Rep. Bob Morgan

Filed: 4/16/2024

 

 


 

 


 
10300HB2472ham002LRB103 28761 RPS 72440 a

1
AMENDMENT TO HOUSE BILL 2472

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

 

 

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1prognosis of the patient, together with the details of charges
2incident to the providing of care, treatment, or services,
3sufficient for the purpose of meeting the proof requirements
4of an insurance policy or a hospital, medical, or dental
5service contract.
6    (b) An insurer or a provider of health care treatment may
7not refuse to accept a claim or bill submitted on duly
8promulgated uniform claim and billing forms. An insurer,
9however, may accept claims and bills submitted on any other
10form.
11    (c) After receipt and adjudication or readjudication of
12any claim or bill with all required documentation from an
13insured or provider, or a notification under 42 U.S.C.
14300gg-136, an accident Accident and health insurer shall send
15explanation of benefits paid statements or claims summary
16statements sent to an insured by the accident and health
17insurer shall be in a format and written in a manner that
18promotes understanding by the insured by setting forth all of
19the following:
20        (1) The total dollar amount submitted to the insurer
21    for payment.
22        (2) Any reduction in the amount paid due to the
23    application of any co-payment, coinsurance, or deductible,
24    along with an explanation of the amount of the co-payment,
25    coinsurance, or deductible applied under the insured's
26    policy.

 

 

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

 

 

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1services, dental services, pharmaceutical services, or medical
2equipment must use the uniform claim and billing forms adopted
3by the Director under this Section.
4(Source: P.A. 91-357, eff. 7-29-99.)
 
5    (215 ILCS 5/155.36)
6    Sec. 155.36. Managed Care Reform and Patient Rights Act.
7Insurance companies that transact the kinds of insurance
8authorized under Class 1(b) or Class 2(a) of Section 4 of this
9Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65,
1070, and 85, subsection (d) of Section 30, and the definition of
11the term "emergency medical condition" in Section 10 of the
12Managed Care Reform and Patient Rights Act. Except as provided
13by Section 85 of the Managed Care Reform and Patient Rights
14Act, no law or rule shall be construed to exempt any
15utilization review program from the requirements of Section 85
16of the Managed Care Reform and Patient Rights Act with respect
17to any insurance described in this Section.
18(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
19    (215 ILCS 5/315.6)  (from Ch. 73, par. 927.6)
20    (Section scheduled to be repealed on January 1, 2027)
21    Sec. 315.6. Application of other Code provisions. Unless
22otherwise provided in this amendatory Act, every fraternal
23benefit society shall be governed by this amendatory Act and
24shall be exempt from all other provisions of the insurance

 

 

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1laws of this State not only in governmental relations with the
2State but for every other purpose, except for those provisions
3specified in this amendatory Act and except as follows:
4        (a) Sections 1, 2, 2.1, 3.1, 117, 118, 132, 132.1,
5    132.2, 132.3, 132.4, 132.5, 132.6, 132.7, 133, 134, 136,
6    138, 139, 140, 141, 141.01, 141.1, 141.2, 141.3, 143,
7    143.31, 143c, 144.1, 147, 148, 149, 150, 151, 152, 153,
8    154.5, 154.6, 154.7, 154.8, 155, 155.04, 155.05, 155.06,
9    155.07, 155.08 and 408 of this Code; and
10        (b) Articles VIII 1/2, XII, XII 1/2, XIII, XXIV, and
11    XXVIII of this Code.
12(Source: P.A. 98-814, eff. 1-1-15.)
 
13    (215 ILCS 5/370s)
14    Sec. 370s. Managed Care Reform and Patient Rights Act. All
15administrators shall comply with Sections 55 and 85 of the
16Managed Care Reform and Patient Rights Act. Except as provided
17by Section 85 of the Managed Care Reform and Patient Rights
18Act, no law or rule shall be construed to exempt any
19utilization review program from the requirements of Section 85
20of the Managed Care Reform and Patient Rights Act with respect
21to any insured or beneficiary described in this Article.
22(Source: P.A. 91-617, eff. 1-1-00.)
 
23    Section 10. The Dental Service Plan Act is amended by
24changing 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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1have timely and proximate access to treatment for mental,
2emotional, nervous, or substance use disorders or conditions
3in accordance with the provisions of paragraph (4) of
4subsection (a) of Section 370c of the Illinois Insurance Code.
5Insurers shall use a comparable process, strategy, evidentiary
6standard, and other factors in the development and application
7of the network adequacy standards for timely and proximate
8access to treatment for mental, emotional, nervous, or
9substance use disorders or conditions and those for the access
10to treatment for medical and surgical conditions. As such, the
11network adequacy standards for timely and proximate access
12shall equally be applied to treatment facilities and providers
13for mental, emotional, nervous, or substance use disorders or
14conditions and specialists providing medical or surgical
15benefits pursuant to the parity requirements of Section 370c.1
16of the Illinois Insurance Code and the federal Paul Wellstone
17and Pete Domenici Mental Health Parity and Addiction Equity
18Act of 2008. Notwithstanding the foregoing, the network
19adequacy standards for timely and proximate access to
20treatment for mental, emotional, nervous, or substance use
21disorders or conditions shall, at a minimum, satisfy the
22following requirements:
23        (A) For beneficiaries residing in the metropolitan
24    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
25    network adequacy standards for timely and proximate access
26    to treatment for mental, emotional, nervous, or substance

 

 

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

 

 

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

 

 

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

 

 

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1    or facility;
2        (2) if patterns of care in the service area do not
3    support the need for the requested number of provider or
4    facility type and the insurer provides data on local
5    patterns of care, such as claims data, referral patterns,
6    or local provider interviews, indicating where the
7    beneficiaries currently seek this type of care or where
8    the physicians currently refer beneficiaries, or both; or
9        (3) other circumstances deemed appropriate by the
10    Department consistent with the requirements of this Act.
11    (h) Insurers are required to report to the Director any
12material change to an approved network plan within 15 days
13after the change occurs and any change that would result in
14failure to meet the requirements of this Act. Upon notice from
15the insurer, the Director shall reevaluate the network plan's
16compliance with the network adequacy and transparency
17standards of this Act.
18(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
19102-1117, eff. 1-13-23.)
 
20    Section 20. The Health Maintenance Organization Act is
21amended by changing Section 5-3 as follows:
 
22    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
23    Sec. 5-3. Insurance Code provisions.
24    (a) Health Maintenance Organizations shall be subject to

 

 

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1the provisions of Sections 133, 134, 136, 137, 139, 140,
2141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
3152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
4155.49, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q,
5356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
6356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
7356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
8356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,
9356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
10356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
11356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,
12356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
13356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
14356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
15368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
16408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
17subsection (2) of Section 367, and Articles IIA, VIII 1/2,
18XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
19Illinois Insurance Code.
20    (b) For purposes of the Illinois Insurance Code, except
21for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
22Health Maintenance Organizations in the following categories
23are deemed to be "domestic companies":
24        (1) a corporation authorized under the Dental Service
25    Plan Act or the Voluntary Health Services Plans Act;
26        (2) a corporation organized under the laws of this

 

 

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

 

 

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

 

 

10300HB2472ham002- 21 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 22 -LRB103 28761 RPS 72440 a

1    made or additional premium to be paid pursuant to this
2    subsection (f)). The Health Maintenance Organization and
3    the group or enrollment unit may agree that the profitable
4    or unprofitable experience may be calculated taking into
5    account the refund period and the immediately preceding 2
6    plan years.
7    The Health Maintenance Organization shall include a
8statement in the evidence of coverage issued to each enrollee
9describing the possibility of a refund or additional premium,
10and upon request of any group or enrollment unit, provide to
11the group or enrollment unit a description of the method used
12to calculate (1) the Health Maintenance Organization's
13profitable experience with respect to the group or enrollment
14unit and the resulting refund to the group or enrollment unit
15or (2) the Health Maintenance Organization's unprofitable
16experience with respect to the group or enrollment unit and
17the resulting additional premium to be paid by the group or
18enrollment unit.
19    In no event shall the Illinois Health Maintenance
20Organization Guaranty Association be liable to pay any
21contractual obligation of an insolvent organization to pay any
22refund authorized under this Section.
23    (g) Rulemaking authority to implement Public Act 95-1045,
24if any, is conditioned on the rules being adopted in
25accordance with all provisions of the Illinois Administrative
26Procedure Act and all rules and procedures of the Joint

 

 

10300HB2472ham002- 23 -LRB103 28761 RPS 72440 a

1Committee on Administrative Rules; any purported rule not so
2adopted, for whatever reason, is unauthorized.
3(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
4102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
51-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
6eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
7102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
81-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
9eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
10103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
116-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
12eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
13    Section 25. The Limited Health Service Organization Act is
14amended by changing Section 4003 as follows:
 
15    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
16    Sec. 4003. Illinois Insurance Code provisions. Limited
17health service organizations shall be subject to the
18provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
19141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153,
20154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49,
21355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10,
22356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
23356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
24356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,

 

 

10300HB2472ham002- 24 -LRB103 28761 RPS 72440 a

1364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
2444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
3XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
4Nothing in this Section shall require a limited health care
5plan to cover any service that is not a limited health service.
6For purposes of the Illinois Insurance Code, except for
7Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
8health service organizations in the following categories are
9deemed to be domestic companies:
10        (1) a corporation under the laws of this State; or
11        (2) a corporation organized under the laws of another
12    state, 30% or more of the enrollees of which are residents
13    of this State, except a corporation subject to
14    substantially the same requirements in its state of
15    organization as is a domestic company under Article VIII
16    1/2 of the Illinois Insurance Code.
17(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
18102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
191-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
20eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
21102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
221-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
23eff. 1-1-24; revised 8-29-23.)
 
24    Section 30. The Managed Care Reform and Patient Rights Act
25is amended by changing Sections 10, 45, and 85 as follows:
 

 

 

10300HB2472ham002- 25 -LRB103 28761 RPS 72440 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;

 

 

10300HB2472ham002- 26 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 27 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 28 -LRB103 28761 RPS 72440 a

1    Security Act of 1974;
2        (5) health care provided pursuant to the Workers'
3    Compensation Act or the Workers' Occupational Diseases
4    Act; and
5        (6) except with respect to subsections (a) and (b) of
6    Section 65 and subsection (a-5) of Section 70,
7    not-for-profit voluntary health services plans with health
8    maintenance organization authority in existence as of
9    January 1, 1999 that are affiliated with a union and that
10    only extend coverage to union members and their
11    dependents.
12    "Health care professional" means a physician, a registered
13professional nurse, or other individual appropriately licensed
14or registered to provide health care services.
15    "Health care provider" means any physician, hospital
16facility, facility licensed under the Nursing Home Care Act,
17long-term care facility as defined in Section 1-113 of the
18Nursing Home Care Act, or other person that is licensed or
19otherwise authorized to deliver health care services. Nothing
20in this Act shall be construed to define Independent Practice
21Associations or Physician-Hospital Organizations as health
22care providers.
23    "Health care services" means any services included in the
24furnishing to any individual of medical care, or the
25hospitalization incident to the furnishing of such care, as
26well as the furnishing to any person of any and all other

 

 

10300HB2472ham002- 29 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 30 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 31 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 32 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 33 -LRB103 28761 RPS 72440 a

1    (f) Until July 1, 2013, if an external independent review
2decision made pursuant to the Illinois Health Carrier External
3Review Act upholds a determination adverse to the covered
4person, the covered person has the right to appeal the final
5decision to the Department; if the external review decision is
6found by the Director to have been arbitrary and capricious,
7then the Director, with consultation from a licensed medical
8professional, may overturn the external review decision and
9require the health carrier to pay for the health care service
10or treatment; such decision, if any, shall be made solely on
11the legal or medical merits of the claim. If an external review
12decision is overturned by the Director pursuant to this
13Section and the health carrier so requests, then the Director
14shall assign a new independent review organization to
15reconsider the overturned decision. The new independent review
16organization shall follow subsection (d) of Section 40 of the
17Health Carrier External Review Act in rendering a decision.
18    (g) Future contractual or employment action by the health
19care plan regarding the patient's physician or other health
20care provider shall not be based solely on the physician's or
21other health care provider's participation in health care
22services appeals, complaints, or external independent reviews
23under the Illinois Health Carrier External Review Act.
24    (h) Nothing in this Section shall be construed to require
25a health care plan to pay for a health care service not covered
26under the enrollee's certificate of coverage or policy.

 

 

10300HB2472ham002- 34 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 35 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 36 -LRB103 28761 RPS 72440 a

1compliance to the Department with the registration required
2under subsection (a), including any renewal registrations.
3Nothing in this subsection supersedes paragraph (2) of
4subsection (e). The utilization review program shall include,
5with its registration materials, attachments that contain
6policies and procedures:
7        (1) to ensure that licensed physicians with relevant
8    board certifications establish all criteria that the
9    algorithmic automated process uses for utilization review;
10    and
11        (2) for a program integrity system that, both before
12    new or revised criteria are used for utilization review
13    and when implementation errors in the algorithmic
14    automated process are identified after new or revised
15    criteria go into effect, requires licensed physicians with
16    relevant board certifications to verify that the
17    algorithmic automated process and corrections to it yield
18    results consistent with the criteria for their certified
19    field.
20    (c) The provisions of this Section do not apply to:
21        (1) persons providing utilization review program
22    services only to the federal government;
23        (2) self-insured health plans under the federal
24    Employee Retirement Income Security Act of 1974, however,
25    this Section does apply to persons conducting a
26    utilization review program on behalf of these health

 

 

10300HB2472ham002- 37 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 38 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 39 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 40 -LRB103 28761 RPS 72440 a

1amount of time for compliance with the plan. If the
2utilization review program does not come into compliance, the
3Department may issue a cease and desist order. Before issuing
4a cease and desist order under this Section, the Department
5shall provide the utilization review program with a written
6notice of the reasons for the order and allow a reasonable
7amount of time to supply additional information demonstrating
8compliance with requirements of this Section and to request a
9hearing. The hearing notice shall be sent by certified mail,
10return receipt requested, and the hearing shall be conducted
11in accordance with the Illinois Administrative Procedure Act.
12    (g) A utilization review program subject to a corrective
13action may continue to conduct business until a final decision
14has been issued by the Department.
15    (h) Any adverse determination made by a health care plan
16or its subcontractors may be appealed in accordance with
17subsection (f) of Section 45.
18    (i) The Director may by rule establish a registration fee
19for each person conducting a utilization review program. All
20fees paid to and collected by the Director under this Section
21shall be deposited into the Insurance Producer Administration
22Fund.
23(Source: P.A. 99-111, eff. 1-1-16.)
 
24    Section 35. The Voluntary Health Services Plans Act is
25amended by changing Section 10 as follows:
 

 

 

10300HB2472ham002- 41 -LRB103 28761 RPS 72440 a

1    (215 ILCS 165/10)  (from Ch. 32, par. 604)
2    Sec. 10. Application of Insurance Code provisions. Health
3services plan corporations and all persons interested therein
4or dealing therewith shall be subject to the provisions of
5Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
6143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3,
7355b, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v,
8356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a,
9356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
10356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22,
11356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32,
12356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
13356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62,
14356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401,
15401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
16and (15) of Section 367 of the Illinois Insurance Code.
17    Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
24102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
2510-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,

 

 

10300HB2472ham002- 42 -LRB103 28761 RPS 72440 a

1eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
2102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff.
31-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
4eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
5103-551, eff. 8-11-23; revised 8-29-23.)
 
6    Section 40. The Health Carrier External Review Act is
7amended by changing Section 10 as follows:
 
8    (215 ILCS 180/10)
9    Sec. 10. Definitions. For the purposes of this Act:
10    "Adverse determination" means:
11        (1) a determination by a health carrier or its
12    designee utilization review organization that, based upon
13    the health information provided for a covered person, a
14    request for a benefit, including any quantity, frequency,
15    duration, or other measurement of a benefit, under the
16    health carrier's health benefit plan upon application of
17    any utilization review technique does not meet the health
18    carrier's requirements for medical necessity,
19    appropriateness, health care setting, level of care, or
20    effectiveness or is determined to be experimental or
21    investigational and the requested benefit is therefore
22    denied, reduced, or terminated or payment is not provided
23    or made, in whole or in part, for the benefit;
24        (2) the denial, reduction, or termination of or

 

 

10300HB2472ham002- 43 -LRB103 28761 RPS 72440 a

1    failure to provide or make payment, in whole or in part,
2    for a benefit based on a determination by a health carrier
3    or its designee utilization review organization that a
4    preexisting condition was present before the effective
5    date of coverage; or
6        (3) a rescission of coverage determination, which does
7    not include a cancellation or discontinuance of coverage
8    that is attributable to a failure to timely pay required
9    premiums or contributions towards the cost of coverage.
10    "Adverse determination" includes unilateral
11determinations that replace the requested health care service
12with an approval of an alternative health care service without
13the agreement of the covered person or the covered person's
14attending provider for the requested health care service, or
15that condition approval of the requested service on first
16trying an alternative health care service, either if the
17request was made under a medical exceptions procedure, or if
18all of the following are true: (1) the requested service was
19not excluded by name, description, or service category under
20the written terms of coverage, (2) the alternative health care
21service poses no greater risk to the patient based on
22generally accepted standards of care, and (3) the alternative
23health care service is at least as likely to produce the same
24or better effect on the covered person's health as the
25requested service based on generally accepted standards of
26care. "Adverse determination" includes determinations made

 

 

10300HB2472ham002- 44 -LRB103 28761 RPS 72440 a

1based on any source of health information pertaining to the
2covered person that is used to deny, reduce, replace,
3condition, or terminate the benefit or payment. "Adverse
4determination" includes determinations made in response to a
5request for authorization when the request was submitted by
6the health care provider regardless of whether the provider
7gave notice to or obtained the consent of the covered person or
8authorized representative to file the request. "Adverse
9determination" does not include substitutions performed under
10Section 19.5 or 25 of the Pharmacy Practice Act.
11    "Authorized representative" means:
12        (1) a person to whom a covered person has given
13    express written consent to represent the covered person
14    for purposes of this Law;
15        (2) a person authorized by law to provide substituted
16    consent for a covered person;
17        (3) a family member of the covered person or the
18    covered person's treating health care professional when
19    the covered person is unable to provide consent;
20        (4) a health care provider when the covered person's
21    health benefit plan requires that a request for a benefit
22    under the plan be initiated by the health care provider;
23    or
24        (5) in the case of an urgent care request, a health
25    care provider with knowledge of the covered person's
26    medical condition.

 

 

10300HB2472ham002- 45 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 46 -LRB103 28761 RPS 72440 a

1benefit plan.
2    "Director" means the Director of the Department of
3Insurance.
4    "Emergency medical condition" means a medical condition
5manifesting itself by acute symptoms of sufficient severity,
6including, but not limited to, severe pain, such that a
7prudent layperson who possesses an average knowledge of health
8and medicine could reasonably expect the absence of immediate
9medical attention to result in:
10        (1) placing the health of the individual or, with
11    respect to a pregnant woman, the health of the woman or her
12    unborn child, in serious jeopardy;
13        (2) serious impairment to bodily functions; or
14        (3) serious dysfunction of any bodily organ or part.
15    "Emergency services" means health care items and services
16furnished or required to evaluate and treat an emergency
17medical condition.
18    "Evidence-based standard" means the conscientious,
19explicit, and judicious use of the current best evidence based
20on an overall systematic review of the research in making
21decisions about the care of individual patients.
22    "Expert opinion" means a belief or an interpretation by
23specialists with experience in a specific area about the
24scientific evidence pertaining to a particular service,
25intervention, or therapy.
26    "Facility" means an institution providing health care

 

 

10300HB2472ham002- 47 -LRB103 28761 RPS 72440 a

1services or a health care setting.
2    "Final adverse determination" means an adverse
3determination involving a covered benefit that has been upheld
4by a health carrier, or its designee utilization review
5organization, at the completion of the health carrier's
6internal grievance process procedures as set forth by the
7Managed Care Reform and Patient Rights Act or as set forth for
8any additional authorization or internal appeal process
9provided by contract between the health carrier and the
10provider. "Final adverse determination" includes
11determinations made in an appeal of a denial of prior
12authorization when the appeal was submitted by the health care
13provider regardless of whether the provider gave notice to or
14obtained the consent of the covered person or authorized
15representative to file an internal appeal.
16    "Health benefit plan" means a policy, contract,
17certificate, plan, or agreement offered or issued by a health
18carrier to provide, deliver, arrange for, pay for, or
19reimburse any of the costs of health care services.
20    "Health care provider" or "provider" means a physician,
21hospital facility, or other health care practitioner licensed,
22accredited, or certified to perform specified health care
23services consistent with State law, responsible for
24recommending health care services on behalf of a covered
25person.
26    "Health care services" means services for the diagnosis,

 

 

10300HB2472ham002- 48 -LRB103 28761 RPS 72440 a

1prevention, treatment, cure, or relief of a health condition,
2illness, injury, or disease.
3    "Health carrier" means an entity subject to the insurance
4laws and regulations of this State, or subject to the
5jurisdiction of the Director, that contracts or offers to
6contract to provide, deliver, arrange for, pay for, or
7reimburse any of the costs of health care services, including
8a sickness and accident insurance company, a health
9maintenance organization, or any other entity providing a plan
10of health insurance, health benefits, or health care services.
11"Health carrier" also means Limited Health Service
12Organizations (LHSO) and Voluntary Health Service Plans.
13    "Health information" means information or data, whether
14oral or recorded in any form or medium, and personal facts or
15information about events or relationships that relate to:
16        (1) the past, present, or future physical, mental, or
17    behavioral health or condition of an individual or a
18    member of the individual's family;
19        (2) the provision of health care services to an
20    individual; or
21        (3) payment for the provision of health care services
22    to an individual.
23    "Independent review organization" means an entity that
24conducts independent external reviews of adverse
25determinations and final adverse determinations.
26    "Medical or scientific evidence" means evidence found in

 

 

10300HB2472ham002- 49 -LRB103 28761 RPS 72440 a

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

 

 

10300HB2472ham002- 50 -LRB103 28761 RPS 72440 a

1        (5) findings, studies, or research conducted by or
2    under the auspices of federal government agencies and
3    nationally recognized federal research institutes,
4    including:
5            (a) the federal Agency for Healthcare Research and
6        Quality;
7            (b) the National Institutes of Health;
8            (c) the National Cancer Institute;
9            (d) the National Academy of Sciences;
10            (e) the Centers for Medicare & Medicaid Services;
11            (f) the federal Food and Drug Administration; and
12            (g) any national board recognized by the National
13        Institutes of Health for the purpose of evaluating the
14        medical value of health care services; or
15        (6) any other medical or scientific evidence that is
16    comparable to the sources listed in items (1) through (5).
17    "Person" means an individual, a corporation, a
18partnership, an association, a joint venture, a joint stock
19company, a trust, an unincorporated organization, any similar
20entity, or any combination of the foregoing.
21    "Prospective review" means a review conducted prior to an
22admission or the provision of a health care service or a course
23of treatment in accordance with a health carrier's requirement
24that the health care service or course of treatment, in whole
25or in part, be approved prior to its provision.
26    "Protected health information" means health information

 

 

10300HB2472ham002- 51 -LRB103 28761 RPS 72440 a

1(i) that identifies an individual who is the subject of the
2information; or (ii) with respect to which there is a
3reasonable basis to believe that the information could be used
4to identify an individual.
5    "Randomized clinical trial" means a controlled prospective
6study of patients that have been randomized into an
7experimental group and a control group at the beginning of the
8study with only the experimental group of patients receiving a
9specific intervention, which includes study of the groups for
10variables and anticipated outcomes over time.
11    "Retrospective review" means any review of a request for a
12benefit that is not a concurrent or prospective review
13request. "Retrospective review" does not include the review of
14a claim that is limited to veracity of documentation or
15accuracy of coding.
16    "Utilization review" has the meaning provided by the
17Managed Care Reform and Patient Rights Act.
18    "Utilization review organization" means a utilization
19review program as defined in the Managed Care Reform and
20Patient Rights Act.
21(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12;
2298-756, eff. 7-16-14.)
 
23    Section 45. The Prior Authorization Reform Act is amended
24by changing Section 55 as follows:
 

 

 

10300HB2472ham002- 52 -LRB103 28761 RPS 72440 a

1    (215 ILCS 200/55)
2    Sec. 55. Denial or penalty.
3    (a) The health insurance issuer or its contracted
4utilization review organization may not revoke or further
5limit, condition, or restrict a previously issued prior
6authorization approval while it remains valid under this Act.
7    (b) Notwithstanding any other provision of law, if a claim
8is properly coded and submitted timely to a health insurance
9issuer, the health insurance issuer shall make payment
10according to the terms of coverage on claims for health care
11services for which prior authorization was required and
12approval received before the rendering of health care
13services, unless one of the following occurs:
14        (1) it is timely determined that the enrollee's health
15    care professional or health care provider knowingly
16    provided health care services that required prior
17    authorization from the health insurance issuer or its
18    contracted utilization review organization without first
19    obtaining prior authorization for those health care
20    services;
21        (2) it is timely determined that the health care
22    services claimed were not performed;
23        (3) it is timely determined that the health care
24    services rendered were contrary to the instructions of the
25    health insurance issuer or its contracted utilization
26    review organization or delegated reviewer if contact was

 

 

10300HB2472ham002- 53 -LRB103 28761 RPS 72440 a

1    made between those parties before the service being
2    rendered;
3        (4) it is timely determined that the enrollee
4    receiving such health care services was not an enrollee of
5    the health care plan; or
6        (5) the approval was based upon a material
7    misrepresentation by the enrollee, health care
8    professional, or health care provider; as used in this
9    paragraph (5), "material" means a fact or situation that
10    is not merely technical in nature and results or could
11    result in a substantial change in the situation.
12    (c) Nothing in this Section shall preclude a utilization
13review organization or a health insurance issuer from
14performing post-service reviews of health care claims for
15purposes of payment integrity or for the prevention of fraud,
16waste, or abuse.
17    (d) If a health insurance issuer imposes a monetary
18penalty on the enrollee for the enrollee's, health care
19professional's, or health care provider's failure to obtain
20any form of prior authorization for a health care service, the
21penalty may not exceed the lesser of:
22        (1) the actual cost of the health care service; or
23        (2) $1,000 per occurrence in addition to the plan
24    cost-sharing provisions.
25    (e) A health insurance issuer may not require both the
26enrollee and the health care professional or health care

 

 

10300HB2472ham002- 54 -LRB103 28761 RPS 72440 a

1provider to obtain any form of prior authorization for the
2same instance of a health care service, nor otherwise require
3more than one prior authorization for the same instance of a
4health care service.
5(Source: P.A. 102-409, eff. 1-1-22.)
 
6    Section 99. Effective date. This Act takes effect January
71, 2025.".