plan shall not be held responsible if the
15    beneficiary or provider voluntarily chooses to schedule an
16    appointment outside of these required time frames.
17        (B) For beneficiaries residing in Illinois counties
18    other than those counties listed in subparagraph (A) of
19    this paragraph, network adequacy standards for timely and
20    proximate access to treatment for mental, emotional,
21    nervous, or substance use disorders or conditions means a
22    beneficiary shall not have to travel longer than 60
23    minutes or 60 miles from the beneficiary's residence to
24    receive outpatient treatment for mental, emotional,
25    nervous, or substance use disorders or conditions.
26    Beneficiaries shall not be required to wait longer than 10

 

 

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1    business days between requesting an initial appointment
2    and being seen by the facility or provider of mental,
3    emotional, nervous, or substance use disorders or
4    conditions for outpatient treatment or to wait longer than
5    20 business days between requesting a repeat or follow-up
6    appointment and being seen by the facility or provider of
7    mental, emotional, nervous, or substance use disorders or
8    conditions for outpatient treatment; however, subject to
9    the protections of paragraph (3) of this subsection, a
10    network plan shall not be held responsible if the
11    beneficiary or provider voluntarily chooses to schedule an
12    appointment outside of these required time frames.
13    (2) For beneficiaries residing in all Illinois counties,
14network adequacy standards for timely and proximate access to
15treatment for mental, emotional, nervous, or substance use
16disorders or conditions means a beneficiary shall not have to
17travel longer than 60 minutes or 60 miles from the
18beneficiary's residence to receive inpatient or residential
19treatment for mental, emotional, nervous, or substance use
20disorders or conditions.
21    (3) If there is no in-network facility or provider
22available for a beneficiary to receive timely and proximate
23access to treatment for mental, emotional, nervous, or
24substance use disorders or conditions in accordance with the
25network adequacy standards outlined in this subsection, the
26insurer shall provide necessary exceptions to its network to

 

 

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1ensure admission and treatment with a provider or at a
2treatment facility in accordance with the network adequacy
3standards in this subsection.
4    (e) Except for network plans solely offered as a group
5health plan, these ratio and time and distance standards apply
6to the lowest cost-sharing tier of any tiered network.
7    (f) The network plan may consider use of other health care
8service delivery options, such as telemedicine or telehealth,
9mobile clinics, and centers of excellence, or other ways of
10delivering care to partially meet the requirements set under
11this Section.
12    (g) Except for the requirements set forth in subsection
13(d-5), insurers who are not able to comply with the provider
14ratios and time and distance standards established by the
15Department may request an exception to these requirements from
16the Department. The Department may grant an exception in the
17following circumstances:
18        (1) if no providers or facilities meet the specific
19    time and distance standard in a specific service area and
20    the insurer (i) discloses information on the distance and
21    travel time points that beneficiaries would have to travel
22    beyond the required criterion to reach the next closest
23    contracted provider outside of the service area and (ii)
24    provides contact information, including names, addresses,
25    and phone numbers for the next closest contracted provider
26    or facility;

 

 

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1        (2) if patterns of care in the service area do not
2    support the need for the requested number of provider or
3    facility type and the insurer provides data on local
4    patterns of care, such as claims data, referral patterns,
5    or local provider interviews, indicating where the
6    beneficiaries currently seek this type of care or where
7    the physicians currently refer beneficiaries, or both; or
8        (3) other circumstances deemed appropriate by the
9    Department consistent with the requirements of this Act.
10    (h) Insurers are required to report to the Director any
11material change to an approved network plan within 15 days
12after the change occurs and any change that would result in
13failure to meet the requirements of this Act. Upon notice from
14the insurer, the Director shall reevaluate the network plan's
15compliance with the network adequacy and transparency
16standards of this Act.
17(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
18102-1117, eff. 1-13-23.)
 
19    Section 20. The Health Maintenance Organization Act is
20amended by changing Section 5-3 as follows:
 
21    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
22    Sec. 5-3. Insurance Code provisions.
23    (a) Health Maintenance Organizations shall be subject to
24the provisions of Sections 133, 134, 136, 137, 139, 140,

 

 

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1141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
2152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
3155.49, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q,
4356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
5356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
6356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
7356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,
8356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
9356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
10356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,
11356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
12356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
13356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
14368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
15408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
16subsection (2) of Section 367, and Articles IIA, VIII 1/2,
17XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
18Illinois Insurance Code.
19    (b) For purposes of the Illinois Insurance Code, except
20for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
21Health Maintenance Organizations in the following categories
22are deemed to be "domestic companies":
23        (1) a corporation authorized under the Dental Service
24    Plan Act or the Voluntary Health Services Plans Act;
25        (2) a corporation organized under the laws of this
26    State; or

 

 

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1        (3) a corporation organized under the laws of another
2    state, 30% or more of the enrollees of which are residents
3    of this State, except a corporation subject to
4    substantially the same requirements in its state of
5    organization as is a "domestic company" under Article VIII
6    1/2 of the Illinois Insurance Code.
7    (c) In considering the merger, consolidation, or other
8acquisition of control of a Health Maintenance Organization
9pursuant to Article VIII 1/2 of the Illinois Insurance Code,
10        (1) the Director shall give primary consideration to
11    the continuation of benefits to enrollees and the
12    financial conditions of the acquired Health Maintenance
13    Organization after the merger, consolidation, or other
14    acquisition of control takes effect;
15        (2)(i) the criteria specified in subsection (1)(b) of
16    Section 131.8 of the Illinois Insurance Code shall not
17    apply and (ii) the Director, in making his determination
18    with respect to the merger, consolidation, or other
19    acquisition of control, need not take into account the
20    effect on competition of the merger, consolidation, or
21    other acquisition of control;
22        (3) the Director shall have the power to require the
23    following information:
24            (A) certification by an independent actuary of the
25        adequacy of the reserves of the Health Maintenance
26        Organization sought to be acquired;

 

 

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1            (B) pro forma financial statements reflecting the
2        combined balance sheets of the acquiring company and
3        the Health Maintenance Organization sought to be
4        acquired as of the end of the preceding year and as of
5        a date 90 days prior to the acquisition, as well as pro
6        forma financial statements reflecting projected
7        combined operation for a period of 2 years;
8            (C) a pro forma business plan detailing an
9        acquiring party's plans with respect to the operation
10        of the Health Maintenance Organization sought to be
11        acquired for a period of not less than 3 years; and
12            (D) such other information as the Director shall
13        require.
14    (d) The provisions of Article VIII 1/2 of the Illinois
15Insurance Code and this Section 5-3 shall apply to the sale by
16any health maintenance organization of greater than 10% of its
17enrollee population (including, without limitation, the health
18maintenance organization's right, title, and interest in and
19to its health care certificates).
20    (e) In considering any management contract or service
21agreement subject to Section 141.1 of the Illinois Insurance
22Code, the Director (i) shall, in addition to the criteria
23specified in Section 141.2 of the Illinois Insurance Code,
24take into account the effect of the management contract or
25service agreement on the continuation of benefits to enrollees
26and the financial condition of the health maintenance

 

 

10300HB2472ham001- 21 -LRB103 28761 RPS 70817 a

1organization to be managed or serviced, and (ii) need not take
2into account the effect of the management contract or service
3agreement on competition.
4    (f) Except for small employer groups as defined in the
5Small Employer Rating, Renewability and Portability Health
6Insurance Act and except for medicare supplement policies as
7defined in Section 363 of the Illinois Insurance Code, a
8Health Maintenance Organization may by contract agree with a
9group or other enrollment unit to effect refunds or charge
10additional premiums under the following terms and conditions:
11        (i) the amount of, and other terms and conditions with
12    respect to, the refund or additional premium are set forth
13    in the group or enrollment unit contract agreed in advance
14    of the period for which a refund is to be paid or
15    additional premium is to be charged (which period shall
16    not be less than one year); and
17        (ii) the amount of the refund or additional premium
18    shall not exceed 20% of the Health Maintenance
19    Organization's profitable or unprofitable experience with
20    respect to the group or other enrollment unit for the
21    period (and, for purposes of a refund or additional
22    premium, the profitable or unprofitable experience shall
23    be calculated taking into account a pro rata share of the
24    Health Maintenance Organization's administrative and
25    marketing expenses, but shall not include any refund to be
26    made or additional premium to be paid pursuant to this

 

 

10300HB2472ham001- 22 -LRB103 28761 RPS 70817 a

1    subsection (f)). The Health Maintenance Organization and
2    the group or enrollment unit may agree that the profitable
3    or unprofitable experience may be calculated taking into
4    account the refund period and the immediately preceding 2
5    plan years.
6    The Health Maintenance Organization shall include a
7statement in the evidence of coverage issued to each enrollee
8describing the possibility of a refund or additional premium,
9and upon request of any group or enrollment unit, provide to
10the group or enrollment unit a description of the method used
11to calculate (1) the Health Maintenance Organization's
12profitable experience with respect to the group or enrollment
13unit and the resulting refund to the group or enrollment unit
14or (2) the Health Maintenance Organization's unprofitable
15experience with respect to the group or enrollment unit and
16the resulting additional premium to be paid by the group or
17enrollment unit.
18    In no event shall the Illinois Health Maintenance
19Organization Guaranty Association be liable to pay any
20contractual obligation of an insolvent organization to pay any
21refund authorized under this Section.
22    (g) Rulemaking authority to implement Public Act 95-1045,
23if any, is conditioned on the rules being adopted in
24accordance with all provisions of the Illinois Administrative
25Procedure Act and all rules and procedures of the Joint
26Committee on Administrative Rules; any purported rule not so

 

 

10300HB2472ham001- 23 -LRB103 28761 RPS 70817 a

1adopted, for whatever reason, is unauthorized.
2(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
3102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
41-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
5eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
6102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
71-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
8eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
9103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
106-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
11eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
12    Section 25. The Limited Health Service Organization Act is
13amended by changing Section 4003 as follows:
 
14    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
15    Sec. 4003. Illinois Insurance Code provisions. Limited
16health service organizations shall be subject to the
17provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
18141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153,
19154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49,
20355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10,
21356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
22356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
23356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
24364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,

 

 

10300HB2472ham001- 24 -LRB103 28761 RPS 70817 a

1444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
2XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
3Nothing in this Section shall require a limited health care
4plan to cover any service that is not a limited health service.
5For purposes of the Illinois Insurance Code, except for
6Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
7health service organizations in the following categories are
8deemed to be domestic companies:
9        (1) a corporation under the laws of this State; or
10        (2) a corporation organized under the laws of another
11    state, 30% or more of the enrollees of which are residents
12    of this State, except a corporation subject to
13    substantially the same requirements in its state of
14    organization as is a domestic company under Article VIII
15    1/2 of the Illinois Insurance Code.
16(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
17102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
181-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
19eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
20102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
211-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
22eff. 1-1-24; revised 8-29-23.)
 
23    Section 30. The Managed Care Reform and Patient Rights Act
24is amended by changing Sections 10, 45, and 85 as follows:
 

 

 

10300HB2472ham001- 25 -LRB103 28761 RPS 70817 a

1    (215 ILCS 134/10)
2    Sec. 10. Definitions. In this Act:
3    For a health care plan under Section 45 or for a
4utilization review program under Section 85, "adverse
5determination" has the meaning given to that term in Section
610 of the Health Carrier External Review Act "Adverse
7determination" means a determination by a health care plan
8under Section 45 or by a utilization review program under
9Section 85 that a health care service is not medically
10necessary.
11    "Clinical peer" means a health care professional who is in
12the same profession and the same or similar specialty as the
13health care provider who typically manages the medical
14condition, procedures, or treatment under review.
15    "Department" means the Department of Insurance.
16    "Emergency medical condition" means a medical condition
17manifesting itself by acute symptoms of sufficient severity,
18regardless of the final diagnosis given, such that a prudent
19layperson, who possesses an average knowledge of health and
20medicine, could reasonably expect the absence of immediate
21medical attention to result in:
22        (1) placing the health of the individual (or, with
23    respect to a pregnant woman, the health of the woman or her
24    unborn child) in serious jeopardy;
25        (2) serious impairment to bodily functions;
26        (3) serious dysfunction of any bodily organ or part;

 

 

10300HB2472ham001- 26 -LRB103 28761 RPS 70817 a

1        (4) inadequately controlled pain; or
2        (5) with respect to a pregnant woman who is having
3    contractions:
4            (A) inadequate time to complete a safe transfer to
5        another hospital before delivery; or
6            (B) a transfer to another hospital may pose a
7        threat to the health or safety of the woman or unborn
8        child.
9    "Emergency medical screening examination" means a medical
10screening examination and evaluation by a physician licensed
11to practice medicine in all its branches, or to the extent
12permitted by applicable laws, by other appropriately licensed
13personnel under the supervision of or in collaboration with a
14physician licensed to practice medicine in all its branches to
15determine whether the need for emergency services exists.
16    "Emergency services" means, with respect to an enrollee of
17a health care plan, transportation services, including but not
18limited to ambulance services, and covered inpatient and
19outpatient hospital services furnished by a provider qualified
20to furnish those services that are needed to evaluate or
21stabilize an emergency medical condition. "Emergency services"
22does not refer to post-stabilization medical services.
23    "Enrollee" means any person and his or her dependents
24enrolled in or covered by a health care plan.
25    "Health care plan" means a plan, including, but not
26limited to, a health maintenance organization, a managed care

 

 

10300HB2472ham001- 27 -LRB103 28761 RPS 70817 a

1community network as defined in the Illinois Public Aid Code,
2or an accountable care entity as defined in the Illinois
3Public Aid Code that receives capitated payments to cover
4medical services from the Department of Healthcare and Family
5Services, that establishes, operates, or maintains a network
6of health care providers that has entered into an agreement
7with the plan to provide health care services to enrollees to
8whom the plan has the ultimate obligation to arrange for the
9provision of or payment for services through organizational
10arrangements for ongoing quality assurance, utilization review
11programs, or dispute resolution. Nothing in this definition
12shall be construed to mean that an independent practice
13association or a physician hospital organization that
14subcontracts with a health care plan is, for purposes of that
15subcontract, a health care plan.
16    For purposes of this definition, "health care plan" shall
17not include the following:
18        (1) indemnity health insurance policies including
19    those using a contracted provider network;
20        (2) health care plans that offer only dental or only
21    vision coverage;
22        (3) preferred provider administrators, as defined in
23    Section 370g(g) of the Illinois Insurance Code;
24        (4) employee or employer self-insured health benefit
25    plans under the federal Employee Retirement Income
26    Security Act of 1974;

 

 

10300HB2472ham001- 28 -LRB103 28761 RPS 70817 a

1        (5) health care provided pursuant to the Workers'
2    Compensation Act or the Workers' Occupational Diseases
3    Act; and
4        (6) except with respect to subsections (a) and (b) of
5    Section 65 and subsection (a-5) of Section 70,
6    not-for-profit voluntary health services plans with health
7    maintenance organization authority in existence as of
8    January 1, 1999 that are affiliated with a union and that
9    only extend coverage to union members and their
10    dependents.
11    "Health care professional" means a physician, a registered
12professional nurse, or other individual appropriately licensed
13or registered to provide health care services.
14    "Health care provider" means any physician, hospital
15facility, facility licensed under the Nursing Home Care Act,
16long-term care facility as defined in Section 1-113 of the
17Nursing Home Care Act, or other person that is licensed or
18otherwise authorized to deliver health care services. Nothing
19in this Act shall be construed to define Independent Practice
20Associations or Physician-Hospital Organizations as health
21care providers.
22    "Health care services" means any services included in the
23furnishing to any individual of medical care, or the
24hospitalization incident to the furnishing of such care, as
25well as the furnishing to any person of any and all other
26services for the purpose of preventing, alleviating, curing,

 

 

10300HB2472ham001- 29 -LRB103 28761 RPS 70817 a

1or healing human illness or injury including behavioral
2health, mental health, home health, and pharmaceutical
3services and products.
4    "Medical director" means a physician licensed in any state
5to practice medicine in all its branches appointed by a health
6care plan.
7    "Person" means a corporation, association, partnership,
8limited liability company, sole proprietorship, or any other
9legal entity.
10    "Physician" means a person licensed under the Medical
11Practice Act of 1987.
12    "Post-stabilization medical services" means health care
13services provided to an enrollee that are furnished in a
14licensed hospital by a provider that is qualified to furnish
15such services, and determined to be medically necessary and
16directly related to the emergency medical condition following
17stabilization.
18    "Stabilization" means, with respect to an emergency
19medical condition, to provide such medical treatment of the
20condition as may be necessary to assure, within reasonable
21medical probability, that no material deterioration of the
22condition is likely to result.
23    "Utilization review" means the evaluation, including any
24evaluation based on an algorithmic automated process, of the
25medical necessity, appropriateness, and efficiency of the use
26of health care services, procedures, and facilities.

 

 

10300HB2472ham001- 30 -LRB103 28761 RPS 70817 a

1    "Utilization review program" means a program established
2by a person to perform utilization review.
3(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
4    (215 ILCS 134/45)
5    Sec. 45. Health care services appeals, complaints, and
6external independent reviews.
7    (a) A health care plan shall establish and maintain an
8appeals procedure as outlined in this Act. Compliance with
9this Act's appeals procedures shall satisfy a health care
10plan's obligation to provide appeal procedures under any other
11State law or rules. All appeals of a health care plan's
12administrative determinations and complaints regarding its
13administrative decisions shall be handled as required under
14Section 50.
15    (b) When an appeal concerns a decision or action by a
16health care plan, its employees, or its subcontractors that
17relates to (i) health care services, including, but not
18limited to, procedures or treatments, for an enrollee with an
19ongoing course of treatment ordered by a health care provider,
20the denial of which could significantly increase the risk to
21an enrollee's health, or (ii) a treatment referral, service,
22procedure, or other health care service, the denial of which
23could significantly increase the risk to an enrollee's health,
24the health care plan must allow for the filing of an appeal
25either orally or in writing. Upon submission of the appeal, a

 

 

10300HB2472ham001- 31 -LRB103 28761 RPS 70817 a

1health care plan must notify the party filing the appeal, as
2soon as possible, but in no event more than 24 hours after the
3submission of the appeal, of all information that the plan
4requires to evaluate the appeal. The health care plan shall
5render a decision on the appeal within 24 hours after receipt
6of the required information. The health care plan shall notify
7the party filing the appeal and the enrollee, enrollee's
8primary care physician, and any health care provider who
9recommended the health care service involved in the appeal of
10its decision orally followed-up by a written notice of the
11determination.
12    (c) For all appeals related to health care services
13including, but not limited to, procedures or treatments for an
14enrollee and not covered by subsection (b) above, the health
15care plan shall establish a procedure for the filing of such
16appeals. Upon submission of an appeal under this subsection, a
17health care plan must notify the party filing an appeal,
18within 3 business days, of all information that the plan
19requires to evaluate the appeal. The health care plan shall
20render a decision on the appeal within 15 business days after
21receipt of the required information. The health care plan
22shall notify the party filing the appeal, the enrollee, the
23enrollee's primary care physician, and any health care
24provider who recommended the health care service involved in
25the appeal orally of its decision followed-up by a written
26notice of the determination.

 

 

10300HB2472ham001- 32 -LRB103 28761 RPS 70817 a

1    (d) An appeal under subsection (b) or (c) may be filed by
2the enrollee, the enrollee's designee or guardian, the
3enrollee's primary care physician, or the enrollee's health
4care provider. A health care plan shall designate a clinical
5peer to review appeals, because these appeals pertain to
6medical or clinical matters and such an appeal must be
7reviewed by an appropriate health care professional. No one
8reviewing an appeal may have had any involvement in the
9initial determination that is the subject of the appeal. The
10written notice of determination required under subsections (b)
11and (c) shall include (i) clear and detailed reasons for the
12determination, (ii) the medical or clinical criteria for the
13determination, which shall be based upon sound clinical
14evidence and reviewed on a periodic basis, and (iii) in the
15case of an adverse determination, the procedures for
16requesting an external independent review as provided by the
17Illinois Health Carrier External Review Act.
18    (e) If an appeal filed under subsection (b) or (c) is
19denied for a reason including, but not limited to, the
20service, procedure, or treatment is not viewed as medically
21necessary, denial of specific tests or procedures, denial of
22referral to specialist physicians or denial of hospitalization
23requests or length of stay requests, any involved party may
24request an external independent review as provided by the
25Illinois Health Carrier External Review Act.
26    (f) Until July 1, 2013, if an external independent review

 

 

10300HB2472ham001- 33 -LRB103 28761 RPS 70817 a

1decision made pursuant to the Illinois Health Carrier External
2Review Act upholds a determination adverse to the covered
3person, the covered person has the right to appeal the final
4decision to the Department; if the external review decision is
5found by the Director to have been arbitrary and capricious,
6then the Director, with consultation from a licensed medical
7professional, may overturn the external review decision and
8require the health carrier to pay for the health care service
9or treatment; such decision, if any, shall be made solely on
10the legal or medical merits of the claim. If an external review
11decision is overturned by the Director pursuant to this
12Section and the health carrier so requests, then the Director
13shall assign a new independent review organization to
14reconsider the overturned decision. The new independent review
15organization shall follow subsection (d) of Section 40 of the
16Health Carrier External Review Act in rendering a decision.
17    (g) Future contractual or employment action by the health
18care plan regarding the patient's physician or other health
19care provider shall not be based solely on the physician's or
20other health care provider's participation in health care
21services appeals, complaints, or external independent reviews
22under the Illinois Health Carrier External Review Act.
23    (h) Nothing in this Section shall be construed to require
24a health care plan to pay for a health care service not covered
25under the enrollee's certificate of coverage or policy.
26    (i) Even if a health care plan or other utilization review

 

 

10300HB2472ham001- 34 -LRB103 28761 RPS 70817 a

1program uses an algorithmic automated process in the course of
2utilization review, the health care plan or other utilization
3review program shall ensure that only a clinical peer makes
4any adverse determination and that any appeal is processed as
5required by this Section, including the restriction that only
6a clinical peer may review an appeal. A health care plan or
7other utilization review program using an automated process
8shall have the accreditation and the policies and procedures
9required by subsection (b-10) of Section 85 of this Act.
10(Source: P.A. 96-857, eff. 7-1-10.)
 
11    (215 ILCS 134/85)
12    Sec. 85. Utilization review program registration.
13    (a) No person may conduct a utilization review program in
14this State unless once every 2 years the person registers the
15utilization review program with the Department and provides
16proof of current accreditation for itself and its
17subcontractors certifies compliance with the Health
18Utilization Management Standards of the Utilization Review
19Accreditation Commission or another accreditation entity
20authorized under this Section Health Utilization Management
21Standards of the American Accreditation Healthcare Commission
22(URAC) sufficient to achieve American Accreditation Healthcare
23Commission (URAC) accreditation or submits evidence of
24accreditation by the American Accreditation Healthcare
25Commission (URAC) for its Health Utilization Management

 

 

10300HB2472ham001- 35 -LRB103 28761 RPS 70817 a

1Standards. Nothing in this Act shall be construed to require a
2health care plan or its subcontractors to become American
3Accreditation Healthcare Commission (URAC) accredited.
4    (b) In addition, the Director of the Department, in
5consultation with the Director of the Department of Public
6Health, may certify alternative utilization review standards
7of national accreditation organizations or entities in order
8for plans to comply with this Section. Any alternative
9utilization review standards shall meet or exceed those
10standards required under subsection (a).
11    (b-5) The Department shall recognize the Accreditation
12Association for Ambulatory Health Care among the list of
13accreditors from which utilization organizations may receive
14accreditation and qualify for reduced registration and renewal
15fees.
16    (b-10) Utilization review programs that use algorithmic
17automated processes in the course of utilization review shall
18use objective, evidence-based criteria compliant with the
19accreditation requirements of the Health Utilization
20Management Standards of the Utilization Review Accreditation
21Commission or the National Committee for Quality Assurance
22(NCQA) and shall provide proof of such compliance to the
23Department with the registration required under subsection
24(a), including any renewal registrations. Nothing in this
25subsection supersedes paragraph (2) of subsection (e). The
26utilization review program shall include, with its

 

 

10300HB2472ham001- 36 -LRB103 28761 RPS 70817 a

1registration materials, attachments that contain policies and
2procedures:
3        (1) to ensure that licensed physicians with relevant
4    board certifications establish all criteria that the
5    algorithmic automated process uses for utilization review;
6    and
7        (2) for a program integrity system that, both before
8    new or revised criteria are used for utilization review
9    and when implementation errors in the algorithmic
10    automated process are identified after new or revised
11    criteria go into effect, requires licensed physicians with
12    relevant board certifications to verify that the
13    algorithmic automated process and corrections to it yield
14    results consistent with the criteria for their certified
15    field.
16    (c) The provisions of this Section do not apply to:
17        (1) persons providing utilization review program
18    services only to the federal government;
19        (2) self-insured health plans under the federal
20    Employee Retirement Income Security Act of 1974, however,
21    this Section does apply to persons conducting a
22    utilization review program on behalf of these health
23    plans;
24        (3) hospitals and medical groups performing
25    utilization review activities for internal purposes unless
26    the utilization review program is conducted for another

 

 

10300HB2472ham001- 37 -LRB103 28761 RPS 70817 a

1    person.
2    Nothing in this Act prohibits a health care plan or other
3entity from contractually requiring an entity designated in
4item (3) of this subsection to adhere to the utilization
5review program requirements of this Act.
6    (d) This registration shall include submission of all of
7the following information regarding utilization review program
8activities:
9        (1) The name, address, and telephone number of the
10    utilization review programs.
11        (2) The organization and governing structure of the
12    utilization review programs.
13        (3) The number of lives for which utilization review
14    is conducted by each utilization review program.
15        (4) Hours of operation of each utilization review
16    program.
17        (5) Description of the grievance process for each
18    utilization review program.
19        (6) Number of covered lives for which utilization
20    review was conducted for the previous calendar year for
21    each utilization review program.
22        (7) Written policies and procedures for protecting
23    confidential information according to applicable State and
24    federal laws for each utilization review program.
25    (e) (1) A utilization review program shall have written
26procedures for assuring that patient-specific information

 

 

10300HB2472ham001- 38 -LRB103 28761 RPS 70817 a

1obtained during the process of utilization review will be:
2        (A) kept confidential in accordance with applicable
3    State and federal laws; and
4        (B) shared only with the enrollee, the enrollee's
5    designee, the enrollee's health care provider, and those
6    who are authorized by law to receive the information.
7    Summary data shall not be considered confidential if it
8does not provide information to allow identification of
9individual patients or health care providers.
10        (2) Only a clinical peer health care professional may
11    make adverse determinations regarding the medical
12    necessity of health care services during the course of
13    utilization review. Either a health care professional or
14    an accredited algorithmic automated process, or both in
15    combination, may certify the medical necessity of a health
16    care service in accordance with accreditation standards.
17    Nothing in this subsection prohibits an accredited
18    algorithmic automated process from being used to refer a
19    case to a clinical peer for a potential adverse
20    determination.
21        (3) When making retrospective reviews, utilization
22    review programs shall base reviews solely on the medical
23    information available to the attending physician or
24    ordering provider at the time the health care services
25    were provided. This paragraph includes billing records and
26    diagnosis or procedure codes that substantively contain

 

 

10300HB2472ham001- 39 -LRB103 28761 RPS 70817 a

1    the same medical information to an equal or lesser degree
2    of specificity as the records the attending physician or
3    ordering provider directly consulted at the time health
4    care services were provided.
5        (4) When making prospective, concurrent, and
6    retrospective determinations, utilization review programs
7    shall collect only information that is necessary to make
8    the determination and shall not routinely require health
9    care providers to numerically code diagnoses or procedures
10    to be considered for certification, unless required under
11    State or federal Medicare or Medicaid rules or
12    regulations, but may request such code if available, or
13    routinely request copies of medical records of all
14    enrollees reviewed. During prospective or concurrent
15    review, copies of medical records shall only be required
16    when necessary to verify that the health care services
17    subject to review are medically necessary. In these cases,
18    only the necessary or relevant sections of the medical
19    record shall be required.
20    (f) If the Department finds that a utilization review
21program is not in compliance with this Section, the Department
22shall issue a corrective action plan and allow a reasonable
23amount of time for compliance with the plan. If the
24utilization review program does not come into compliance, the
25Department may issue a cease and desist order. Before issuing
26a cease and desist order under this Section, the Department

 

 

10300HB2472ham001- 40 -LRB103 28761 RPS 70817 a

1shall provide the utilization review program with a written
2notice of the reasons for the order and allow a reasonable
3amount of time to supply additional information demonstrating
4compliance with requirements of this Section and to request a
5hearing. The hearing notice shall be sent by certified mail,
6return receipt requested, and the hearing shall be conducted
7in accordance with the Illinois Administrative Procedure Act.
8    (g) A utilization review program subject to a corrective
9action may continue to conduct business until a final decision
10has been issued by the Department.
11    (h) Any adverse determination made by a health care plan
12or its subcontractors may be appealed in accordance with
13subsection (f) of Section 45.
14    (i) The Director may by rule establish a registration fee
15for each person conducting a utilization review program. All
16fees paid to and collected by the Director under this Section
17shall be deposited into the Insurance Producer Administration
18Fund.
19(Source: P.A. 99-111, eff. 1-1-16.)
 
20    Section 35. The Voluntary Health Services Plans Act is
21amended by changing Section 10 as follows:
 
22    (215 ILCS 165/10)  (from Ch. 32, par. 604)
23    Sec. 10. Application of Insurance Code provisions. Health
24services plan corporations and all persons interested therein

 

 

10300HB2472ham001- 41 -LRB103 28761 RPS 70817 a

1or dealing therewith shall be subject to the provisions of
2Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
3143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3,
4355b, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v,
5356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a,
6356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
7356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22,
8356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32,
9356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
10356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62,
11356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401,
12401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
13and (15) of Section 367 of the Illinois Insurance Code.
14    Rulemaking authority to implement Public Act 95-1045, if
15any, is conditioned on the rules being adopted in accordance
16with all provisions of the Illinois Administrative Procedure
17Act and all rules and procedures of the Joint Committee on
18Administrative Rules; any purported rule not so adopted, for
19whatever reason, is unauthorized.
20(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
21102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
2210-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,
23eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
24102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff.
251-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
26eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;

 

 

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1103-551, eff. 8-11-23; revised 8-29-23.)
 
2    Section 40. The Health Carrier External Review Act is
3amended by changing Section 10 as follows:
 
4    (215 ILCS 180/10)
5    Sec. 10. Definitions. For the purposes of this Act:
6    "Adverse determination" means:
7        (1) a determination by a health carrier or its
8    designee utilization review organization that, based upon
9    the health information provided, a request for a benefit,
10    including any quantity, frequency, duration, or other
11    measurement of a benefit, under the health carrier's
12    health benefit plan upon application of any utilization
13    review technique does not meet the health carrier's
14    requirements for medical necessity, appropriateness,
15    health care setting, level of care, or effectiveness or is
16    determined to be experimental or investigational and the
17    requested benefit is therefore denied, reduced, or
18    terminated or payment is not provided or made, in whole or
19    in part, for the benefit;
20        (2) the denial, reduction, or termination of or
21    failure to provide or make payment, in whole or in part,
22    for a benefit based on a determination by a health carrier
23    or its designee utilization review organization that a
24    preexisting condition was present before the effective

 

 

10300HB2472ham001- 43 -LRB103 28761 RPS 70817 a

1    date of coverage; or
2        (3) a rescission of coverage determination, which does
3    not include a cancellation or discontinuance of coverage
4    that is attributable to a failure to timely pay required
5    premiums or contributions towards the cost of coverage.
6    "Adverse determination" includes unilateral
7determinations that replace the requested health care service
8with an approval of an alternative health care service, or
9that condition approval of the requested service on first
10trying an alternative health care service, either if the
11request was made under a medical exceptions procedure, or if
12all of the following are true: (1) the requested service was
13not excluded by name, description, or service category under
14the written terms of coverage, (2) the alternative health care
15service poses no greater risk to the patient based on
16generally accepted standards of care, and (3) the alternative
17health care service is at least as likely to produce the same
18or better effect on the covered person's health as the
19requested service based on generally accepted standards of
20care. "Adverse determination" includes determinations made
21based on any source of health information pertaining to the
22covered person that is used to deny, reduce, replace,
23condition, or terminate the benefit or payment. "Adverse
24determination" includes determinations made in response to a
25request for authorization when the request was submitted by
26the health care provider regardless of whether the provider

 

 

10300HB2472ham001- 44 -LRB103 28761 RPS 70817 a

1gave notice to or obtained the consent of the covered person or
2authorized representative to file the request. "Adverse
3determination" does not include substitutions performed under
4Section 19.5 or 25 of the Pharmacy Practice Act.
5    "Authorized representative" means:
6        (1) a person to whom a covered person has given
7    express written consent to represent the covered person
8    for purposes of this Law;
9        (2) a person authorized by law to provide substituted
10    consent for a covered person;
11        (3) a family member of the covered person or the
12    covered person's treating health care professional when
13    the covered person is unable to provide consent;
14        (4) a health care provider when the covered person's
15    health benefit plan requires that a request for a benefit
16    under the plan be initiated by the health care provider;
17    or
18        (5) in the case of an urgent care request, a health
19    care provider with knowledge of the covered person's
20    medical condition.
21    "Best evidence" means evidence based on:
22        (1) randomized clinical trials;
23        (2) if randomized clinical trials are not available,
24    then cohort studies or case-control studies;
25        (3) if items (1) and (2) are not available, then
26    case-series; or

 

 

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1        (4) if items (1), (2), and (3) are not available, then
2    expert opinion.
3    "Case-series" means an evaluation of a series of patients
4with a particular outcome, without the use of a control group.
5    "Clinical review criteria" means the written screening
6procedures, decision abstracts, clinical protocols, and
7practice guidelines used by a health carrier to determine the
8necessity and appropriateness of health care services.
9    "Cohort study" means a prospective evaluation of 2 groups
10of patients with only one group of patients receiving specific
11intervention.
12    "Concurrent review" means a review conducted during a
13patient's stay or course of treatment in a facility, the
14office of a health care professional, or other inpatient or
15outpatient health care setting.
16    "Covered benefits" or "benefits" means those health care
17services to which a covered person is entitled under the terms
18of a health benefit plan.
19    "Covered person" means a policyholder, subscriber,
20enrollee, or other individual participating in a health
21benefit plan.
22    "Director" means the Director of the Department of
23Insurance.
24    "Emergency medical condition" means a medical condition
25manifesting itself by acute symptoms of sufficient severity,
26including, but not limited to, severe pain, such that a

 

 

10300HB2472ham001- 46 -LRB103 28761 RPS 70817 a

1prudent layperson who possesses an average knowledge of health
2and medicine could reasonably expect the absence of immediate
3medical attention to result in:
4        (1) placing the health of the individual or, with
5    respect to a pregnant woman, the health of the woman or her
6    unborn child, in serious jeopardy;
7        (2) serious impairment to bodily functions; or
8        (3) serious dysfunction of any bodily organ or part.
9    "Emergency services" means health care items and services
10furnished or required to evaluate and treat an emergency
11medical condition.
12    "Evidence-based standard" means the conscientious,
13explicit, and judicious use of the current best evidence based
14on an overall systematic review of the research in making
15decisions about the care of individual patients.
16    "Expert opinion" means a belief or an interpretation by
17specialists with experience in a specific area about the
18scientific evidence pertaining to a particular service,
19intervention, or therapy.
20    "Facility" means an institution providing health care
21services or a health care setting.
22    "Final adverse determination" means an adverse
23determination involving a covered benefit that has been upheld
24by a health carrier, or its designee utilization review
25organization, at the completion of the health carrier's
26internal grievance process procedures as set forth by the

 

 

10300HB2472ham001- 47 -LRB103 28761 RPS 70817 a

1Managed Care Reform and Patient Rights Act or as set forth for
2any additional authorization or internal appeal process
3provided by contract between the health carrier and the
4provider. "Final adverse determination" includes
5determinations made in an appeal of a denial of prior
6authorization when the appeal was submitted by the health care
7provider regardless of whether the provider gave notice to or
8obtained the consent of the covered person or authorized
9representative to file an internal appeal.
10    "Health benefit plan" means a policy, contract,
11certificate, plan, or agreement offered or issued by a health
12carrier to provide, deliver, arrange for, pay for, or
13reimburse any of the costs of health care services.
14    "Health care provider" or "provider" means a physician,
15hospital facility, or other health care practitioner licensed,
16accredited, or certified to perform specified health care
17services consistent with State law, responsible for
18recommending health care services on behalf of a covered
19person.
20    "Health care services" means services for the diagnosis,
21prevention, treatment, cure, or relief of a health condition,
22illness, injury, or disease.
23    "Health carrier" means an entity subject to the insurance
24laws and regulations of this State, or subject to the
25jurisdiction of the Director, that contracts or offers to
26contract to provide, deliver, arrange for, pay for, or

 

 

10300HB2472ham001- 48 -LRB103 28761 RPS 70817 a

1reimburse any of the costs of health care services, including
2a sickness and accident insurance company, a health
3maintenance organization, or any other entity providing a plan
4of health insurance, health benefits, or health care services.
5"Health carrier" also means Limited Health Service
6Organizations (LHSO) and Voluntary Health Service Plans.
7    "Health information" means information or data, whether
8oral or recorded in any form or medium, and personal facts or
9information about events or relationships that relate to:
10        (1) the past, present, or future physical, mental, or
11    behavioral health or condition of an individual or a
12    member of the individual's family;
13        (2) the provision of health care services to an
14    individual; or
15        (3) payment for the provision of health care services
16    to an individual.
17    "Independent review organization" means an entity that
18conducts independent external reviews of adverse
19determinations and final adverse determinations.
20    "Medical or scientific evidence" means evidence found in
21the following sources:
22        (1) peer-reviewed scientific studies published in or
23    accepted for publication by medical journals that meet
24    nationally recognized requirements for scientific
25    manuscripts and that submit most of their published
26    articles for review by experts who are not part of the

 

 

10300HB2472ham001- 49 -LRB103 28761 RPS 70817 a

1    editorial staff;
2        (2) peer-reviewed medical literature, including
3    literature relating to therapies reviewed and approved by
4    a qualified institutional review board, biomedical
5    compendia, and other medical literature that meet the
6    criteria of the National Institutes of Health's Library of
7    Medicine for indexing in Index Medicus (Medline) and
8    Elsevier Science Ltd. for indexing in Excerpta Medicus
9    (EMBASE);
10        (3) medical journals recognized by the Secretary of
11    Health and Human Services under Section 1861(t)(2) of the
12    federal Social Security Act;
13        (4) the following standard reference compendia:
14            (a) The American Hospital Formulary Service-Drug
15        Information;
16            (b) Drug Facts and Comparisons;
17            (c) The American Dental Association Accepted
18        Dental Therapeutics; and
19            (d) The United States Pharmacopoeia-Drug
20        Information;
21        (5) findings, studies, or research conducted by or
22    under the auspices of federal government agencies and
23    nationally recognized federal research institutes,
24    including:
25            (a) the federal Agency for Healthcare Research and
26        Quality;

 

 

10300HB2472ham001- 50 -LRB103 28761 RPS 70817 a

1            (b) the National Institutes of Health;
2            (c) the National Cancer Institute;
3            (d) the National Academy of Sciences;
4            (e) the Centers for Medicare & Medicaid Services;
5            (f) the federal Food and Drug Administration; and
6            (g) any national board recognized by the National
7        Institutes of Health for the purpose of evaluating the
8        medical value of health care services; or
9        (6) any other medical or scientific evidence that is
10    comparable to the sources listed in items (1) through (5).
11    "Person" means an individual, a corporation, a
12partnership, an association, a joint venture, a joint stock
13company, a trust, an unincorporated organization, any similar
14entity, or any combination of the foregoing.
15    "Prospective review" means a review conducted prior to an
16admission or the provision of a health care service or a course
17of treatment in accordance with a health carrier's requirement
18that the health care service or course of treatment, in whole
19or in part, be approved prior to its provision.
20    "Protected health information" means health information
21(i) that identifies an individual who is the subject of the
22information; or (ii) with respect to which there is a
23reasonable basis to believe that the information could be used
24to identify an individual.
25    "Randomized clinical trial" means a controlled prospective
26study of patients that have been randomized into an

 

 

10300HB2472ham001- 51 -LRB103 28761 RPS 70817 a

1experimental group and a control group at the beginning of the
2study with only the experimental group of patients receiving a
3specific intervention, which includes study of the groups for
4variables and anticipated outcomes over time.
5    "Retrospective review" means any review of a request for a
6benefit that is not a concurrent or prospective review
7request. "Retrospective review" does not include the review of
8a claim that is limited to veracity of documentation or
9accuracy of coding.
10    "Utilization review" has the meaning provided by the
11Managed Care Reform and Patient Rights Act.
12    "Utilization review organization" means a utilization
13review program as defined in the Managed Care Reform and
14Patient Rights Act.
15(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12;
1698-756, eff. 7-16-14.)
 
17    Section 45. The Prior Authorization Reform Act is amended
18by changing Section 55 as follows:
 
19    (215 ILCS 200/55)
20    Sec. 55. Denial or penalty.
21    (a) The health insurance issuer or its contracted
22utilization review organization may not revoke or further
23limit, condition, or restrict a previously issued prior
24authorization approval while it remains valid under this Act.

 

 

10300HB2472ham001- 52 -LRB103 28761 RPS 70817 a

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

 

 

10300HB2472ham001- 53 -LRB103 28761 RPS 70817 a

1    misrepresentation by the enrollee, health care
2    professional, or health care provider; as used in this
3    paragraph (5), "material" means a fact or situation that
4    is not merely technical in nature and results or could
5    result in a substantial change in the situation.
6    (c) Nothing in this Section shall preclude a utilization
7review organization or a health insurance issuer from
8performing post-service reviews of health care claims for
9purposes of payment integrity or for the prevention of fraud,
10waste, or abuse.
11    (d) If a health insurance issuer imposes a monetary
12penalty on the enrollee for the enrollee's, health care
13professional's, or health care provider's failure to obtain
14any form of prior authorization for a health care service, the
15penalty may not exceed the lesser of:
16        (1) the actual cost of the health care service; or
17        (2) $1,000 per occurrence in addition to the plan
18    cost-sharing provisions.
19    (e) A health insurance issuer may not require both the
20enrollee and the health care professional or health care
21provider to obtain any form of prior authorization for the
22same instance of a health care service, nor otherwise require
23more than one prior authorization for the same instance of a
24health care service.
25(Source: P.A. 102-409, eff. 1-1-22.)
 

 

 

10300HB2472ham001- 54 -LRB103 28761 RPS 70817 a

1    Section 99. Effective date. This Act takes effect January
21, 2025.".