HB5395 EngrossedLRB103 37071 RPS 67189 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4
Article 1.

 
5    Section 1-1. This Act may be referred to as the Health Care
6Protection Act.
 
7
Article 2.

 
8    Section 2-5. The Illinois Administrative Procedure Act is
9amended by adding Section 5-45.55 as follows:
 
10    (5 ILCS 100/5-45.55 new)
11    Sec. 5-45.55. Emergency rulemaking; Network Adequacy and
12Transparency Act. To provide for the expeditious and timely
13implementation of the Network Adequacy and Transparency Act,
14emergency rules implementing federal standards for provider
15ratios, travel time and distance, and appointment wait times
16if such standards apply to health insurance coverage regulated
17by the Department of Insurance and are more stringent than the
18State standards extant at the time the final federal standards
19are published may be adopted in accordance with Section 5-45
20by the Department of Insurance. The adoption of emergency

 

 

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1rules authorized by Section 5-45 and this Section is deemed to
2be necessary for the public interest, safety, and welfare.
 
3    Section 2-10. The Network Adequacy and Transparency Act is
4amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and
5by adding Sections 35, 40, 50, and 55 as follows:
 
6    (215 ILCS 124/3)
7    Sec. 3. Applicability of Act. This Act applies to an
8individual or group policy of accident and health insurance
9coverage with a network plan amended, delivered, issued, or
10renewed in this State on or after January 1, 2019. This Act
11does not apply to an individual or group policy for excepted
12benefits or short-term, limited-duration health insurance
13coverage dental or vision insurance or a limited health
14service organization with a network plan amended, delivered,
15issued, or renewed in this State on or after January 1, 2019,
16except to the extent that federal law establishes network
17adequacy and transparency standards for stand-alone dental
18plans, which the Department shall enforce for plans amended,
19delivered, issued, or renewed on or after January 1, 2025.
20(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
 
21    (215 ILCS 124/5)
22    Sec. 5. Definitions. In this Act:
23    "Authorized representative" means a person to whom a

 

 

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1beneficiary has given express written consent to represent the
2beneficiary; a person authorized by law to provide substituted
3consent for a beneficiary; or the beneficiary's treating
4provider only when the beneficiary or his or her family member
5is unable to provide consent.
6    "Beneficiary" means an individual, an enrollee, an
7insured, a participant, or any other person entitled to
8reimbursement for covered expenses of or the discounting of
9provider fees for health care services under a program in
10which the beneficiary has an incentive to utilize the services
11of a provider that has entered into an agreement or
12arrangement with an issuer insurer.
13    "Department" means the Department of Insurance.
14    "Essential community provider" has the meaning ascribed to
15that term in 45 CFR 156.235.
16    "Excepted benefits" has the meaning ascribed to that term
17in 42 U.S.C. 300gg-91(c).
18    "Exchange" has the meaning ascribed to that term in 45 CFR
19155.20.
20    "Director" means the Director of Insurance.
21    "Family caregiver" means a relative, partner, friend, or
22neighbor who has a significant relationship with the patient
23and administers or assists the patient with activities of
24daily living, instrumental activities of daily living, or
25other medical or nursing tasks for the quality and welfare of
26that patient.

 

 

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1    "Group health plan" has the meaning ascribed to that term
2in Section 5 of the Illinois Health Insurance Portability and
3Accountability Act.
4    "Health insurance coverage" has the meaning ascribed to
5that term in Section 5 of the Illinois Health Insurance
6Portability and Accountability Act. "Health insurance
7coverage" does not include any coverage or benefits under
8Medicare or under the medical assistance program established
9under Article V of the Illinois Public Aid Code.
10    "Issuer" means a "health insurance issuer" as defined in
11Section 5 of the Illinois Health Insurance Portability and
12Accountability Act.
13    "Insurer" means any entity that offers individual or group
14accident and health insurance, including, but not limited to,
15health maintenance organizations, preferred provider
16organizations, exclusive provider organizations, and other
17plan structures requiring network participation, excluding the
18medical assistance program under the Illinois Public Aid Code,
19the State employees group health insurance program, workers
20compensation insurance, and pharmacy benefit managers.
21    "Material change" means a significant reduction in the
22number of providers available in a network plan, including,
23but not limited to, a reduction of 10% or more in a specific
24type of providers within any county, the removal of a major
25health system that causes a network to be significantly
26different within any county from the network when the

 

 

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1beneficiary purchased the network plan, or any change that
2would cause the network to no longer satisfy the requirements
3of this Act or the Department's rules for network adequacy and
4transparency.
5    "Network" means the group or groups of preferred providers
6providing services to a network plan.
7    "Network plan" means an individual or group policy of
8accident and health insurance coverage that either requires a
9covered person to use or creates incentives, including
10financial incentives, for a covered person to use providers
11managed, owned, under contract with, or employed by the issuer
12or by a third party contracted to arrange, contract for, or
13administer such provider-related incentives for the issuer
14insurer.
15    "Ongoing course of treatment" means (1) treatment for a
16life-threatening condition, which is a disease or condition
17for which likelihood of death is probable unless the course of
18the disease or condition is interrupted; (2) treatment for a
19serious acute condition, defined as a disease or condition
20requiring complex ongoing care that the covered person is
21currently receiving, such as chemotherapy, radiation therapy,
22or post-operative visits, or a serious and complex condition
23as defined under 42 U.S.C. 300gg-113(b)(2); (3) a course of
24treatment for a health condition that a treating provider
25attests that discontinuing care by that provider would worsen
26the condition or interfere with anticipated outcomes; or (4)

 

 

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1the third trimester of pregnancy through the post-partum
2period; (5) undergoing a course of institutional or inpatient
3care from the provider within the meaning of 42 U.S.C.
4300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective
5surgery from the provider, including receipt of preoperative
6or postoperative care from such provider with respect to such
7a surgery; (7) being determined to be terminally ill, as
8determined under 42 U.S.C. 1395x(dd)(3)(A), and receiving
9treatment for such illness from such provider; or (8) any
10other treatment of a condition or disease that requires
11repeated health care services pursuant to a plan of treatment
12by a provider because of the potential for changes in the
13therapeutic regimen or because of the potential for a
14recurrence of symptoms.
15    "Preferred provider" means any provider who has entered,
16either directly or indirectly, into an agreement with an
17employer or risk-bearing entity relating to health care
18services that may be rendered to beneficiaries under a network
19plan.
20    "Providers" means physicians licensed to practice medicine
21in all its branches, other health care professionals,
22hospitals, or other health care institutions or facilities
23that provide health care services.
24    "Short-term, limited-duration insurance" means any type of
25accident and health insurance offered or provided within this
26State pursuant to a group or individual policy or individual

 

 

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1certificate by a company, regardless of the situs state of the
2delivery of the policy, that has an expiration date specified
3in the contract that is fewer than 365 days after the original
4effective date. Regardless of the duration of coverage,
5"short-term, limited-duration insurance" does not include
6excepted benefits or any student health insurance coverage.
7    "Stand-alone dental plan" has the meaning ascribed to that
8term in 45 CFR 156.400.
9    "Telehealth" has the meaning given to that term in Section
10356z.22 of the Illinois Insurance Code.
11    "Telemedicine" has the meaning given to that term in
12Section 49.5 of the Medical Practice Act of 1987.
13    "Tiered network" means a network that identifies and
14groups some or all types of provider and facilities into
15specific groups to which different provider reimbursement,
16covered person cost-sharing or provider access requirements,
17or any combination thereof, apply for the same services.
18    "Woman's principal health care provider" means a physician
19licensed to practice medicine in all of its branches
20specializing in obstetrics, gynecology, or family practice.
21(Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)
 
22    (215 ILCS 124/10)
23    Sec. 10. Network adequacy.
24    (a) Before issuing, delivering, or renewing a network
25plan, an issuer An insurer providing a network plan shall file

 

 

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1a description of all of the following with the Director:
2        (1) The written policies and procedures for adding
3    providers to meet patient needs based on increases in the
4    number of beneficiaries, changes in the
5    patient-to-provider ratio, changes in medical and health
6    care capabilities, and increased demand for services.
7        (2) The written policies and procedures for making
8    referrals within and outside the network.
9        (3) The written policies and procedures on how the
10    network plan will provide 24-hour, 7-day per week access
11    to network-affiliated primary care, emergency services,
12    and women's principal health care providers.
13    An issuer insurer shall not prohibit a preferred provider
14from discussing any specific or all treatment options with
15beneficiaries irrespective of the insurer's position on those
16treatment options or from advocating on behalf of
17beneficiaries within the utilization review, grievance, or
18appeals processes established by the issuer insurer in
19accordance with any rights or remedies available under
20applicable State or federal law.
21    (b) Before issuing, delivering, or renewing a network
22plan, an issuer Insurers must file for review a description of
23the services to be offered through a network plan. The
24description shall include all of the following:
25        (1) A geographic map of the area proposed to be served
26    by the plan by county service area and zip code, including

 

 

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1    marked locations for preferred providers.
2        (2) As deemed necessary by the Department, the names,
3    addresses, phone numbers, and specialties of the providers
4    who have entered into preferred provider agreements under
5    the network plan.
6        (3) The number of beneficiaries anticipated to be
7    covered by the network plan.
8        (4) An Internet website and toll-free telephone number
9    for beneficiaries and prospective beneficiaries to access
10    current and accurate lists of preferred providers in each
11    plan, additional information about the plan, as well as
12    any other information required by Department rule.
13        (5) A description of how health care services to be
14    rendered under the network plan are reasonably accessible
15    and available to beneficiaries. The description shall
16    address all of the following:
17            (A) the type of health care services to be
18        provided by the network plan;
19            (B) the ratio of physicians and other providers to
20        beneficiaries, by specialty and including primary care
21        physicians and facility-based physicians when
22        applicable under the contract, necessary to meet the
23        health care needs and service demands of the currently
24        enrolled population;
25            (C) the travel and distance standards for plan
26        beneficiaries in county service areas; and

 

 

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1            (D) a description of how the use of telemedicine,
2        telehealth, or mobile care services may be used to
3        partially meet the network adequacy standards, if
4        applicable.
5        (6) A provision ensuring that whenever a beneficiary
6    has made a good faith effort, as evidenced by accessing
7    the provider directory, calling the network plan, and
8    calling the provider, to utilize preferred providers for a
9    covered service and it is determined the insurer does not
10    have the appropriate preferred providers due to
11    insufficient number, type, unreasonable travel distance or
12    delay, or preferred providers refusing to provide a
13    covered service because it is contrary to the conscience
14    of the preferred providers, as protected by the Health
15    Care Right of Conscience Act, the issuer insurer shall
16    ensure, directly or indirectly, by terms contained in the
17    payer contract, that the beneficiary will be provided the
18    covered service at no greater cost to the beneficiary than
19    if the service had been provided by a preferred provider.
20    This paragraph (6) does not apply to: (A) a beneficiary
21    who willfully chooses to access a non-preferred provider
22    for health care services available through the panel of
23    preferred providers, or (B) a beneficiary enrolled in a
24    health maintenance organization. In these circumstances,
25    the contractual requirements for non-preferred provider
26    reimbursements shall apply unless Section 356z.3a of the

 

 

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1    Illinois Insurance Code requires otherwise. In no event
2    shall a beneficiary who receives care at a participating
3    health care facility be required to search for
4    participating providers under the circumstances described
5    in subsection (b) or (b-5) of Section 356z.3a of the
6    Illinois Insurance Code except under the circumstances
7    described in paragraph (2) of subsection (b-5).
8        (7) A provision that the beneficiary shall receive
9    emergency care coverage such that payment for this
10    coverage is not dependent upon whether the emergency
11    services are performed by a preferred or non-preferred
12    provider and the coverage shall be at the same benefit
13    level as if the service or treatment had been rendered by a
14    preferred provider. For purposes of this paragraph (7),
15    "the same benefit level" means that the beneficiary is
16    provided the covered service at no greater cost to the
17    beneficiary than if the service had been provided by a
18    preferred provider. This provision shall be consistent
19    with Section 356z.3a of the Illinois Insurance Code.
20        (8) A limitation that, if the plan provides that the
21    beneficiary will incur a penalty for failing to
22    pre-certify inpatient hospital treatment, the penalty may
23    not exceed $1,000 per occurrence in addition to the plan
24    cost sharing provisions.
25        (9) For a network plan to be offered through the
26    Exchange in the individual or small group market, as well

 

 

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1    as any off-Exchange mirror of such a network plan,
2    evidence that the network plan includes essential
3    community providers in accordance with rules established
4    by the Exchange that will operate in this State for the
5    applicable plan year.
6    (c) The issuer network plan shall demonstrate to the
7Director a minimum ratio of providers to plan beneficiaries as
8required by the Department for each network plan.
9        (1) The minimum ratio of physicians or other providers
10    to plan beneficiaries shall be established annually by the
11    Department in consultation with the Department of Public
12    Health based upon the guidance from the federal Centers
13    for Medicare and Medicaid Services. The Department shall
14    not establish ratios for vision or dental providers who
15    provide services under dental-specific or vision-specific
16    benefits, except to the extent provided under federal law
17    for stand-alone dental plans. The Department shall
18    consider establishing ratios for the following physicians
19    or other providers:
20            (A) Primary Care;
21            (B) Pediatrics;
22            (C) Cardiology;
23            (D) Gastroenterology;
24            (E) General Surgery;
25            (F) Neurology;
26            (G) OB/GYN;

 

 

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1            (H) Oncology/Radiation;
2            (I) Ophthalmology;
3            (J) Urology;
4            (K) Behavioral Health;
5            (L) Allergy/Immunology;
6            (M) Chiropractic;
7            (N) Dermatology;
8            (O) Endocrinology;
9            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
10            (Q) Infectious Disease;
11            (R) Nephrology;
12            (S) Neurosurgery;
13            (T) Orthopedic Surgery;
14            (U) Physiatry/Rehabilitative;
15            (V) Plastic Surgery;
16            (W) Pulmonary;
17            (X) Rheumatology;
18            (Y) Anesthesiology;
19            (Z) Pain Medicine;
20            (AA) Pediatric Specialty Services;
21            (BB) Outpatient Dialysis; and
22            (CC) HIV.
23        (2) The Director shall establish a process for the
24    review of the adequacy of these standards, along with an
25    assessment of additional specialties to be included in the
26    list under this subsection (c).

 

 

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1        (3) Notwithstanding any other law or rule, the minimum
2    ratio for each provider type shall be no less than any such
3    ratio established for qualified health plans in
4    Federally-Facilitated Exchanges by federal law or by the
5    federal Centers for Medicare and Medicaid Services, even
6    if the network plan is issued in the large group market or
7    is otherwise not issued through an exchange. Federal
8    standards for stand-alone dental plans shall only apply to
9    such network plans. In the absence of an applicable
10    Department rule, the federal standards shall apply for the
11    time period specified in the federal law, regulation, or
12    guidance. If the Centers for Medicare and Medicaid
13    Services establish standards that are more stringent than
14    the standards in effect under any Department rule, the
15    Department may amend its rules to conform to the more
16    stringent federal standards.
17    (d) The network plan shall demonstrate to the Director
18maximum travel and distance standards and appointment wait
19time standards for plan beneficiaries, which shall be
20established annually by the Department in consultation with
21the Department of Public Health based upon the guidance from
22the federal Centers for Medicare and Medicaid Services. These
23standards shall consist of the maximum minutes or miles to be
24traveled by a plan beneficiary for each county type, such as
25large counties, metro counties, or rural counties as defined
26by Department rule.

 

 

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1    The maximum travel time and distance standards must
2include standards for each physician and other provider
3category listed for which ratios have been established.
4    The Director shall establish a process for the review of
5the adequacy of these standards along with an assessment of
6additional specialties to be included in the list under this
7subsection (d).
8    Notwithstanding any other law or Department rule, the
9maximum travel time and distance standards and appointment
10wait time standards shall be no greater than any such
11standards established for qualified health plans in
12Federally-Facilitated Exchanges by federal law or by the
13federal Centers for Medicare and Medicaid Services, even if
14the network plan is issued in the large group market or is
15otherwise not issued through an exchange. Federal standards
16for stand-alone dental plans shall only apply to such network
17plans. In the absence of an applicable Department rule, the
18federal standards shall apply for the time period specified in
19the federal law, regulation, or guidance. If the Centers for
20Medicare and Medicaid Services establish standards that are
21more stringent than the standards in effect under any
22Department rule, the Department may amend its rules to conform
23to the more stringent federal standards.
24    If the federal area designations for the maximum time or
25distance or appointment wait time standards required are
26changed by the most recent Letter to Issuers in the

 

 

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1Federally-facilitated Marketplaces, the Department shall post
2on its website notice of such changes and may amend its rules
3to conform to those designations if the Director deems
4appropriate.
5    (d-5)(1) Every issuer insurer shall ensure that
6beneficiaries have timely and proximate access to treatment
7for mental, emotional, nervous, or substance use disorders or
8conditions in accordance with the provisions of paragraph (4)
9of subsection (a) of Section 370c of the Illinois Insurance
10Code. Issuers Insurers shall use a comparable process,
11strategy, evidentiary standard, and other factors in the
12development and application of the network adequacy standards
13for timely and proximate access to treatment for mental,
14emotional, nervous, or substance use disorders or conditions
15and those for the access to treatment for medical and surgical
16conditions. As such, the network adequacy standards for timely
17and proximate access shall equally be applied to treatment
18facilities and providers for mental, emotional, nervous, or
19substance use disorders or conditions and specialists
20providing medical or surgical benefits pursuant to the parity
21requirements of Section 370c.1 of the Illinois Insurance Code
22and the federal Paul Wellstone and Pete Domenici Mental Health
23Parity and Addiction Equity Act of 2008. Notwithstanding the
24foregoing, the network adequacy standards for timely and
25proximate access to treatment for mental, emotional, nervous,
26or substance use disorders or conditions shall, at a minimum,

 

 

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

 

 

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

 

 

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1    (3) If there is no in-network facility or provider
2available for a beneficiary to receive timely and proximate
3access to treatment for mental, emotional, nervous, or
4substance use disorders or conditions in accordance with the
5network adequacy standards outlined in this subsection, the
6issuer insurer shall provide necessary exceptions to its
7network to ensure admission and treatment with a provider or
8at a treatment facility in accordance with the network
9adequacy standards in this subsection.
10    (4) If the federal Centers for Medicare and Medicaid
11Services establishes or law requires more stringent standards
12for qualified health plans in the Federally-Facilitated
13Exchanges, the federal standards shall control for all network
14plans for the time period specified in the federal law,
15regulation, or guidance, even if the network plan is issued in
16the large group market, is issued through a different type of
17Exchange, or is otherwise not issued through an Exchange.
18    (e) Except for network plans solely offered as a group
19health plan, these ratio and time and distance standards apply
20to the lowest cost-sharing tier of any tiered network.
21    (f) The network plan may consider use of other health care
22service delivery options, such as telemedicine or telehealth,
23mobile clinics, and centers of excellence, or other ways of
24delivering care to partially meet the requirements set under
25this Section.
26    (g) Except for the requirements set forth in subsection

 

 

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1(d-5), issuers insurers who are not able to comply with the
2provider ratios and time and distance or appointment wait time
3standards established under this Act or federal law by the
4Department may request an exception to these requirements from
5the Department. The Department may grant an exception in the
6following circumstances:
7        (1) if no providers or facilities meet the specific
8    time and distance standard in a specific service area and
9    the issuer insurer (i) discloses information on the
10    distance and travel time points that beneficiaries would
11    have to travel beyond the required criterion to reach the
12    next closest contracted provider outside of the service
13    area and (ii) provides contact information, including
14    names, addresses, and phone numbers for the next closest
15    contracted provider or facility;
16        (2) if patterns of care in the service area do not
17    support the need for the requested number of provider or
18    facility type and the issuer insurer provides data on
19    local patterns of care, such as claims data, referral
20    patterns, or local provider interviews, indicating where
21    the beneficiaries currently seek this type of care or
22    where the physicians currently refer beneficiaries, or
23    both; or
24        (3) other circumstances deemed appropriate by the
25    Department consistent with the requirements of this Act.
26    (h) Issuers Insurers are required to report to the

 

 

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1Director any material change to an approved network plan
2within 15 business days after the change occurs and any change
3that would result in failure to meet the requirements of this
4Act. The issuer shall submit a revised version of the portions
5of the network adequacy filing affected by the material
6change, as determined by the Director by rule, and the issuer
7shall attach versions with the changes indicated for each
8document that was revised from the previous version of the
9filing. Upon notice from the issuer insurer, the Director
10shall reevaluate the network plan's compliance with the
11network adequacy and transparency standards of this Act. For
12every day past 15 business days that the issuer fails to submit
13a revised network adequacy filing to the Director, the
14Director may order a fine of $5,000 per day.
15    (i) If a network plan is inadequate under this Act with
16respect to a provider type in a county, and if the network plan
17does not have an approved exception for that provider type in
18that county pursuant to subsection (g), an issuer shall cover
19out-of-network claims for covered health care services
20received from that provider type within that county at the
21in-network benefit level and shall retroactively adjudicate
22and reimburse beneficiaries to achieve that objective if their
23claims were processed at the out-of-network level contrary to
24this subsection. Nothing in this subsection shall be construed
25to supersede Section 356z.3a of the Illinois Insurance Code.
26    (j) If the Director determines that a network is

 

 

HB5395 Engrossed- 22 -LRB103 37071 RPS 67189 b

1inadequate in any county and no exception has been granted
2under subsection (g) and the issuer does not have a process in
3place to comply with subsection (d-5), the Director may
4prohibit the network plan from being issued or renewed within
5that county until the Director determines that the network is
6adequate apart from processes and exceptions described in
7subsections (d-5) and (g). Nothing in this subsection shall be
8construed to terminate any beneficiary's health insurance
9coverage under a network plan before the expiration of the
10beneficiary's policy period if the Director makes a
11determination under this subsection after the issuance or
12renewal of the beneficiary's policy or certificate because of
13a material change. Policies or certificates issued or renewed
14in violation of this subsection may subject the issuer to a
15civil penalty of $5,000 per policy.
16    (k) For the Department to enforce any new or modified
17federal standard before the Department adopts the standard by
18rule, the Department must, no later than May 15 before the
19start of the plan year, give public notice to the affected
20health insurance issuers through a bulletin.
21(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
22102-1117, eff. 1-13-23.)
 
23    (215 ILCS 124/15)
24    Sec. 15. Notice of nonrenewal or termination.
25    (a) A network plan must give at least 60 days' notice of

 

 

HB5395 Engrossed- 23 -LRB103 37071 RPS 67189 b

1nonrenewal or termination of a provider to the provider and to
2the beneficiaries served by the provider. The notice shall
3include a name and address to which a beneficiary or provider
4may direct comments and concerns regarding the nonrenewal or
5termination and the telephone number maintained by the
6Department for consumer complaints. Immediate written notice
7may be provided without 60 days' notice when a provider's
8license has been disciplined by a State licensing board or
9when the network plan reasonably believes direct imminent
10physical harm to patients under the provider's providers care
11may occur. The notice to the beneficiary shall provide the
12individual with an opportunity to notify the issuer of the
13individual's need for transitional care.
14    (b) Primary care providers must notify active affected
15patients of nonrenewal or termination of the provider from the
16network plan, except in the case of incapacitation.
17(Source: P.A. 100-502, eff. 9-15-17.)
 
18    (215 ILCS 124/20)
19    Sec. 20. Transition of services.
20    (a) A network plan shall provide for continuity of care
21for its beneficiaries as follows:
22        (1) If a beneficiary's physician or hospital provider
23    leaves the network plan's network of providers for reasons
24    other than termination of a contract in situations
25    involving imminent harm to a patient or a final

 

 

HB5395 Engrossed- 24 -LRB103 37071 RPS 67189 b

1    disciplinary action by a State licensing board and the
2    provider remains within the network plan's service area,
3    if benefits provided under such network plan with respect
4    to such provider or facility are terminated because of a
5    change in the terms of the participation of such provider
6    or facility in such plan, or if a contract between a group
7    health plan and a health insurance issuer offering a
8    network plan in connection with the group health plan is
9    terminated and results in a loss of benefits provided
10    under such plan with respect to such provider, then the
11    network plan shall permit the beneficiary to continue an
12    ongoing course of treatment with that provider during a
13    transitional period for the following duration:
14            (A) 90 days from the date of the notice to the
15        beneficiary of the provider's disaffiliation from the
16        network plan if the beneficiary has an ongoing course
17        of treatment; or
18            (B) if the beneficiary has entered the third
19        trimester of pregnancy at the time of the provider's
20        disaffiliation, a period that includes the provision
21        of post-partum care directly related to the delivery.
22        (2) Notwithstanding the provisions of paragraph (1) of
23    this subsection (a), such care shall be authorized by the
24    network plan during the transitional period in accordance
25    with the following:
26            (A) the provider receives continued reimbursement

 

 

HB5395 Engrossed- 25 -LRB103 37071 RPS 67189 b

1        from the network plan at the rates and terms and
2        conditions applicable under the terminated contract
3        prior to the start of the transitional period;
4            (B) the provider adheres to the network plan's
5        quality assurance requirements, including provision to
6        the network plan of necessary medical information
7        related to such care; and
8            (C) the provider otherwise adheres to the network
9        plan's policies and procedures, including, but not
10        limited to, procedures regarding referrals and
11        obtaining preauthorizations for treatment.
12        (3) The provisions of this Section governing health
13    care provided during the transition period do not apply if
14    the beneficiary has successfully transitioned to another
15    provider participating in the network plan, if the
16    beneficiary has already met or exceeded the benefit
17    limitations of the plan, or if the care provided is not
18    medically necessary.
19    (b) A network plan shall provide for continuity of care
20for new beneficiaries as follows:
21        (1) If a new beneficiary whose provider is not a
22    member of the network plan's provider network, but is
23    within the network plan's service area, enrolls in the
24    network plan, the network plan shall permit the
25    beneficiary to continue an ongoing course of treatment
26    with the beneficiary's current physician during a

 

 

HB5395 Engrossed- 26 -LRB103 37071 RPS 67189 b

1    transitional period:
2            (A) of 90 days from the effective date of
3        enrollment if the beneficiary has an ongoing course of
4        treatment; or
5            (B) if the beneficiary has entered the third
6        trimester of pregnancy at the effective date of
7        enrollment, that includes the provision of post-partum
8        care directly related to the delivery.
9        (2) If a beneficiary, or a beneficiary's authorized
10    representative, elects in writing to continue to receive
11    care from such provider pursuant to paragraph (1) of this
12    subsection (b), such care shall be authorized by the
13    network plan for the transitional period in accordance
14    with the following:
15            (A) the provider receives reimbursement from the
16        network plan at rates established by the network plan;
17            (B) the provider adheres to the network plan's
18        quality assurance requirements, including provision to
19        the network plan of necessary medical information
20        related to such care; and
21            (C) the provider otherwise adheres to the network
22        plan's policies and procedures, including, but not
23        limited to, procedures regarding referrals and
24        obtaining preauthorization for treatment.
25        (3) The provisions of this Section governing health
26    care provided during the transition period do not apply if

 

 

HB5395 Engrossed- 27 -LRB103 37071 RPS 67189 b

1    the beneficiary has successfully transitioned to another
2    provider participating in the network plan, if the
3    beneficiary has already met or exceeded the benefit
4    limitations of the plan, or if the care provided is not
5    medically necessary.
6    (c) In no event shall this Section be construed to require
7a network plan to provide coverage for benefits not otherwise
8covered or to diminish or impair preexisting condition
9limitations contained in the beneficiary's contract.
10    (d) A provider shall comply with the requirements of 42
11U.S.C. 300gg-138.
12(Source: P.A. 100-502, eff. 9-15-17.)
 
13    (215 ILCS 124/25)
14    Sec. 25. Network transparency.
15    (a) A network plan shall post electronically an
16up-to-date, accurate, and complete provider directory for each
17of its network plans, with the information and search
18functions, as described in this Section.
19        (1) In making the directory available electronically,
20    the network plans shall ensure that the general public is
21    able to view all of the current providers for a plan
22    through a clearly identifiable link or tab and without
23    creating or accessing an account or entering a policy or
24    contract number.
25        (2) An issuer's failure to update a network plan's

 

 

HB5395 Engrossed- 28 -LRB103 37071 RPS 67189 b

1    directory shall subject the issuer to a civil penalty of
2    $5,000 per month. The network plan shall update the online
3    provider directory at least monthly. Providers shall
4    notify the network plan electronically or in writing
5    within 10 business days of any changes to their
6    information as listed in the provider directory, including
7    the information required in subsections (b), (c), and (d)
8    subparagraph (K) of paragraph (1) of subsection (b). With
9    regard to subparagraph (I) of paragraph (1) of subsection
10    (b), the provider must give notice to the issuer within 20
11    business days of deciding to cease accepting new patients
12    covered by the plan if the new patient limitation is
13    expected to last 40 business days or longer. The network
14    plan shall update its online provider directory in a
15    manner consistent with the information provided by the
16    provider within 2 10 business days after being notified of
17    the change by the provider. Nothing in this paragraph (2)
18    shall void any contractual relationship between the
19    provider and the plan.
20        (3) At least once every 90 days, the issuer The
21    network plan shall audit each network plan's periodically
22    at least 25% of its provider directories for accuracy,
23    make any corrections necessary, and retain documentation
24    of the audit. The network plan shall submit the audit to
25    the Director upon request. As part of these audits, the
26    network plan shall contact any provider in its network

 

 

HB5395 Engrossed- 29 -LRB103 37071 RPS 67189 b

1    that has not submitted a claim to the plan or otherwise
2    communicated his or her intent to continue participation
3    in the plan's network. The audits shall comply with 42
4    U.S.C. 300gg-115(a)(2), except that "provider directory
5    information" shall include all information required to be
6    included in a provider directory pursuant to this Act.
7        (4) A network plan shall provide a print copy of a
8    current provider directory or a print copy of the
9    requested directory information upon request of a
10    beneficiary or a prospective beneficiary. Except when an
11    issuer's print copies use the same provider information as
12    the electronic provider directory on each print copy's
13    date of printing, print Print copies must be updated at
14    least every 90 days quarterly and an errata that reflects
15    changes in the provider network must be included in each
16    update updated quarterly.
17        (5) For each network plan, a network plan shall
18    include, in plain language in both the electronic and
19    print directory, the following general information:
20            (A) in plain language, a description of the
21        criteria the plan has used to build its provider
22        network;
23            (B) if applicable, in plain language, a
24        description of the criteria the issuer insurer or
25        network plan has used to create tiered networks;
26            (C) if applicable, in plain language, how the

 

 

HB5395 Engrossed- 30 -LRB103 37071 RPS 67189 b

1        network plan designates the different provider tiers
2        or levels in the network and identifies for each
3        specific provider, hospital, or other type of facility
4        in the network which tier each is placed, for example,
5        by name, symbols, or grouping, in order for a
6        beneficiary-covered person or a prospective
7        beneficiary-covered person to be able to identify the
8        provider tier; and
9            (D) if applicable, a notation that authorization
10        or referral may be required to access some providers.
11        (6) A network plan shall make it clear for both its
12    electronic and print directories what provider directory
13    applies to which network plan, such as including the
14    specific name of the network plan as marketed and issued
15    in this State. The network plan shall include in both its
16    electronic and print directories a customer service email
17    address and telephone number or electronic link that
18    beneficiaries or the general public may use to notify the
19    network plan of inaccurate provider directory information
20    and contact information for the Department's Office of
21    Consumer Health Insurance.
22        (7) A provider directory, whether in electronic or
23    print format, shall accommodate the communication needs of
24    individuals with disabilities, and include a link to or
25    information regarding available assistance for persons
26    with limited English proficiency.

 

 

HB5395 Engrossed- 31 -LRB103 37071 RPS 67189 b

1    (b) For each network plan, a network plan shall make
2available through an electronic provider directory the
3following information in a searchable format:
4        (1) for health care professionals:
5            (A) name;
6            (B) gender;
7            (C) participating office locations;
8            (D) specialty, if applicable;
9            (E) medical group affiliations, if applicable;
10            (F) facility affiliations, if applicable;
11            (G) participating facility affiliations, if
12        applicable;
13            (H) languages spoken other than English, if
14        applicable;
15            (I) whether accepting new patients;
16            (J) board certifications, if applicable; and
17            (K) use of telehealth or telemedicine, including,
18        but not limited to:
19                (i) whether the provider offers the use of
20            telehealth or telemedicine to deliver services to
21            patients for whom it would be clinically
22            appropriate;
23                (ii) what modalities are used and what types
24            of services may be provided via telehealth or
25            telemedicine; and
26                (iii) whether the provider has the ability and

 

 

HB5395 Engrossed- 32 -LRB103 37071 RPS 67189 b

1            willingness to include in a telehealth or
2            telemedicine encounter a family caregiver who is
3            in a separate location than the patient if the
4            patient wishes and provides his or her consent;
5            and
6            (L) whether the health care professional accepts
7        appointment requests from patients.
8        (2) for hospitals:
9            (A) hospital name;
10            (B) hospital type (such as acute, rehabilitation,
11        children's, or cancer);
12            (C) participating hospital location; and
13            (D) hospital accreditation status; and
14        (3) for facilities, other than hospitals, by type:
15            (A) facility name;
16            (B) facility type;
17            (C) types of services performed; and
18            (D) participating facility location or locations.
19    (c) For the electronic provider directories, for each
20network plan, a network plan shall make available all of the
21following information in addition to the searchable
22information required in this Section:
23        (1) for health care professionals:
24            (A) contact information, including both a
25        telephone number and digital contact information if
26        the provider has supplied digital contact information;

 

 

HB5395 Engrossed- 33 -LRB103 37071 RPS 67189 b

1        and
2            (B) languages spoken other than English by
3        clinical staff, if applicable;
4        (2) for hospitals, telephone number and digital
5    contact information; and
6        (3) for facilities other than hospitals, telephone
7    number.
8    (d) The issuer insurer or network plan shall make
9available in print, upon request, the following provider
10directory information for the applicable network plan:
11        (1) for health care professionals:
12            (A) name;
13            (B) contact information, including a telephone
14        number and digital contact information if the provider
15        has supplied digital contact information;
16            (C) participating office location or locations;
17            (D) specialty, if applicable;
18            (E) languages spoken other than English, if
19        applicable;
20            (F) whether accepting new patients; and
21            (G) use of telehealth or telemedicine, including,
22        but not limited to:
23                (i) whether the provider offers the use of
24            telehealth or telemedicine to deliver services to
25            patients for whom it would be clinically
26            appropriate;

 

 

HB5395 Engrossed- 34 -LRB103 37071 RPS 67189 b

1                (ii) what modalities are used and what types
2            of services may be provided via telehealth or
3            telemedicine; and
4                (iii) whether the provider has the ability and
5            willingness to include in a telehealth or
6            telemedicine encounter a family caregiver who is
7            in a separate location than the patient if the
8            patient wishes and provides his or her consent;
9            and
10            (H) whether the health care professional accepts
11        appointment requests from patients.
12        (2) for hospitals:
13            (A) hospital name;
14            (B) hospital type (such as acute, rehabilitation,
15        children's, or cancer); and
16            (C) participating hospital location, and telephone
17        number, and digital contact information; and
18        (3) for facilities, other than hospitals, by type:
19            (A) facility name;
20            (B) facility type;
21            (C) types of services performed; and
22            (D) participating facility location or locations,
23        and telephone numbers, and digital contact information
24        for each location.
25    (e) The network plan shall include a disclosure in the
26print format provider directory that the information included

 

 

HB5395 Engrossed- 35 -LRB103 37071 RPS 67189 b

1in the directory is accurate as of the date of printing and
2that beneficiaries or prospective beneficiaries should consult
3the issuer's insurer's electronic provider directory on its
4website and contact the provider. The network plan shall also
5include a telephone number in the print format provider
6directory for a customer service representative where the
7beneficiary can obtain current provider directory information.
8    (f) The Director may conduct periodic audits of the
9accuracy of provider directories. A network plan shall not be
10subject to any fines or penalties for information required in
11this Section that a provider submits that is inaccurate or
12incomplete.
13    (g) To the extent not otherwise provided in this Act, an
14issuer shall comply with the requirements of 42 U.S.C.
15300gg-115, except that "provider directory information" shall
16include all information required to be included in a provider
17directory pursuant to this Section.
18    (h) This Section applies to network plans not otherwise
19exempt under Section 3, including stand-alone dental plans.
20(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
 
21    (215 ILCS 124/30)
22    Sec. 30. Administration and enforcement.
23    (a) Issuers Insurers, as defined in this Act, have a
24continuing obligation to comply with the requirements of this
25Act. Other than the duties specifically created in this Act,

 

 

HB5395 Engrossed- 36 -LRB103 37071 RPS 67189 b

1nothing in this Act is intended to preclude, prevent, or
2require the adoption, modification, or termination of any
3utilization management, quality management, or claims
4processing methodologies of an issuer insurer.
5    (b) Nothing in this Act precludes, prevents, or requires
6the adoption, modification, or termination of any network plan
7term, benefit, coverage or eligibility provision, or payment
8methodology.
9    (c) The Director shall enforce the provisions of this Act
10pursuant to the enforcement powers granted to it by law.
11    (d) The Department shall adopt rules to enforce compliance
12with this Act to the extent necessary.
13    (e) In accordance with Section 5-45 of the Illinois
14Administrative Procedure Act, the Department may adopt
15emergency rules to implement federal standards for provider
16ratios, travel time and distance, and appointment wait times
17if such standards apply to health insurance coverage regulated
18by the Department and are more stringent than the State
19standards extant at the time the final federal standards are
20published.
21(Source: P.A. 100-502, eff. 9-15-17.)
 
22    (215 ILCS 124/35 new)
23    Sec. 35. Provider requirements. Providers shall comply
24with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations
25promulgated thereunder, as well as Section 20 and paragraph

 

 

HB5395 Engrossed- 37 -LRB103 37071 RPS 67189 b

1(2) of subsection (a) of Section 25 of this Act, except that
2"provider directory information" includes all information
3required to be included in a provider directory pursuant to
4Section 25 of this Act.
 
5    (215 ILCS 124/40 new)
6    Sec. 40. Confidentiality.
7    (a) All records in the custody or possession of the
8Department are presumed to be open to public inspection or
9copying unless exempt from disclosure by Section 7 or 7.5 of
10the Freedom of Information Act. Except as otherwise provided
11in this Section or other applicable law, the filings required
12under this Act shall be open to public inspection or copying.
13    (b) The following information shall not be deemed
14confidential:
15        (1) actual or projected ratios of providers to
16    beneficiaries;
17        (2) actual or projected time and distance between
18    network providers and beneficiaries or actual or projected
19    waiting times for a beneficiary to see a network provider;
20        (3) geographic maps of network providers;
21        (4) requests for exceptions under subsection (g) of
22    Section 10, except with respect to any discussion of
23    ongoing or planned contractual negotiations with providers
24    that the issuer requests to be treated as confidential;
25        (5) provider directories and provider lists; and

 

 

HB5395 Engrossed- 38 -LRB103 37071 RPS 67189 b

1        (6) insurer or Department statements of determination
2    as to whether a network plan has satisfied this Act's
3    requirements regarding the information described in this
4    subsection.
5    (c) An issuer's work papers and reports on the results of a
6self-audit of its provider directories, including any
7communications between the issuer and the Department, shall
8remain confidential unless expressly waived by the issuer or
9unless deemed public information under federal law.
10    (d) The filings required under Section 10 of this Act
11shall be confidential while they remain under the Department's
12review but shall become open to public inspection and copying
13upon completion of the review, except as provided in this
14Section or under other applicable law.
15    (e) Nothing in this Section shall supersede the statutory
16requirement that work papers obtained during a market conduct
17examination be deemed confidential.
 
18    (215 ILCS 124/50 new)
19    Sec. 50. Funds for enforcement. Moneys from fines and
20penalties collected from issuers for violations of this Act
21shall be deposited into the Insurance Producer Administration
22Fund for appropriation by the General Assembly to the
23Department to be used for providing financial support of the
24Department's enforcement of this Act.
 

 

 

HB5395 Engrossed- 39 -LRB103 37071 RPS 67189 b

1    (215 ILCS 124/55 new)
2    Sec. 55. Uniform electronic provider directory information
3notification forms.
4    (a) On or before January 1, 2026, the Department shall
5develop and publish a uniform electronic provider directory
6information form that issuers shall make available to
7onboarding, current, and former preferred providers to notify
8the issuer of the provider's currently accurate provider
9directory information under Section 25 of this Act and 42
10U.S.C. 300gg-139. The form shall address information needed
11from newly onboarding preferred providers, updates to
12previously supplied provider directory information, reporting
13an inaccurate directory entry of previously supplied
14information, contract terminations, and differences in
15information for specific network plans offered by an issuer,
16such as whether the provider is a preferred provider for the
17network plan or is accepting new patients under that plan. The
18Department shall allow issuers to implement this form through
19either a PDF or a web portal that requests the same
20information.
21    (b) Notwithstanding any other provision of law to the
22contrary, beginning 6 months after the Department publishes
23the uniform electronic provider directory information form and
24no later than July 1, 2026, every provider must use the uniform
25electronic provider directory information form to notify
26issuers of their provider directory information as required

 

 

HB5395 Engrossed- 40 -LRB103 37071 RPS 67189 b

1under Section 25 of this Act and 42 U.S.C. 300gg-139. Issuers
2shall accept this form as sufficient to update their provider
3directories. Issuers shall not accept paper or fax submissions
4of provider directory information from providers.
5    (c) The Uniform Electronic Provider Directory Information
6Form Task Force is created. The purpose of this task force is
7to provide input and advice to the Department of Insurance in
8the development of a uniform electronic provider directory
9information form. The task force shall include at least the
10following individuals:
11        (1) the Director of Insurance or a designee, as chair;
12        (2) the Marketplace Director or a designee;
13        (3) the Director of the Division of Professional
14    Regulation or a designee;
15        (4) the Director of Public Health or a designee;
16        (5) the Secretary of Innovation and Technology or a
17    designee;
18        (6) the Director of Healthcare and Family Services or
19    a designee;
20        (7) the following individuals appointed by the
21    Director:
22            (A) one representative of a statewide association
23        representing physicians;
24            (B) one representative of a statewide association
25        representing nurses;
26            (C) one representative of a statewide organization

 

 

HB5395 Engrossed- 41 -LRB103 37071 RPS 67189 b

1        representing a majority of Illinois hospitals;
2            (D) one representative of a statewide organization
3        representing Illinois pharmacies;
4            (E) one representative of a statewide organization
5        representing mental health care providers;
6            (F) one representative of a statewide organization
7        representing substance use disorder health care
8        providers;
9            (G) 2 representatives of health insurance issuers
10        doing business in this State or issuer trade
11        associations, at least one of which represents a
12        State-domiciled mutual health insurance company, with
13        a demonstrated expertise in the business of health
14        insurance or health benefits administration; and
15            (H) 2 representatives of a health insurance
16        consumer advocacy group.
17    (d) The Department shall convene the task force described
18in this Section no later than April 1, 2025.
19    (e) The Department, in development of the uniform
20electronic provider directory information form, and the task
21force, in offering input, shall take into consideration the
22following:
23        (1) readability and user experience;
24        (2) interoperability;
25        (3) existing regulations established by the federal
26    Centers for Medicare and Medicaid Services, the Department

 

 

HB5395 Engrossed- 42 -LRB103 37071 RPS 67189 b

1    of Insurance, the Department of Healthcare and Family
2    Service, the Department of Financial and Professional
3    Regulation, and the Department of Public Health;
4        (4) potential opportunities to avoid duplication of
5    data collection efforts, including, but not limited to,
6    opportunities related to:
7            (A) integrating any provider reporting required
8        under Section 25 of this Act and 42 U.S.C. 300gg-139
9        with the provider reporting required under the Health
10        Care Professional Credentials Data Collection Act;
11            (B) furnishing information to any national
12        provider directory established by the federal Centers
13        for Medicare and Medicaid Services or another federal
14        agency with jurisdiction over health care providers;
15        and
16            (C) furnishing information in compliance with the
17        Patients' Right to Know Act;
18        (5) compatibility with the Illinois Health Benefits
19    Exchange;
20        (6) provider licensing requirements and forms; and
21        (7) information needed to classify a provider under
22    any specialty type for which a network adequacy standard
23    may be established under this Act when a specialty board
24    certification or State license does not currently exist.
 
25    Section 2-15. The Managed Care Reform and Patient Rights

 

 

HB5395 Engrossed- 43 -LRB103 37071 RPS 67189 b

1Act is amended by changing Sections 20 and 25 as follows:
 
2    (215 ILCS 134/20)
3    Sec. 20. Notice of nonrenewal or termination. A health
4care plan must give at least 60 days notice of nonrenewal or
5termination of a health care provider to the health care
6provider and to the enrollees served by the health care
7provider. The notice shall include a name and address to which
8an enrollee or health care provider may direct comments and
9concerns regarding the nonrenewal or termination. Immediate
10written notice may be provided without 60 days notice when a
11health care provider's license has been disciplined by a State
12licensing board. The notice to the enrollee shall provide the
13individual with an opportunity to notify the health care plan
14of the individual's need for transitional care.
15(Source: P.A. 91-617, eff. 1-1-00.)
 
16    (215 ILCS 134/25)
17    Sec. 25. Transition of services.
18    (a) A health care plan shall provide for continuity of
19care for its enrollees as follows:
20        (1) If an enrollee's health care provider physician
21    leaves the health care plan's network of health care
22    providers for reasons other than termination of a contract
23    in situations involving imminent harm to a patient or a
24    final disciplinary action by a State licensing board and

 

 

HB5395 Engrossed- 44 -LRB103 37071 RPS 67189 b

1    the provider physician remains within the health care
2    plan's service area, or if benefits provided under such
3    health care plan with respect to such provider are
4    terminated because of a change in the terms of the
5    participation of such provider in such plan, or if a
6    contract between a group health plan, as defined in
7    Section 5 of the Illinois Health Insurance Portability and
8    Accountability Act, and a health care plan offered in
9    connection with the group health plan is terminated and
10    results in a loss of benefits provided under such plan
11    with respect to such provider, the health care plan shall
12    permit the enrollee to continue an ongoing course of
13    treatment with that provider physician during a
14    transitional period:
15            (A) of 90 days from the date of the notice of
16        provider's physician's termination from the health
17        care plan to the enrollee of the provider's
18        physician's disaffiliation from the health care plan
19        if the enrollee has an ongoing course of treatment; or
20            (B) if the enrollee has entered the third
21        trimester of pregnancy at the time of the provider's
22        physician's disaffiliation, that includes the
23        provision of post-partum care directly related to the
24        delivery.
25        (2) Notwithstanding the provisions in item (1) of this
26    subsection, such care shall be authorized by the health

 

 

HB5395 Engrossed- 45 -LRB103 37071 RPS 67189 b

1    care plan during the transitional period only if the
2    provider physician agrees:
3            (A) to continue to accept reimbursement from the
4        health care plan at the rates applicable prior to the
5        start of the transitional period;
6            (B) to adhere to the health care plan's quality
7        assurance requirements and to provide to the health
8        care plan necessary medical information related to
9        such care; and
10            (C) to otherwise adhere to the health care plan's
11        policies and procedures, including but not limited to
12        procedures regarding referrals and obtaining
13        preauthorizations for treatment.
14        (3) During an enrollee's plan year, a health care plan
15    shall not remove a drug from its formulary or negatively
16    change its preferred or cost-tier sharing unless, at least
17    60 days before making the formulary change, the health
18    care plan:
19            (A) provides general notification of the change in
20        its formulary to current and prospective enrollees;
21            (B) directly notifies enrollees currently
22        receiving coverage for the drug, including information
23        on the specific drugs involved and the steps they may
24        take to request coverage determinations and
25        exceptions, including a statement that a certification
26        of medical necessity by the enrollee's prescribing

 

 

HB5395 Engrossed- 46 -LRB103 37071 RPS 67189 b

1        provider will result in continuation of coverage at
2        the existing level; and
3            (C) directly notifies in writing by first class
4        mail and through an electronic transmission, if
5        available, the prescribing provider of all health care
6        plan enrollees currently prescribed the drug affected
7        by the proposed change; the notice shall include a
8        one-page form by which the prescribing provider can
9        notify the health care plan in writing or
10        electronically by first class mail that coverage of
11        the drug for the enrollee is medically necessary.
12        The notification in paragraph (C) may direct the
13    prescribing provider to an electronic portal through which
14    the prescribing provider may electronically file a
15    certification to the health care plan that coverage of the
16    drug for the enrollee is medically necessary. The
17    prescribing provider may make a secure electronic
18    signature beside the words "certification of medical
19    necessity", and this certification shall authorize
20    continuation of coverage for the drug.
21        If the prescribing provider certifies to the health
22    care plan either in writing or electronically that the
23    drug is medically necessary for the enrollee as provided
24    in paragraph (C), a health care plan shall authorize
25    coverage for the drug prescribed based solely on the
26    prescribing provider's assertion that coverage is

 

 

HB5395 Engrossed- 47 -LRB103 37071 RPS 67189 b

1    medically necessary, and the health care plan is
2    prohibited from making modifications to the coverage
3    related to the covered drug, including, but not limited
4    to:
5            (i) increasing the out-of-pocket costs for the
6        covered drug;
7            (ii) moving the covered drug to a more restrictive
8        tier; or
9            (iii) denying an enrollee coverage of the drug for
10        which the enrollee has been previously approved for
11        coverage by the health care plan.
12        Nothing in this item (3) prevents a health care plan
13    from removing a drug from its formulary or denying an
14    enrollee coverage if the United States Food and Drug
15    Administration has issued a statement about the drug that
16    calls into question the clinical safety of the drug, the
17    drug manufacturer has notified the United States Food and
18    Drug Administration of a manufacturing discontinuance or
19    potential discontinuance of the drug as required by
20    Section 506C of the Federal Food, Drug, and Cosmetic Act,
21    as codified in 21 U.S.C. 356c, or the drug manufacturer
22    has removed the drug from the market.
23        Nothing in this item (3) prohibits a health care plan,
24    by contract, written policy or procedure, or any other
25    agreement or course of conduct, from requiring a
26    pharmacist to effect substitutions of prescription drugs

 

 

HB5395 Engrossed- 48 -LRB103 37071 RPS 67189 b

1    consistent with Section 19.5 of the Pharmacy Practice Act,
2    under which a pharmacist may substitute an interchangeable
3    biologic for a prescribed biologic product, and Section 25
4    of the Pharmacy Practice Act, under which a pharmacist may
5    select a generic drug determined to be therapeutically
6    equivalent by the United States Food and Drug
7    Administration and in accordance with the Illinois Food,
8    Drug and Cosmetic Act.
9        This item (3) applies to a policy or contract that is
10    amended, delivered, issued, or renewed on or after January
11    1, 2019. This item (3) does not apply to a health plan as
12    defined in the State Employees Group Insurance Act of 1971
13    or medical assistance under Article V of the Illinois
14    Public Aid Code.
15    (b) A health care plan shall provide for continuity of
16care for new enrollees as follows:
17        (1) If a new enrollee whose physician is not a member
18    of the health care plan's provider network, but is within
19    the health care plan's service area, enrolls in the health
20    care plan, the health care plan shall permit the enrollee
21    to continue an ongoing course of treatment with the
22    enrollee's current physician during a transitional period:
23            (A) of 90 days from the effective date of
24        enrollment if the enrollee has an ongoing course of
25        treatment; or
26            (B) if the enrollee has entered the third

 

 

HB5395 Engrossed- 49 -LRB103 37071 RPS 67189 b

1        trimester of pregnancy at the effective date of
2        enrollment, that includes the provision of post-partum
3        care directly related to the delivery.
4        (2) If an enrollee elects to continue to receive care
5    from such physician pursuant to item (1) of this
6    subsection, such care shall be authorized by the health
7    care plan for the transitional period only if the
8    physician agrees:
9            (A) to accept reimbursement from the health care
10        plan at rates established by the health care plan;
11        such rates shall be the level of reimbursement
12        applicable to similar physicians within the health
13        care plan for such services;
14            (B) to adhere to the health care plan's quality
15        assurance requirements and to provide to the health
16        care plan necessary medical information related to
17        such care; and
18            (C) to otherwise adhere to the health care plan's
19        policies and procedures including, but not limited to
20        procedures regarding referrals and obtaining
21        preauthorization for treatment.
22    (c) In no event shall this Section be construed to require
23a health care plan to provide coverage for benefits not
24otherwise covered or to diminish or impair preexisting
25condition limitations contained in the enrollee's contract. In
26no event shall this Section be construed to prohibit the

 

 

HB5395 Engrossed- 50 -LRB103 37071 RPS 67189 b

1addition of prescription drugs to a health care plan's list of
2covered drugs during the coverage year.
3    (d) In this Section, "ongoing course of treatment" has the
4meaning ascribed to that term in Section 5 of the Network
5Adequacy and Transparency Act.
6(Source: P.A. 100-1052, eff. 8-24-18.)
 
7
Article 3.

 
8    Section 3-5. The Illinois Insurance Code is amended by
9changing Section 355 as follows:
 
10    (215 ILCS 5/355)  (from Ch. 73, par. 967)
11    Sec. 355. Accident and health policies; provisions.
12    (a) As used in this Section:
13    "Inadequate rate" means a rate:
14        (1) that is insufficient to sustain projected losses
15    and expenses to which the rate applies; and
16        (2) the continued use of which endangers the solvency
17    of an insurer using that rate.
18    "Large employer" has the meaning provided in the Illinois
19Health Insurance Portability and Accountability Act.
20    "Plain language" has the meaning provided in the federal
21Plain Writing Act of 2010 and subsequent guidance documents,
22including the Federal Plain Language Guidelines.
23    "Unreasonable rate increase" means a rate increase that

 

 

HB5395 Engrossed- 51 -LRB103 37071 RPS 67189 b

1the Director determines to be excessive, unjustified, or
2unfairly discriminatory in accordance with 45 CFR 154.205.
3    (b) No policy of insurance against loss or damage from the
4sickness, or from the bodily injury or death of the insured by
5accident shall be issued or delivered to any person in this
6State until a copy of the form thereof and of the
7classification of risks and the premium rates pertaining
8thereto have been filed with the Director; nor shall it be so
9issued or delivered until the Director shall have approved
10such policy pursuant to the provisions of Section 143. If the
11Director disapproves the policy form, he or she shall make a
12written decision stating the respects in which such form does
13not comply with the requirements of law and shall deliver a
14copy thereof to the company and it shall be unlawful
15thereafter for any such company to issue any policy in such
16form. On and after January 1, 2025, any form filing submitted
17for large employer group accident and health insurance shall
18be automatically deemed approved within 90 days of the
19submission date unless the Director extends by not more than
20an additional 30 days the period within which the form shall be
21approved or disapproved by giving written notice to the
22insurer of such extension before the expiration of the 90
23days. Any form in receipt of such an extension shall be
24automatically deemed approved within 120 days of the
25submission date. The Director may toll the filing due to a
26conflict in legal interpretation of federal or State law as

 

 

HB5395 Engrossed- 52 -LRB103 37071 RPS 67189 b

1long as the tolling is applied uniformly to all applicable
2forms, written notification is provided to the insurer prior
3to the tolling, the duration of the tolling is provided within
4the notice to the insurer, and justification for the tolling
5is posted to the Department's website. The Director may
6disapprove the filing if the insurer fails to respond to an
7objection or request for additional information within the
8timeframe identified for response. As used in this subsection,
9"large employer" has the meaning given in Section 5 of the
10federal Health Insurance Portability and Accountability Act.
11    (c) For plan year 2026 and thereafter, premium rates for
12all individual and small group accident and health insurance
13policies must be filed with the Department for approval.
14Unreasonable rate increases or inadequate rates shall be
15modified or disapproved. For any plan year during which the
16Illinois Health Benefits Exchange operates as a full
17State-based exchange, the Department shall provide insurers at
18least 30 days' notice of the deadline to submit rate filings.
19    (c-5) Unless prohibited under federal law, for plan year
202026 and thereafter, each insurer proposing to offer a
21qualified health plan issued in the individual market through
22the Illinois Health Benefits Exchange must incorporate the
23following approach in its rate filing under this Section:
24        (1) The rate filing must apply a cost-sharing
25    reduction defunding adjustment factor within a range that:
26            (A) is uniform across all insurers;

 

 

HB5395 Engrossed- 53 -LRB103 37071 RPS 67189 b

1            (B) is consistent with the total adjustment
2        expected to be needed to cover actual cost-sharing
3        reduction costs across all silver plans on the
4        Illinois Health Benefits Exchange statewide, provided
5        that such costs are calculated assuming utilization by
6        the State's full individual-market risk pool; and
7            (C) assumes that the only on-Exchange silver plans
8        that will be purchased are the 87% and 94%
9        cost-sharing reduction variations.
10        (2) The rate filing must apply an induced demand
11    factor based on the following formula: (Plan Actuarial
12    Value)2 - (Plan Actuarial Value) + 1.24.
13    In the annual notice to insurers described in subsection
14(c), the Department must include the specific numerical range
15calculated for the applicable plan year under paragraph (1) of
16this subsection (c-5) and the formula in paragraph (2) of this
17subsection (c-5).
18    (d) For plan year 2025 and thereafter, the Department
19shall post all insurers' rate filings and summaries on the
20Department's website 5 business days after the rate filing
21deadline set by the Department in annual guidance. The rate
22filings and summaries posted to the Department's website shall
23exclude information that is proprietary or trade secret
24information protected under paragraph (g) of subsection (1) of
25Section 7 of the Freedom of Information Act or confidential or
26privileged under any applicable insurance law or rule. All

 

 

HB5395 Engrossed- 54 -LRB103 37071 RPS 67189 b

1summaries shall include a brief justification of any rate
2increase or decrease requested, including the number of
3individual members, the medical loss ratio, medical trend,
4administrative costs, and any other information required by
5rule. The plain writing summary shall include notification of
6the public comment period established in subsection (e).
7    (e) The Department shall open a 30-day public comment
8period on the rate filings beginning on the date that all of
9the rate filings are posted on the Department's website. The
10Department shall post all of the comments received to the
11Department's website within 5 business days after the comment
12period ends.
13    (f) After the close of the public comment period described
14in subsection (e), the Department, beginning for plan year
152026, shall issue a decision to approve, disapprove, or modify
16a rate filing within 60 days. Any rate filing or any rates
17within a filing on which the Director does not issue a decision
18within 60 days shall automatically be deemed approved. The
19Director's decision shall take into account the actuarial
20justifications and public comments. The Department shall
21notify the insurer of the decision, make the decision
22available to the public by posting it on the Department's
23website, and include an explanation of the findings, actuarial
24justifications, and rationale that are the basis for the
25decision. Any company whose rate has been modified or
26disapproved shall be allowed to request a hearing within 10

 

 

HB5395 Engrossed- 55 -LRB103 37071 RPS 67189 b

1days after the action taken. The action of the Director in
2disapproving a rate shall be subject to judicial review under
3the Administrative Review Law.
4    (g) If, following the issuance of a decision but before
5the effective date of the premium rates approved by the
6decision, an event occurs that materially affects the
7Director's decision to approve, deny, or modify the rates, the
8Director may consider supplemental facts or data reasonably
9related to the event.
10    (h) The Department shall adopt rules implementing the
11procedures described in subsections (d) through (g) by March
1231, 2024.
13    (i) Subsection (a) and subsections (c) through (h) of this
14Section do not apply to grandfathered health plans as defined
15in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C.
16300gg-91; student health insurance coverage as defined in 45
17CFR 147.145; the large group market as defined in Section 5 of
18the Illinois Health Insurance Portability and Accountability
19Act; or short-term, limited-duration health insurance coverage
20as defined in Section 5 of the Short-Term, Limited-Duration
21Health Insurance Coverage Act. For a filing of premium rates
22or classifications of risk for any of these types of coverage,
23the Director's initial review period shall not exceed 60 days
24to issue informal objections to the company that request
25additional clarification, explanation, substantiating
26documentation, or correction of concerns identified in the

 

 

HB5395 Engrossed- 56 -LRB103 37071 RPS 67189 b

1filing before the company implements the premium rates,
2classifications, or related rate-setting methodologies
3described in the filing, except that the Director may extend
4by not more than an additional 30 days the period of initial
5review by giving written notice to the company of such
6extension before the expiration of the initial 60-day period.
7Nothing in this subsection shall confer authority upon the
8Director to approve, modify, or disapprove rates where that
9authority is not provided by other law. Nothing in this
10subsection shall prohibit the Director from conducting any
11investigation, examination, hearing, or other formal
12administrative or enforcement proceeding with respect to a
13company's rate filing or implementation thereof under
14applicable law at any time, including after the period of
15initial review.
16(Source: P.A. 103-106, eff. 1-1-24.)
 
17    Section 3-10. The Illinois Health Benefits Exchange Law is
18amended by changing Section 5-5 as follows:
 
19    (215 ILCS 122/5-5)
20    Sec. 5-5. State health benefits exchange. It is declared
21that this State, beginning October 1, 2013, in accordance with
22Section 1311 of the federal Patient Protection and Affordable
23Care Act, shall establish a State health benefits exchange to
24be known as the Illinois Health Benefits Exchange in order to

 

 

HB5395 Engrossed- 57 -LRB103 37071 RPS 67189 b

1help individuals and small employers with no more than 50
2employees shop for, select, and enroll in qualified,
3affordable private health plans that fit their needs at
4competitive prices. The Exchange shall separate coverage pools
5for individuals and small employers and shall supplement and
6not supplant any existing private health insurance market for
7individuals and small employers. The Department of Insurance
8shall operate the Illinois Health Benefits Exchange as a
9State-based exchange using the federal platform by plan year
102025 and as a State-based exchange by plan year 2026. The
11Director of Insurance may require that all plans in the
12individual and small group markets, other than grandfathered
13health plans, be made available for comparison on the Illinois
14Health Benefits Exchange, but may not require that all plans
15in the individual and small group markets be purchased
16exclusively on the Illinois Health Benefits Exchange. Through
17the adoption of rules, the Director of Insurance may require
18that plans offered on the exchange conform with standardized
19plan designs that provide for standardized cost sharing for
20covered health services. Except when it is inconsistent with
21State law, the Department of Insurance shall enforce the
22coverage requirements under the federal Patient Protection and
23Affordable Care Act, including the coverage of all United
24States Preventive Services Task Force Grade A and B preventive
25services without cost sharing notwithstanding any federal
26overturning or repeal of 42 U.S.C. 300gg-13(a)(1), that apply

 

 

HB5395 Engrossed- 58 -LRB103 37071 RPS 67189 b

1to the individual and small group markets. Beginning for plan
2year 2026, if a health insurance issuer offers a product as
3defined under 45 CFR 144.103 at the gold or silver level
4through the Illinois Health Benefits Exchange, the issuer must
5offer that product at both the gold and silver levels. The
6Director of Insurance may elect to add a small business health
7options program to the Illinois Health Benefits Exchange to
8help small employers enroll their employees in qualified
9health plans in the small group market. The General Assembly
10shall appropriate funds to establish the Illinois Health
11Benefits Exchange.
12(Source: P.A. 103-103, eff. 6-27-23.)
 
13
Article 4.

 
14    Section 4-5. The Illinois Insurance Code is amended by
15changing Section 355 as follows:
 
16    (215 ILCS 5/355)  (from Ch. 73, par. 967)
17    Sec. 355. Accident and health policies; provisions.
18    (a) As used in this Section:
19    "Inadequate rate" means a rate:
20        (1) that is insufficient to sustain projected losses
21    and expenses to which the rate applies; and
22        (2) the continued use of which endangers the solvency
23    of an insurer using that rate.

 

 

HB5395 Engrossed- 59 -LRB103 37071 RPS 67189 b

1    "Large employer" has the meaning provided in the Illinois
2Health Insurance Portability and Accountability Act.
3    "Plain language" has the meaning provided in the federal
4Plain Writing Act of 2010 and subsequent guidance documents,
5including the Federal Plain Language Guidelines.
6    "Unreasonable rate increase" means a rate increase that
7the Director determines to be excessive, unjustified, or
8unfairly discriminatory in accordance with 45 CFR 154.205.
9    (b) No policy of insurance against loss or damage from the
10sickness, or from the bodily injury or death of the insured by
11accident shall be issued or delivered to any person in this
12State until a copy of the form thereof and of the
13classification of risks and the premium rates pertaining
14thereto have been filed with the Director; nor shall it be so
15issued or delivered until the Director shall have approved
16such policy pursuant to the provisions of Section 143. If the
17Director disapproves the policy form, he or she shall make a
18written decision stating the respects in which such form does
19not comply with the requirements of law and shall deliver a
20copy thereof to the company and it shall be unlawful
21thereafter for any such company to issue any policy in such
22form. On and after January 1, 2025, any form filing submitted
23for large employer group accident and health insurance shall
24be automatically deemed approved within 90 days of the
25submission date unless the Director extends by not more than
26an additional 30 days the period within which the form shall be

 

 

HB5395 Engrossed- 60 -LRB103 37071 RPS 67189 b

1approved or disapproved by giving written notice to the
2insurer of such extension before the expiration of the 90
3days. Any form in receipt of such an extension shall be
4automatically deemed approved within 120 days of the
5submission date. The Director may toll the filing due to a
6conflict in legal interpretation of federal or State law as
7long as the tolling is applied uniformly to all applicable
8forms, written notification is provided to the insurer prior
9to the tolling, the duration of the tolling is provided within
10the notice to the insurer, and justification for the tolling
11is posted to the Department's website. The Director may
12disapprove the filing if the insurer fails to respond to an
13objection or request for additional information within the
14timeframe identified for response. As used in this subsection,
15"large employer" has the meaning given in Section 5 of the
16federal Health Insurance Portability and Accountability Act.
17    (c) For plan year 2026 and thereafter, premium rates for
18all individual and small group accident and health insurance
19policies must be filed with the Department for approval.
20Unreasonable rate increases or inadequate rates shall be
21modified or disapproved. For any plan year during which the
22Illinois Health Benefits Exchange operates as a full
23State-based exchange, the Department shall provide insurers at
24least 30 days' notice of the deadline to submit rate filings.
25    (d) For plan year 2025 and thereafter, the Department
26shall post all insurers' rate filings and summaries on the

 

 

HB5395 Engrossed- 61 -LRB103 37071 RPS 67189 b

1Department's website 5 business days after the rate filing
2deadline set by the Department in annual guidance. The rate
3filings and summaries posted to the Department's website shall
4exclude information that is proprietary or trade secret
5information protected under paragraph (g) of subsection (1) of
6Section 7 of the Freedom of Information Act or confidential or
7privileged under any applicable insurance law or rule. All
8summaries shall include a brief justification of any rate
9increase or decrease requested, including the number of
10individual members, the medical loss ratio, medical trend,
11administrative costs, and any other information required by
12rule. The plain writing summary shall include notification of
13the public comment period established in subsection (e).
14    (e) The Department shall open a 30-day public comment
15period on the rate filings beginning on the date that all of
16the rate filings are posted on the Department's website. The
17Department shall post all of the comments received to the
18Department's website within 5 business days after the comment
19period ends.
20    (f) After the close of the public comment period described
21in subsection (e), the Department, beginning for plan year
222026, shall issue a decision to approve, disapprove, or modify
23a rate filing within 60 days. Any rate filing or any rates
24within a filing on which the Director does not issue a decision
25within 60 days shall automatically be deemed approved. The
26Director's decision shall take into account the actuarial

 

 

HB5395 Engrossed- 62 -LRB103 37071 RPS 67189 b

1justifications and public comments. The Department shall
2notify the insurer of the decision, make the decision
3available to the public by posting it on the Department's
4website, and include an explanation of the findings, actuarial
5justifications, and rationale that are the basis for the
6decision. Any company whose rate has been modified or
7disapproved shall be allowed to request a hearing within 10
8days after the action taken. The action of the Director in
9disapproving a rate shall be subject to judicial review under
10the Administrative Review Law.
11    (g) If, following the issuance of a decision but before
12the effective date of the premium rates approved by the
13decision, an event occurs that materially affects the
14Director's decision to approve, deny, or modify the rates, the
15Director may consider supplemental facts or data reasonably
16related to the event.
17    (h) The Department shall adopt rules implementing the
18procedures described in subsections (d) through (g) by March
1931, 2024.
20    (i) Subsection (a), and subsections (c) through (h), and
21subsection (j) of this Section do not apply to grandfathered
22health plans as defined in 45 CFR 147.140; excepted benefits
23as defined in 42 U.S.C. 300gg-91; student health insurance
24coverage as defined in 45 CFR 147.145; the large group market
25as defined in Section 5 of the Illinois Health Insurance
26Portability and Accountability Act; or short-term,

 

 

HB5395 Engrossed- 63 -LRB103 37071 RPS 67189 b

1limited-duration health insurance coverage as defined in
2Section 5 of the Short-Term, Limited-Duration Health Insurance
3Coverage Act. For a filing of premium rates or classifications
4of risk for any of these types of coverage, the Director's
5initial review period shall not exceed 60 days to issue
6informal objections to the company that request additional
7clarification, explanation, substantiating documentation, or
8correction of concerns identified in the filing before the
9company implements the premium rates, classifications, or
10related rate-setting methodologies described in the filing,
11except that the Director may extend by not more than an
12additional 30 days the period of initial review by giving
13written notice to the company of such extension before the
14expiration of the initial 60-day period. Nothing in this
15subsection shall confer authority upon the Director to
16approve, modify, or disapprove rates where that authority is
17not provided by other law. Nothing in this subsection shall
18prohibit the Director from conducting any investigation,
19examination, hearing, or other formal administrative or
20enforcement proceeding with respect to a company's rate filing
21or implementation thereof under applicable law at any time,
22including after the period of initial review.
23    (j) Subsections (c) through (h) do not apply to group
24policies issued to large employers. For large employer group
25policies issued, delivered, amended, or renewed on or after
26January 1, 2026 that are not described in subsection (i), the

 

 

HB5395 Engrossed- 64 -LRB103 37071 RPS 67189 b

1premium rates and risk classifications, including any rate
2manuals and rules used to arrive at the rates, must be filed
3with the Department annually for approval at least 120 days
4before the rates are intended to take effect.
5        (1) A rate filing shall be modified or disapproved if
6    rates will be unreasonable in relation to the benefits,
7    unjustified, or unfairly discriminatory, or otherwise in
8    violation of applicable State or federal law.
9        (2) Within 60 days of receipt of the rate filing, the
10    Director shall issue a decision to approve, disapprove, or
11    modify the filing along with the reasons and actuarial
12    justification for the decision. Any rate filing or rates
13    within a filing on which the Director does not issue a
14    decision within 60 days shall be automatically deemed
15    approved.
16        (3) Any company whose rate or rate filing has been
17    modified or disapproved shall be allowed to request a
18    hearing within 10 days after the action taken. The action
19    of the Director in disapproving a rate or rate filing
20    shall be subject to judicial review under the
21    Administrative Review Law.
22        (4) Nothing in this subsection requires a company to
23    file a large employer group policy's final premium rates
24    for prior approval if the company negotiates the final
25    rates or rate adjustments with the large employer in
26    accordance with the rate manual and rules of the currently

 

 

HB5395 Engrossed- 65 -LRB103 37071 RPS 67189 b

1    approved rate filing for the policy.
2(Source: P.A. 103-106, eff. 1-1-24.)
 
3    Section 4-10. The Health Maintenance Organization Act is
4amended by changing Section 4-12 as follows:
 
5    (215 ILCS 125/4-12)  (from Ch. 111 1/2, par. 1409.5)
6    Sec. 4-12. Changes in rate methodology and benefits,
7material modifications. A health maintenance organization
8shall file with the Director, prior to use, a notice of any
9change in rate methodology, or benefits and of any material
10modification of any matter or document furnished pursuant to
11Section 2-1, together with such supporting documents as are
12necessary to fully explain the change or modification.
13    (a) Contract modifications described in subsections
14(c)(5), (c)(6) and (c)(7) of Section 2-1 shall include all
15form agreements between the organization and enrollees,
16providers, administrators of services and insurers of health
17maintenance organizations.
18    (b) Material transactions or series of transactions other
19than those described in subsection (a) of this Section, the
20total annual value of which exceeds the greater of $100,000 or
215% of net earned subscription revenue for the most current
2212-month period as determined from filed financial statements.
23    (c) Any agreement between the organization and an insurer
24shall be subject to the provisions of the laws of this State

 

 

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1regarding reinsurance as provided in Article XI of the
2Illinois Insurance Code. All reinsurance agreements must be
3filed. Approval of the Director is required for all agreements
4except the following: individual stop loss, aggregate excess,
5hospitalization benefits or out-of-area of the participating
6providers unless 20% or more of the organization's total risk
7is reinsured, in which case all reinsurance agreements require
8approval.
9    (d) In addition to any applicable provisions of this Act,
10premium rate filings shall be subject to subsections (a) and
11(c) through (j) (i) of Section 355 of the Illinois Insurance
12Code.
13(Source: P.A. 103-106, eff. 1-1-24.)
 
14    Section 4-15. The Limited Health Service Organization Act
15is amended by changing Section 3006 as follows:
 
16    (215 ILCS 130/3006)  (from Ch. 73, par. 1503-6)
17    Sec. 3006. Changes in rate methodology and benefits;
18material modifications; addition of limited health services.
19    (a) A limited health service organization shall file with
20the Director prior to use, a notice of any change in rate
21methodology, charges, or benefits and of any material
22modification of any matter or document furnished pursuant to
23Section 2001, together with such supporting documents as are
24necessary to fully explain the change or modification.

 

 

HB5395 Engrossed- 67 -LRB103 37071 RPS 67189 b

1        (1) Contract modifications described in paragraphs (5)
2    and (6) of subsection (c) of Section 2001 shall include
3    all agreements between the organization and enrollees,
4    providers, administrators of services, and insurers of
5    limited health services; also other material transactions
6    or series of transactions, the total annual value of which
7    exceeds the greater of $100,000 or 5% of net earned
8    subscription revenue for the most current 12-month 12
9    month period as determined from filed financial
10    statements.
11        (2) Contract modification for reinsurance. Any
12    agreement between the organization and an insurer shall be
13    subject to the provisions of Article XI of the Illinois
14    Insurance Code, as now or hereafter amended. All
15    reinsurance agreements must be filed with the Director.
16    Approval of the Director in required agreements must be
17    filed. Approval of the director is required for all
18    agreements except individual stop loss, aggregate excess,
19    hospitalization benefits, or out-of-area of the
20    participating providers, unless 20% or more of the
21    organization's total risk is reinsured, in which case all
22    reinsurance agreements shall require approval.
23    (b) If a limited health service organization desires to
24add one or more additional limited health services, it shall
25file a notice with the Director and, at the same time, submit
26the information required by Section 2001 if different from

 

 

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1that filed with the prepaid limited health service
2organization's application. Issuance of such an amended
3certificate of authority shall be subject to the conditions of
4Section 2002 of this Act.
5    (c) In addition to any applicable provisions of this Act,
6premium rate filings shall be subject to subsection (i) and,
7for pharmaceutical policies, subsection (j) of Section 355 of
8the Illinois Insurance Code.
9(Source: P.A. 103-106, eff. 1-1-24; revised 1-2-24.)
 
10
Article 5.

 
11    Section 5-5. The Illinois Insurance Code is amended by
12changing Sections 121-2.05, 356z.18, 367.3, 367a, and 368f and
13by adding Section 352c as follows:
 
14    (215 ILCS 5/121-2.05)  (from Ch. 73, par. 733-2.05)
15    Sec. 121-2.05. Group insurance policies issued and
16delivered in other State-Transactions in this State. With the
17exception of insurance transactions authorized under Sections
18230.2 or 367.3 of this Code or transactions described under
19Section 352c, transactions in this State involving group
20legal, group life and group accident and health or blanket
21accident and health insurance or group annuities where the
22master policy of such groups was lawfully issued and delivered
23in, and under the laws of, a State in which the insurer was

 

 

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1authorized to do an insurance business, to a group properly
2established pursuant to law or regulation, and where the
3policyholder is domiciled or otherwise has a bona fide situs.
4(Source: P.A. 86-753.)
 
5    (215 ILCS 5/352c new)
6    Sec. 352c. Short-term, limited-duration insurance
7prohibited; rules for excepted benefits.
8    (a) Definitions. As used in this Section:
9    "Excepted benefits" has the meaning given to that term in
1042 U.S.C. 300gg-91 and implementing regulations. "Excepted
11benefits" includes individual, group, or blanket coverage.
12    "Short-term, limited-duration insurance" means any type of
13accident and health insurance offered or provided within this
14State pursuant to a group or individual policy or individual
15certificate by a company, regardless of the situs state of the
16delivery of the policy, that has an expiration date specified
17in the contract that is fewer than 365 days after the original
18effective date. Regardless of the duration of coverage,
19"short-term, limited-duration insurance" does not include
20excepted benefits or any student health insurance coverage.
21    "Student health insurance coverage" has the meaning given
22to that term in 45 CFR 147.145.
23    (b) On and after January 1, 2025, no company shall issue,
24deliver, amend, or renew short-term, limited-duration
25insurance to any natural or legal person that is a resident or

 

 

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1domiciled in this State.
2    (c) To prevent the use, design, and combination of
3excepted benefits to circumvent State or federal requirements
4for comprehensive forms of health insurance coverage, to
5prevent confusion or misinformation of insureds about
6duplicate or distinct types of coverage, and to ensure a
7measure of consistency within product lines across the
8individual, group, and blanket markets, the Department may
9adopt rules as deemed necessary that prescribe specific
10standards for or restrictions on policy provisions, benefit
11design, disclosures, and sales and marketing practices for
12excepted benefits. For purposes of these rules, the Director's
13authority under subsections (3) and (4) of Section 355a is
14extended to group and blanket excepted benefits. To ensure
15compliance with these rules, the Director may require policy
16forms and rates to be filed as provided in Sections 143 and 355
17and rules thereunder with respect to excepted benefits
18coverage intended to be issued to residents of this State
19under a master contract issued to a group domiciled or
20otherwise with bona fide situs outside of this State. This
21subsection does not apply to limited-scope dental,
22limited-scope vision, long-term care, Medicare supplement,
23credit life, credit health, or any excepted benefits that are
24filed under subsections (b) through (l) of Class 2 or under
25Class 3 of Section 4. Nothing in this subsection shall be
26construed to limit the Director's authority under other

 

 

HB5395 Engrossed- 71 -LRB103 37071 RPS 67189 b

1statutes.
 
2    (215 ILCS 5/356z.18)
3    (Text of Section before amendment by P.A. 103-512)
4    Sec. 356z.18. Prosthetic and customized orthotic devices.
5    (a) For the purposes of this Section:
6    "Customized orthotic device" means a supportive device for
7the body or a part of the body, the head, neck, or extremities,
8and includes the replacement or repair of the device based on
9the patient's physical condition as medically necessary,
10excluding foot orthotics defined as an in-shoe device designed
11to support the structural components of the foot during
12weight-bearing activities.
13    "Licensed provider" means a prosthetist, orthotist, or
14pedorthist licensed to practice in this State.
15    "Prosthetic device" means an artificial device to replace,
16in whole or in part, an arm or leg and includes accessories
17essential to the effective use of the device and the
18replacement or repair of the device based on the patient's
19physical condition as medically necessary.
20    (b) This amendatory Act of the 96th General Assembly shall
21provide benefits to any person covered thereunder for expenses
22incurred in obtaining a prosthetic or custom orthotic device
23from any Illinois licensed prosthetist, licensed orthotist, or
24licensed pedorthist as required under the Orthotics,
25Prosthetics, and Pedorthics Practice Act.

 

 

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1    (c) A group or individual major medical policy of accident
2or health insurance or managed care plan or medical, health,
3or hospital service corporation contract that provides
4coverage for prosthetic or custom orthotic care and is
5amended, delivered, issued, or renewed 6 months after the
6effective date of this amendatory Act of the 96th General
7Assembly must provide coverage for prosthetic and orthotic
8devices in accordance with this subsection (c). The coverage
9required under this Section shall be subject to the other
10general exclusions, limitations, and financial requirements of
11the policy, including coordination of benefits, participating
12provider requirements, utilization review of health care
13services, including review of medical necessity, case
14management, and experimental and investigational treatments,
15and other managed care provisions under terms and conditions
16that are no less favorable than the terms and conditions that
17apply to substantially all medical and surgical benefits
18provided under the plan or coverage.
19    (d) The policy or plan or contract may require prior
20authorization for the prosthetic or orthotic devices in the
21same manner that prior authorization is required for any other
22covered benefit.
23    (e) Repairs and replacements of prosthetic and orthotic
24devices are also covered, subject to the co-payments and
25deductibles, unless necessitated by misuse or loss.
26    (f) A policy or plan or contract may require that, if

 

 

HB5395 Engrossed- 73 -LRB103 37071 RPS 67189 b

1coverage is provided through a managed care plan, the benefits
2mandated pursuant to this Section shall be covered benefits
3only if the prosthetic or orthotic devices are provided by a
4licensed provider employed by a provider service who contracts
5with or is designated by the carrier, to the extent that the
6carrier provides in-network and out-of-network service, the
7coverage for the prosthetic or orthotic device shall be
8offered no less extensively.
9    (g) The policy or plan or contract shall also meet
10adequacy requirements as established by the Health Care
11Reimbursement Reform Act of 1985 of the Illinois Insurance
12Code.
13    (h) This Section shall not apply to accident only,
14specified disease, short-term travel hospital or medical,
15hospital confinement indemnity or other fixed indemnity,
16credit, dental, vision, Medicare supplement, long-term care,
17basic hospital and medical-surgical expense coverage,
18disability income insurance coverage, coverage issued as a
19supplement to liability insurance, workers' compensation
20insurance, or automobile medical payment insurance.
21(Source: P.A. 96-833, eff. 6-1-10.)
 
22    (Text of Section after amendment by P.A. 103-512)
23    Sec. 356z.18. Prosthetic and customized orthotic devices.
24    (a) For the purposes of this Section:
25    "Customized orthotic device" means a supportive device for

 

 

HB5395 Engrossed- 74 -LRB103 37071 RPS 67189 b

1the body or a part of the body, the head, neck, or extremities,
2and includes the replacement or repair of the device based on
3the patient's physical condition as medically necessary,
4excluding foot orthotics defined as an in-shoe device designed
5to support the structural components of the foot during
6weight-bearing activities.
7    "Licensed provider" means a prosthetist, orthotist, or
8pedorthist licensed to practice in this State.
9    "Prosthetic device" means an artificial device to replace,
10in whole or in part, an arm or leg and includes accessories
11essential to the effective use of the device and the
12replacement or repair of the device based on the patient's
13physical condition as medically necessary.
14    (b) This amendatory Act of the 96th General Assembly shall
15provide benefits to any person covered thereunder for expenses
16incurred in obtaining a prosthetic or custom orthotic device
17from any Illinois licensed prosthetist, licensed orthotist, or
18licensed pedorthist as required under the Orthotics,
19Prosthetics, and Pedorthics Practice Act.
20    (c) A group or individual major medical policy of accident
21or health insurance or managed care plan or medical, health,
22or hospital service corporation contract that provides
23coverage for prosthetic or custom orthotic care and is
24amended, delivered, issued, or renewed 6 months after the
25effective date of this amendatory Act of the 96th General
26Assembly must provide coverage for prosthetic and orthotic

 

 

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1devices in accordance with this subsection (c). The coverage
2required under this Section shall be subject to the other
3general exclusions, limitations, and financial requirements of
4the policy, including coordination of benefits, participating
5provider requirements, utilization review of health care
6services, including review of medical necessity, case
7management, and experimental and investigational treatments,
8and other managed care provisions under terms and conditions
9that are no less favorable than the terms and conditions that
10apply to substantially all medical and surgical benefits
11provided under the plan or coverage.
12    (d) With respect to an enrollee at any age, in addition to
13coverage of a prosthetic or custom orthotic device required by
14this Section, benefits shall be provided for a prosthetic or
15custom orthotic device determined by the enrollee's provider
16to be the most appropriate model that is medically necessary
17for the enrollee to perform physical activities, as
18applicable, such as running, biking, swimming, and lifting
19weights, and to maximize the enrollee's whole body health and
20strengthen the lower and upper limb function.
21    (e) The requirements of this Section do not constitute an
22addition to this State's essential health benefits that
23requires defrayal of costs by this State pursuant to 42 U.S.C.
2418031(d)(3)(B).
25    (f) The policy or plan or contract may require prior
26authorization for the prosthetic or orthotic devices in the

 

 

HB5395 Engrossed- 76 -LRB103 37071 RPS 67189 b

1same manner that prior authorization is required for any other
2covered benefit.
3    (g) Repairs and replacements of prosthetic and orthotic
4devices are also covered, subject to the co-payments and
5deductibles, unless necessitated by misuse or loss.
6    (h) A policy or plan or contract may require that, if
7coverage is provided through a managed care plan, the benefits
8mandated pursuant to this Section shall be covered benefits
9only if the prosthetic or orthotic devices are provided by a
10licensed provider employed by a provider service who contracts
11with or is designated by the carrier, to the extent that the
12carrier provides in-network and out-of-network service, the
13coverage for the prosthetic or orthotic device shall be
14offered no less extensively.
15    (i) The policy or plan or contract shall also meet
16adequacy requirements as established by the Health Care
17Reimbursement Reform Act of 1985 of the Illinois Insurance
18Code.
19    (j) This Section shall not apply to accident only,
20specified disease, short-term travel hospital or medical,
21hospital confinement indemnity or other fixed indemnity,
22credit, dental, vision, Medicare supplement, long-term care,
23basic hospital and medical-surgical expense coverage,
24disability income insurance coverage, coverage issued as a
25supplement to liability insurance, workers' compensation
26insurance, or automobile medical payment insurance.

 

 

HB5395 Engrossed- 77 -LRB103 37071 RPS 67189 b

1(Source: P.A. 103-512, eff. 1-1-25.)
 
2    (215 ILCS 5/367.3)  (from Ch. 73, par. 979.3)
3    Sec. 367.3. Group accident and health insurance;
4discretionary groups.
5    (a) No group health insurance offered to a resident of
6this State under a policy issued to a group, other than one
7specifically described in Section 367(1), shall be delivered
8or issued for delivery in this State unless the Director
9determines that:
10        (1) the issuance of the policy is not contrary to the
11    public interest;
12        (2) the issuance of the policy will result in
13    economies of acquisition and administration; and
14        (3) the benefits under the policy are reasonable in
15    relation to the premium charged.
16    (b) No such group health insurance may be offered in this
17State under a policy issued in another state unless this State
18or the state in which the group policy is issued has made a
19determination that the requirements of subsection (a) have
20been met.
21    Where insurance is to be offered in this State under a
22policy described in this subsection, the insurer shall file
23for informational review purposes:
24        (1) a copy of the group master contract;
25        (2) a copy of the statute authorizing the issuance of

 

 

HB5395 Engrossed- 78 -LRB103 37071 RPS 67189 b

1    the group policy in the state of situs, which statute has
2    the same or similar requirements as this State, or in the
3    absence of such statute, a certification by an officer of
4    the company that the policy meets the Illinois minimum
5    standards required for individual accident and health
6    policies under authority of Section 401 of this Code, as
7    now or hereafter amended, as promulgated by rule at 50
8    Illinois Administrative Code, Ch. I, Sec. 2007, et seq.,
9    as now or hereafter amended, or by a successor rule;
10        (3) evidence of approval by the state of situs of the
11    group master policy; and
12        (4) copies of all supportive material furnished to the
13    state of situs to satisfy the criteria for approval.
14    (c) The Director may, at any time after receipt of the
15information required under subsection (b) and after finding
16that the standards of subsection (a) have not been met, order
17the insurer to cease the issuance or marketing of that
18coverage in this State.
19    (d) Notwithstanding subsections (a) and (b), group Group
20accident and health insurance subject to the provisions of
21this Section is also subject to the provisions of Sections
22352c and Section 367i of this Code and rules thereunder.
23(Source: P.A. 90-655, eff. 7-30-98.)
 
24    (215 ILCS 5/367a)  (from Ch. 73, par. 979a)
25    Sec. 367a. Blanket accident and health insurance.

 

 

HB5395 Engrossed- 79 -LRB103 37071 RPS 67189 b

1    (1) Blanket accident and health insurance is the that form
2of accident and health insurance providing excepted benefits,
3as defined in Section 352c, that covers covering special
4groups of persons as enumerated in one of the following
5paragraphs (a) to (g), inclusive:
6    (a) Under a policy or contract issued to any carrier for
7hire, which shall be deemed the policyholder, covering a group
8defined as all persons who may become passengers on such
9carrier.
10    (b) Under a policy or contract issued to an employer, who
11shall be deemed the policyholder, covering all employees or
12any group of employees defined by reference to exceptional
13hazards incident to such employment.
14    (c) Under a policy or contract issued to a college,
15school, or other institution of learning or to the head or
16principal thereof, who or which shall be deemed the
17policyholder, covering students or teachers. However, except
18where inconsistent with 45 CFR 147.145, student health
19insurance coverage other than excepted benefits that is
20provided pursuant to a written agreement with an institution
21of higher education for the benefit of its enrolled students
22and their dependents shall remain subject to the standards and
23requirements for individual coverage.
24    (d) Under a policy or contract issued in the name of any
25volunteer fire department, first aid, or other such volunteer
26group, which shall be deemed the policyholder, covering all of

 

 

HB5395 Engrossed- 80 -LRB103 37071 RPS 67189 b

1the members of such department or group.
2    (e) Under a policy or contract issued to a creditor, who
3shall be deemed the policyholder, to insure debtors of the
4creditors; Provided, however, that in the case of a loan which
5is subject to the Small Loans Act, no insurance premium or
6other cost shall be directly or indirectly charged or assessed
7against, or collected or received from the borrower.
8    (f) Under a policy or contract issued to a sports team or
9to a camp, which team or camp sponsor shall be deemed the
10policyholder, covering members or campers.
11    (g) Under a policy or contract issued to any other
12substantially similar group which, in the discretion of the
13Director, may be subject to the issuance of a blanket accident
14and health policy or contract.
15    (2) Any insurance company authorized to write accident and
16health insurance in this state shall have the power to issue
17blanket accident and health insurance. No such blanket policy
18may be issued or delivered in this State unless a copy of the
19form thereof shall have been filed in accordance with Section
20355, and it contains in substance such of those provisions
21contained in Sections 357.1 through 357.30 as may be
22applicable to blanket accident and health insurance and the
23following provisions:
24    (a) A provision that the policy and the application shall
25constitute the entire contract between the parties, and that
26all statements made by the policyholder shall, in absence of

 

 

HB5395 Engrossed- 81 -LRB103 37071 RPS 67189 b

1fraud, be deemed representations and not warranties, and that
2no such statements shall be used in defense to a claim under
3the policy, unless it is contained in a written application.
4    (b) A provision that to the group or class thereof
5originally insured shall be added from time to time all new
6persons or individuals eligible for coverage.
7    (3) An individual application shall not be required from a
8person covered under a blanket accident or health policy or
9contract, nor shall it be necessary for the insurer to furnish
10each person a certificate.
11    (4) All benefits under any blanket accident and health
12policy shall be payable to the person insured, or to his
13designated beneficiary or beneficiaries, or to his or her
14estate, except that if the person insured be a minor or person
15under legal disability, such benefits may be made payable to
16his or her parent, guardian, or other person actually
17supporting him or her. Provided further, however, that the
18policy may provide that all or any portion of any indemnities
19provided by any such policy on account of hospital, nursing,
20medical or surgical services may, at the insurer's option, be
21paid directly to the hospital or person rendering such
22services; but the policy may not require that the service be
23rendered by a particular hospital or person. Payment so made
24shall discharge the insurer's obligation with respect to the
25amount of insurance so paid.
26    (5) Nothing contained in this section shall be deemed to

 

 

HB5395 Engrossed- 82 -LRB103 37071 RPS 67189 b

1affect the legal liability of policyholders for the death of
2or injury to, any such member of such group.
3(Source: P.A. 83-1362.)
 
4    (215 ILCS 5/368f)
5    Sec. 368f. Military service member insurance
6reinstatement.
7    (a) No Illinois resident activated for military service
8and no spouse or dependent of the resident who becomes
9eligible for a federal government-sponsored health insurance
10program, including the TriCare program providing coverage for
11civilian dependents of military personnel, as a result of the
12activation shall be denied reinstatement into the same
13individual health insurance coverage with the health insurer
14that the resident lapsed as a result of activation or becoming
15covered by the federal government-sponsored health insurance
16program. The resident shall have the right to reinstatement in
17the same individual health insurance coverage without medical
18underwriting, subject to payment of the current premium
19charged to other persons of the same age and gender that are
20covered under the same individual health coverage. Except in
21the case of birth or adoption that occurs during the period of
22activation, reinstatement must be into the same coverage type
23as the resident held prior to lapsing the individual health
24insurance coverage and at the same or, at the option of the
25resident, higher deductible level. The reinstatement rights

 

 

HB5395 Engrossed- 83 -LRB103 37071 RPS 67189 b

1provided under this subsection (a) are not available to a
2resident or dependents if the activated person is discharged
3from the military under other than honorable conditions.
4    (b) The health insurer with which the reinstatement is
5being requested must receive a request for reinstatement no
6later than 63 days following the later of (i) deactivation or
7(ii) loss of coverage under the federal government-sponsored
8health insurance program. The health insurer may request proof
9of loss of coverage and the timing of the loss of coverage of
10the government-sponsored coverage in order to determine
11eligibility for reinstatement into the individual coverage.
12The effective date of the reinstatement of individual health
13coverage shall be the first of the month following receipt of
14the notice requesting reinstatement.
15    (c) All insurers must provide written notice to the
16policyholder of individual health coverage of the rights
17described in subsection (a) of this Section. In lieu of the
18inclusion of the notice in the individual health insurance
19policy, an insurance company may satisfy the notification
20requirement by providing a single written notice:
21        (1) in conjunction with the enrollment process for a
22    policyholder initially enrolling in the individual
23    coverage on or after the effective date of this amendatory
24    Act of the 94th General Assembly; or
25        (2) by mailing written notice to policyholders whose
26    coverage was effective prior to the effective date of this

 

 

HB5395 Engrossed- 84 -LRB103 37071 RPS 67189 b

1    amendatory Act of the 94th General Assembly no later than
2    90 days following the effective date of this amendatory
3    Act of the 94th General Assembly.
4    (d) The provisions of subsection (a) of this Section do
5not apply to any policy or certificate providing coverage for
6any specified disease, specified accident or accident-only
7coverage, credit, dental, disability income, hospital
8indemnity or other fixed indemnity, long-term care, Medicare
9supplement, vision care, or short-term travel nonrenewable
10health policy or other limited-benefit supplemental insurance,
11or any coverage issued as a supplement to any liability
12insurance, workers' compensation or similar insurance, or any
13insurance under which benefits are payable with or without
14regard to fault, whether written on a group, blanket, or
15individual basis.
16    (e) Nothing in this Section shall require an insurer to
17reinstate the resident if the insurer requires residency in an
18enrollment area and those residency requirements are not met
19after deactivation or loss of coverage under the
20government-sponsored health insurance program.
21    (f) All terms, conditions, and limitations of the
22individual coverage into which reinstatement is made apply
23equally to all insureds enrolled in the coverage.
24    (g) The Secretary may adopt rules as may be necessary to
25carry out the provisions of this Section.
26(Source: P.A. 94-1037, eff. 7-20-06.)
 

 

 

HB5395 Engrossed- 85 -LRB103 37071 RPS 67189 b

1    Section 5-10. The Health Maintenance Organization Act is
2amended by changing Section 5-3 as follows:
 
3    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
4    Sec. 5-3. Insurance Code provisions.
5    (a) Health Maintenance Organizations shall be subject to
6the provisions of Sections 133, 134, 136, 137, 139, 140,
7141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
8154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
9352c, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q,
10356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
11356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
12356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
13356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,
14356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
15356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
16356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,
17356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
18356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
19356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
20368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
21408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
22subsection (2) of Section 367, and Articles IIA, VIII 1/2,
23XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
24Illinois Insurance Code.

 

 

HB5395 Engrossed- 86 -LRB103 37071 RPS 67189 b

1    (b) For purposes of the Illinois Insurance Code, except
2for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
3Health Maintenance Organizations in the following categories
4are deemed to be "domestic companies":
5        (1) a corporation authorized under the Dental Service
6    Plan Act or the Voluntary Health Services Plans Act;
7        (2) a corporation organized under the laws of this
8    State; or
9        (3) a corporation organized under the laws of another
10    state, 30% or more of the enrollees of which are residents
11    of this State, except a corporation subject to
12    substantially the same requirements in its state of
13    organization as is a "domestic company" under Article VIII
14    1/2 of the Illinois Insurance Code.
15    (c) In considering the merger, consolidation, or other
16acquisition of control of a Health Maintenance Organization
17pursuant to Article VIII 1/2 of the Illinois Insurance Code,
18        (1) the Director shall give primary consideration to
19    the continuation of benefits to enrollees and the
20    financial conditions of the acquired Health Maintenance
21    Organization after the merger, consolidation, or other
22    acquisition of control takes effect;
23        (2)(i) the criteria specified in subsection (1)(b) of
24    Section 131.8 of the Illinois Insurance Code shall not
25    apply and (ii) the Director, in making his determination
26    with respect to the merger, consolidation, or other

 

 

HB5395 Engrossed- 87 -LRB103 37071 RPS 67189 b

1    acquisition of control, need not take into account the
2    effect on competition of the merger, consolidation, or
3    other acquisition of control;
4        (3) the Director shall have the power to require the
5    following information:
6            (A) certification by an independent actuary of the
7        adequacy of the reserves of the Health Maintenance
8        Organization sought to be acquired;
9            (B) pro forma financial statements reflecting the
10        combined balance sheets of the acquiring company and
11        the Health Maintenance Organization sought to be
12        acquired as of the end of the preceding year and as of
13        a date 90 days prior to the acquisition, as well as pro
14        forma financial statements reflecting projected
15        combined operation for a period of 2 years;
16            (C) a pro forma business plan detailing an
17        acquiring party's plans with respect to the operation
18        of the Health Maintenance Organization sought to be
19        acquired for a period of not less than 3 years; and
20            (D) such other information as the Director shall
21        require.
22    (d) The provisions of Article VIII 1/2 of the Illinois
23Insurance Code and this Section 5-3 shall apply to the sale by
24any health maintenance organization of greater than 10% of its
25enrollee population (including, without limitation, the health
26maintenance organization's right, title, and interest in and

 

 

HB5395 Engrossed- 88 -LRB103 37071 RPS 67189 b

1to its health care certificates).
2    (e) In considering any management contract or service
3agreement subject to Section 141.1 of the Illinois Insurance
4Code, the Director (i) shall, in addition to the criteria
5specified in Section 141.2 of the Illinois Insurance Code,
6take into account the effect of the management contract or
7service agreement on the continuation of benefits to enrollees
8and the financial condition of the health maintenance
9organization to be managed or serviced, and (ii) need not take
10into account the effect of the management contract or service
11agreement on competition.
12    (f) Except for small employer groups as defined in the
13Small Employer Rating, Renewability and Portability Health
14Insurance Act and except for medicare supplement policies as
15defined in Section 363 of the Illinois Insurance Code, a
16Health Maintenance Organization may by contract agree with a
17group or other enrollment unit to effect refunds or charge
18additional premiums under the following terms and conditions:
19        (i) the amount of, and other terms and conditions with
20    respect to, the refund or additional premium are set forth
21    in the group or enrollment unit contract agreed in advance
22    of the period for which a refund is to be paid or
23    additional premium is to be charged (which period shall
24    not be less than one year); and
25        (ii) the amount of the refund or additional premium
26    shall not exceed 20% of the Health Maintenance

 

 

HB5395 Engrossed- 89 -LRB103 37071 RPS 67189 b

1    Organization's profitable or unprofitable experience with
2    respect to the group or other enrollment unit for the
3    period (and, for purposes of a refund or additional
4    premium, the profitable or unprofitable experience shall
5    be calculated taking into account a pro rata share of the
6    Health Maintenance Organization's administrative and
7    marketing expenses, but shall not include any refund to be
8    made or additional premium to be paid pursuant to this
9    subsection (f)). The Health Maintenance Organization and
10    the group or enrollment unit may agree that the profitable
11    or unprofitable experience may be calculated taking into
12    account the refund period and the immediately preceding 2
13    plan years.
14    The Health Maintenance Organization shall include a
15statement in the evidence of coverage issued to each enrollee
16describing the possibility of a refund or additional premium,
17and upon request of any group or enrollment unit, provide to
18the group or enrollment unit a description of the method used
19to calculate (1) the Health Maintenance Organization's
20profitable experience with respect to the group or enrollment
21unit and the resulting refund to the group or enrollment unit
22or (2) the Health Maintenance Organization's unprofitable
23experience with respect to the group or enrollment unit and
24the resulting additional premium to be paid by the group or
25enrollment unit.
26    In no event shall the Illinois Health Maintenance

 

 

HB5395 Engrossed- 90 -LRB103 37071 RPS 67189 b

1Organization Guaranty Association be liable to pay any
2contractual obligation of an insolvent organization to pay any
3refund authorized under this Section.
4    (g) Rulemaking authority to implement Public Act 95-1045,
5if any, is conditioned on the rules being adopted in
6accordance with all provisions of the Illinois Administrative
7Procedure Act and all rules and procedures of the Joint
8Committee on Administrative Rules; any purported rule not so
9adopted, for whatever reason, is unauthorized.
10(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
11102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
121-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
13eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
14102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
151-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
16eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
17103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
186-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
19eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
20    Section 5-15. The Limited Health Service Organization Act
21is amended by changing Section 4003 as follows:
 
22    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
23    Sec. 4003. Illinois Insurance Code provisions. Limited
24health service organizations shall be subject to the

 

 

HB5395 Engrossed- 91 -LRB103 37071 RPS 67189 b

1provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
2141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
3154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c,
4355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10,
5356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
6356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
7356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
8364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
9444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
10XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
11Nothing in this Section shall require a limited health care
12plan to cover any service that is not a limited health service.
13For purposes of the Illinois Insurance Code, except for
14Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
15health service organizations in the following categories are
16deemed to be domestic companies:
17        (1) a corporation under the laws of this State; or
18        (2) a corporation organized under the laws of another
19    state, 30% or more of the enrollees of which are residents
20    of this State, except a corporation subject to
21    substantially the same requirements in its state of
22    organization as is a domestic company under Article VIII
23    1/2 of the Illinois Insurance Code.
24(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
25102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
261-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,

 

 

HB5395 Engrossed- 92 -LRB103 37071 RPS 67189 b

1eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
2102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
31-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
4eff. 1-1-24; revised 8-29-23.)
 
5    (215 ILCS 190/Act rep.)
6    Section 5-20. The Short-Term, Limited-Duration Health
7Insurance Coverage Act is repealed.
 
8
Article 6.

 
9    Section 6-5. The Illinois Insurance Code is amended by
10changing Sections 155.36, 155.37, 356z.40, and 370c as
11follows:
 
12    (215 ILCS 5/155.36)
13    Sec. 155.36. Managed Care Reform and Patient Rights Act.
14Insurance companies that transact the kinds of insurance
15authorized under Class 1(b) or Class 2(a) of Section 4 of this
16Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65,
1770, and 85, and 87, subsection (d) of Section 30, and the
18definitions definition of the term "emergency medical
19condition" and any other term in Section 10 of the Managed Care
20Reform and Patient Rights Act that is used in the other
21Sections listed in this Section.
22(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 

 

 

HB5395 Engrossed- 93 -LRB103 37071 RPS 67189 b

1    (215 ILCS 5/155.37)
2    Sec. 155.37. Drug formulary; notice.
3    (a) Insurance companies that transact the kinds of
4insurance authorized under Class 1(b) or Class 2(a) of Section
54 of this Code and provide coverage for prescription drugs
6through the use of a drug formulary must notify insureds of any
7change in the formulary. A company may comply with this
8Section by posting changes in the formulary on its website.
9    (b) No later than October 1, 2025, insurance companies
10that use a drug formulary shall post the formulary on their
11websites in a manner that is searchable and accessible to the
12general public without requiring an individual to create any
13account. This formulary shall adhere to a template developed
14by the Department by March 31, 2025, which shall take into
15consideration existing requirements for reporting of
16information established by the federal Centers for Medicare
17and Medicaid Services as well as display of cost-sharing
18information. This template and all formularies also shall do
19all the following:
20        (1) include information on cost-sharing tiers and
21    utilization controls, such as prior authorization, for
22    each covered drug;
23        (2) indicate any drugs on the formulary that are
24    preferred over other drugs on the formulary;
25        (3) include information to educate insureds about the

 

 

HB5395 Engrossed- 94 -LRB103 37071 RPS 67189 b

1    differences between drugs administered or provided under a
2    policy's medical benefit and drugs covered under a drug
3    benefit and how to obtain coverage information about drugs
4    that are not covered under the drug benefit;
5        (4) include information to educate insureds that
6    policies that provide drug benefits are required to have a
7    method for enrollees to obtain drugs not listed in the
8    formulary if they are deemed medically necessary by a
9    clinician under Section 45.1 of the Managed Care Reform
10    and Patient Rights Act;
11        (5) include information on which medications are
12    covered, including both generic and brand name; and
13        (6) include information on what tier of the plan's
14    drug formulary each medication is in.
15    (c) No formulary may establish a step therapy requirement
16for any formulary drug or any drug covered as a result of a
17medical exceptions procedure.
18(Source: P.A. 92-440, eff. 8-17-01; 92-651, eff. 7-11-02.)
 
19    (215 ILCS 5/356z.40)
20    Sec. 356z.40. Pregnancy and postpartum coverage.
21    (a) An individual or group policy of accident and health
22insurance or managed care plan amended, delivered, issued, or
23renewed on or after the effective date of this amendatory Act
24of the 102nd General Assembly shall provide coverage for
25pregnancy and newborn care in accordance with 42 U.S.C.

 

 

HB5395 Engrossed- 95 -LRB103 37071 RPS 67189 b

118022(b) regarding essential health benefits.
2    (b) Benefits under this Section shall be as follows:
3        (1) An individual who has been identified as
4    experiencing a high-risk pregnancy by the individual's
5    treating provider shall have access to clinically
6    appropriate case management programs. As used in this
7    subsection, "case management" means a mechanism to
8    coordinate and assure continuity of services, including,
9    but not limited to, health services, social services, and
10    educational services necessary for the individual. "Case
11    management" involves individualized assessment of needs,
12    planning of services, referral, monitoring, and advocacy
13    to assist an individual in gaining access to appropriate
14    services and closure when services are no longer required.
15    "Case management" is an active and collaborative process
16    involving a single qualified case manager, the individual,
17    the individual's family, the providers, and the community.
18    This includes close coordination and involvement with all
19    service providers in the management plan for that
20    individual or family, including assuring that the
21    individual receives the services. As used in this
22    subsection, "high-risk pregnancy" means a pregnancy in
23    which the pregnant or postpartum individual or baby is at
24    an increased risk for poor health or complications during
25    pregnancy or childbirth, including, but not limited to,
26    hypertension disorders, gestational diabetes, and

 

 

HB5395 Engrossed- 96 -LRB103 37071 RPS 67189 b

1    hemorrhage.
2        (2) An individual shall have access to medically
3    necessary treatment of a mental, emotional, nervous, or
4    substance use disorder or condition consistent with the
5    requirements set forth in this Section and in Sections
6    370c and 370c.1 of this Code.
7        (3) The benefits provided for inpatient and outpatient
8    services for the treatment of a mental, emotional,
9    nervous, or substance use disorder or condition related to
10    pregnancy or postpartum complications shall be provided if
11    determined to be medically necessary, consistent with the
12    requirements of Sections 370c and 370c.1 of this Code. The
13    facility or provider shall notify the insurer of both the
14    admission and the initial treatment plan within 48 hours
15    after admission or initiation of treatment. Subject to the
16    requirements of Sections 370c and 370c.1 of this Code,
17    nothing Nothing in this paragraph shall prevent an insurer
18    from applying concurrent and post-service utilization
19    review of health care services, including review of
20    medical necessity, case management, experimental and
21    investigational treatments, managed care provisions, and
22    other terms and conditions of the insurance policy.
23        (4) The benefits for the first 48 hours of initiation
24    of services for an inpatient admission, detoxification or
25    withdrawal management program, or partial hospitalization
26    admission for the treatment of a mental, emotional,

 

 

HB5395 Engrossed- 97 -LRB103 37071 RPS 67189 b

1    nervous, or substance use disorder or condition related to
2    pregnancy or postpartum complications shall be provided
3    without post-service or concurrent review of medical
4    necessity, as the medical necessity for the first 48 hours
5    of such services shall be determined solely by the covered
6    pregnant or postpartum individual's provider. Subject to
7    Section 370c and 370c.1 of this Code, nothing Nothing in
8    this paragraph shall prevent an insurer from applying
9    concurrent and post-service utilization review, including
10    the review of medical necessity, case management,
11    experimental and investigational treatments, managed care
12    provisions, and other terms and conditions of the
13    insurance policy, of any inpatient admission,
14    detoxification or withdrawal management program admission,
15    or partial hospitalization admission services for the
16    treatment of a mental, emotional, nervous, or substance
17    use disorder or condition related to pregnancy or
18    postpartum complications received 48 hours after the
19    initiation of such services. If an insurer determines that
20    the services are no longer medically necessary, then the
21    covered person shall have the right to external review
22    pursuant to the requirements of the Health Carrier
23    External Review Act.
24        (5) If an insurer determines that continued inpatient
25    care, detoxification or withdrawal management, partial
26    hospitalization, intensive outpatient treatment, or

 

 

HB5395 Engrossed- 98 -LRB103 37071 RPS 67189 b

1    outpatient treatment in a facility is no longer medically
2    necessary, the insurer shall, within 24 hours, provide
3    written notice to the covered pregnant or postpartum
4    individual and the covered pregnant or postpartum
5    individual's provider of its decision and the right to
6    file an expedited internal appeal of the determination.
7    The insurer shall review and make a determination with
8    respect to the internal appeal within 24 hours and
9    communicate such determination to the covered pregnant or
10    postpartum individual and the covered pregnant or
11    postpartum individual's provider. If the determination is
12    to uphold the denial, the covered pregnant or postpartum
13    individual and the covered pregnant or postpartum
14    individual's provider have the right to file an expedited
15    external appeal. An independent utilization review
16    organization shall make a determination within 72 hours.
17    If the insurer's determination is upheld and it is
18    determined that continued inpatient care, detoxification
19    or withdrawal management, partial hospitalization,
20    intensive outpatient treatment, or outpatient treatment is
21    not medically necessary, the insurer shall remain
22    responsible for providing benefits for the inpatient care,
23    detoxification or withdrawal management, partial
24    hospitalization, intensive outpatient treatment, or
25    outpatient treatment through the day following the date
26    the determination is made, and the covered pregnant or

 

 

HB5395 Engrossed- 99 -LRB103 37071 RPS 67189 b

1    postpartum individual shall only be responsible for any
2    applicable copayment, deductible, and coinsurance for the
3    stay through that date as applicable under the policy. The
4    covered pregnant or postpartum individual shall not be
5    discharged or released from the inpatient facility,
6    detoxification or withdrawal management, partial
7    hospitalization, intensive outpatient treatment, or
8    outpatient treatment until all internal appeals and
9    independent utilization review organization appeals are
10    exhausted. A decision to reverse an adverse determination
11    shall comply with the Health Carrier External Review Act.
12        (6) Except as otherwise stated in this subsection (b),
13    the benefits and cost-sharing shall be provided to the
14    same extent as for any other medical condition covered
15    under the policy.
16        (7) The benefits required by paragraphs (2) and (6) of
17    this subsection (b) are to be provided to all covered
18    pregnant or postpartum individuals with a diagnosis of a
19    mental, emotional, nervous, or substance use disorder or
20    condition. The presence of additional related or unrelated
21    diagnoses shall not be a basis to reduce or deny the
22    benefits required by this subsection (b).
23(Source: P.A. 102-665, eff. 10-8-21.)
 
24    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
25    Sec. 370c. Mental and emotional disorders.

 

 

HB5395 Engrossed- 100 -LRB103 37071 RPS 67189 b

1    (a)(1) On and after January 1, 2022 (the effective date of
2Public Act 102-579), every insurer that amends, delivers,
3issues, or renews group accident and health policies providing
4coverage for hospital or medical treatment or services for
5illness on an expense-incurred basis shall provide coverage
6for the medically necessary treatment of mental, emotional,
7nervous, or substance use disorders or conditions consistent
8with the parity requirements of Section 370c.1 of this Code.
9    (2) Each insured that is covered for mental, emotional,
10nervous, or substance use disorders or conditions shall be
11free to select the physician licensed to practice medicine in
12all its branches, licensed clinical psychologist, licensed
13clinical social worker, licensed clinical professional
14counselor, licensed marriage and family therapist, licensed
15speech-language pathologist, or other licensed or certified
16professional at a program licensed pursuant to the Substance
17Use Disorder Act of his or her choice to treat such disorders,
18and the insurer shall pay the covered charges of such
19physician licensed to practice medicine in all its branches,
20licensed clinical psychologist, licensed clinical social
21worker, licensed clinical professional counselor, licensed
22marriage and family therapist, licensed speech-language
23pathologist, or other licensed or certified professional at a
24program licensed pursuant to the Substance Use Disorder Act up
25to the limits of coverage, provided (i) the disorder or
26condition treated is covered by the policy, and (ii) the

 

 

HB5395 Engrossed- 101 -LRB103 37071 RPS 67189 b

1physician, licensed psychologist, licensed clinical social
2worker, licensed clinical professional counselor, licensed
3marriage and family therapist, licensed speech-language
4pathologist, or other licensed or certified professional at a
5program licensed pursuant to the Substance Use Disorder Act is
6authorized to provide said services under the statutes of this
7State and in accordance with accepted principles of his or her
8profession.
9    (3) Insofar as this Section applies solely to licensed
10clinical social workers, licensed clinical professional
11counselors, licensed marriage and family therapists, licensed
12speech-language pathologists, and other licensed or certified
13professionals at programs licensed pursuant to the Substance
14Use Disorder Act, those persons who may provide services to
15individuals shall do so after the licensed clinical social
16worker, licensed clinical professional counselor, licensed
17marriage and family therapist, licensed speech-language
18pathologist, or other licensed or certified professional at a
19program licensed pursuant to the Substance Use Disorder Act
20has informed the patient of the desirability of the patient
21conferring with the patient's primary care physician.
22    (4) "Mental, emotional, nervous, or substance use disorder
23or condition" means a condition or disorder that involves a
24mental health condition or substance use disorder that falls
25under any of the diagnostic categories listed in the mental
26and behavioral disorders chapter of the current edition of the

 

 

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1World Health Organization's International Classification of
2Disease or that is listed in the most recent version of the
3American Psychiatric Association's Diagnostic and Statistical
4Manual of Mental Disorders. "Mental, emotional, nervous, or
5substance use disorder or condition" includes any mental
6health condition that occurs during pregnancy or during the
7postpartum period and includes, but is not limited to,
8postpartum depression.
9    (5) Medically necessary treatment and medical necessity
10determinations shall be interpreted and made in a manner that
11is consistent with and pursuant to subsections (h) through
12(t).
13    (b)(1) (Blank).
14    (2) (Blank).
15    (2.5) (Blank).
16    (3) Unless otherwise prohibited by federal law and
17consistent with the parity requirements of Section 370c.1 of
18this Code, the reimbursing insurer that amends, delivers,
19issues, or renews a group or individual policy of accident and
20health insurance, a qualified health plan offered through the
21health insurance marketplace, or a provider of treatment of
22mental, emotional, nervous, or substance use disorders or
23conditions shall furnish medical records or other necessary
24data that substantiate that initial or continued treatment is
25at all times medically necessary. An insurer shall provide a
26mechanism for the timely review by a provider holding the same

 

 

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1license and practicing in the same specialty as the patient's
2provider, who is unaffiliated with the insurer, jointly
3selected by the patient (or the patient's next of kin or legal
4representative if the patient is unable to act for himself or
5herself), the patient's provider, and the insurer in the event
6of a dispute between the insurer and patient's provider
7regarding the medical necessity of a treatment proposed by a
8patient's provider. If the reviewing provider determines the
9treatment to be medically necessary, the insurer shall provide
10reimbursement for the treatment. Future contractual or
11employment actions by the insurer regarding the patient's
12provider may not be based on the provider's participation in
13this procedure. Nothing prevents the insured from agreeing in
14writing to continue treatment at his or her expense. When
15making a determination of the medical necessity for a
16treatment modality for mental, emotional, nervous, or
17substance use disorders or conditions, an insurer must make
18the determination in a manner that is consistent with the
19manner used to make that determination with respect to other
20diseases or illnesses covered under the policy, including an
21appeals process. Medical necessity determinations for
22substance use disorders shall be made in accordance with
23appropriate patient placement criteria established by the
24American Society of Addiction Medicine. No additional criteria
25may be used to make medical necessity determinations for
26substance use disorders.

 

 

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1    (4) A group health benefit plan amended, delivered,
2issued, or renewed on or after January 1, 2019 (the effective
3date of Public Act 100-1024) or an individual policy of
4accident and health insurance or a qualified health plan
5offered through the health insurance marketplace amended,
6delivered, issued, or renewed on or after January 1, 2019 (the
7effective date of Public Act 100-1024):
8        (A) shall provide coverage based upon medical
9    necessity for the treatment of a mental, emotional,
10    nervous, or substance use disorder or condition consistent
11    with the parity requirements of Section 370c.1 of this
12    Code; provided, however, that in each calendar year
13    coverage shall not be less than the following:
14            (i) 45 days of inpatient treatment; and
15            (ii) beginning on June 26, 2006 (the effective
16        date of Public Act 94-921), 60 visits for outpatient
17        treatment including group and individual outpatient
18        treatment; and
19            (iii) for plans or policies delivered, issued for
20        delivery, renewed, or modified after January 1, 2007
21        (the effective date of Public Act 94-906), 20
22        additional outpatient visits for speech therapy for
23        treatment of pervasive developmental disorders that
24        will be in addition to speech therapy provided
25        pursuant to item (ii) of this subparagraph (A); and
26        (B) may not include a lifetime limit on the number of

 

 

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1    days of inpatient treatment or the number of outpatient
2    visits covered under the plan.
3        (C) (Blank).
4    (5) An issuer of a group health benefit plan or an
5individual policy of accident and health insurance or a
6qualified health plan offered through the health insurance
7marketplace may not count toward the number of outpatient
8visits required to be covered under this Section an outpatient
9visit for the purpose of medication management and shall cover
10the outpatient visits under the same terms and conditions as
11it covers outpatient visits for the treatment of physical
12illness.
13    (5.5) An individual or group health benefit plan amended,
14delivered, issued, or renewed on or after September 9, 2015
15(the effective date of Public Act 99-480) shall offer coverage
16for medically necessary acute treatment services and medically
17necessary clinical stabilization services. The treating
18provider shall base all treatment recommendations and the
19health benefit plan shall base all medical necessity
20determinations for substance use disorders in accordance with
21the most current edition of the Treatment Criteria for
22Addictive, Substance-Related, and Co-Occurring Conditions
23established by the American Society of Addiction Medicine. The
24treating provider shall base all treatment recommendations and
25the health benefit plan shall base all medical necessity
26determinations for medication-assisted treatment in accordance

 

 

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1with the most current Treatment Criteria for Addictive,
2Substance-Related, and Co-Occurring Conditions established by
3the American Society of Addiction Medicine.
4    As used in this subsection:
5    "Acute treatment services" means 24-hour medically
6supervised addiction treatment that provides evaluation and
7withdrawal management and may include biopsychosocial
8assessment, individual and group counseling, psychoeducational
9groups, and discharge planning.
10    "Clinical stabilization services" means 24-hour treatment,
11usually following acute treatment services for substance
12abuse, which may include intensive education and counseling
13regarding the nature of addiction and its consequences,
14relapse prevention, outreach to families and significant
15others, and aftercare planning for individuals beginning to
16engage in recovery from addiction.
17    (6) An issuer of a group health benefit plan may provide or
18offer coverage required under this Section through a managed
19care plan.
20    (6.5) An individual or group health benefit plan amended,
21delivered, issued, or renewed on or after January 1, 2019 (the
22effective date of Public Act 100-1024):
23        (A) shall not impose prior authorization requirements,
24    other than those established under the Treatment Criteria
25    for Addictive, Substance-Related, and Co-Occurring
26    Conditions established by the American Society of

 

 

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1    Addiction Medicine, on a prescription medication approved
2    by the United States Food and Drug Administration that is
3    prescribed or administered for the treatment of substance
4    use disorders;
5        (B) shall not impose any step therapy requirements,
6    other than those established under the Treatment Criteria
7    for Addictive, Substance-Related, and Co-Occurring
8    Conditions established by the American Society of
9    Addiction Medicine, before authorizing coverage for a
10    prescription medication approved by the United States Food
11    and Drug Administration that is prescribed or administered
12    for the treatment of substance use disorders;
13        (C) shall place all prescription medications approved
14    by the United States Food and Drug Administration
15    prescribed or administered for the treatment of substance
16    use disorders on, for brand medications, the lowest tier
17    of the drug formulary developed and maintained by the
18    individual or group health benefit plan that covers brand
19    medications and, for generic medications, the lowest tier
20    of the drug formulary developed and maintained by the
21    individual or group health benefit plan that covers
22    generic medications; and
23        (D) shall not exclude coverage for a prescription
24    medication approved by the United States Food and Drug
25    Administration for the treatment of substance use
26    disorders and any associated counseling or wraparound

 

 

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1    services on the grounds that such medications and services
2    were court ordered.
3    (7) (Blank).
4    (8) (Blank).
5    (9) With respect to all mental, emotional, nervous, or
6substance use disorders or conditions, coverage for inpatient
7treatment shall include coverage for treatment in a
8residential treatment center certified or licensed by the
9Department of Public Health or the Department of Human
10Services.
11    (c) This Section shall not be interpreted to require
12coverage for speech therapy or other habilitative services for
13those individuals covered under Section 356z.15 of this Code.
14    (d) With respect to a group or individual policy of
15accident and health insurance or a qualified health plan
16offered through the health insurance marketplace, the
17Department and, with respect to medical assistance, the
18Department of Healthcare and Family Services shall each
19enforce the requirements of this Section and Sections 356z.23
20and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
21Mental Health Parity and Addiction Equity Act of 2008, 42
22U.S.C. 18031(j), and any amendments to, and federal guidance
23or regulations issued under, those Acts, including, but not
24limited to, final regulations issued under the Paul Wellstone
25and Pete Domenici Mental Health Parity and Addiction Equity
26Act of 2008 and final regulations applying the Paul Wellstone

 

 

HB5395 Engrossed- 109 -LRB103 37071 RPS 67189 b

1and Pete Domenici Mental Health Parity and Addiction Equity
2Act of 2008 to Medicaid managed care organizations, the
3Children's Health Insurance Program, and alternative benefit
4plans. Specifically, the Department and the Department of
5Healthcare and Family Services shall take action:
6        (1) proactively ensuring compliance by individual and
7    group policies, including by requiring that insurers
8    submit comparative analyses, as set forth in paragraph (6)
9    of subsection (k) of Section 370c.1, demonstrating how
10    they design and apply nonquantitative treatment
11    limitations, both as written and in operation, for mental,
12    emotional, nervous, or substance use disorder or condition
13    benefits as compared to how they design and apply
14    nonquantitative treatment limitations, as written and in
15    operation, for medical and surgical benefits;
16        (2) evaluating all consumer or provider complaints
17    regarding mental, emotional, nervous, or substance use
18    disorder or condition coverage for possible parity
19    violations;
20        (3) performing parity compliance market conduct
21    examinations or, in the case of the Department of
22    Healthcare and Family Services, parity compliance audits
23    of individual and group plans and policies, including, but
24    not limited to, reviews of:
25            (A) nonquantitative treatment limitations,
26        including, but not limited to, prior authorization

 

 

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1        requirements, concurrent review, retrospective review,
2        step therapy, network admission standards,
3        reimbursement rates, and geographic restrictions;
4            (B) denials of authorization, payment, and
5        coverage; and
6            (C) other specific criteria as may be determined
7        by the Department.
8    The findings and the conclusions of the parity compliance
9market conduct examinations and audits shall be made public.
10    The Director may adopt rules to effectuate any provisions
11of the Paul Wellstone and Pete Domenici Mental Health Parity
12and Addiction Equity Act of 2008 that relate to the business of
13insurance.
14    (e) Availability of plan information.
15        (1) The criteria for medical necessity determinations
16    made under a group health plan, an individual policy of
17    accident and health insurance, or a qualified health plan
18    offered through the health insurance marketplace with
19    respect to mental health or substance use disorder
20    benefits (or health insurance coverage offered in
21    connection with the plan with respect to such benefits)
22    must be made available by the plan administrator (or the
23    health insurance issuer offering such coverage) to any
24    current or potential participant, beneficiary, or
25    contracting provider upon request.
26        (2) The reason for any denial under a group health

 

 

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1    benefit plan, an individual policy of accident and health
2    insurance, or a qualified health plan offered through the
3    health insurance marketplace (or health insurance coverage
4    offered in connection with such plan or policy) of
5    reimbursement or payment for services with respect to
6    mental, emotional, nervous, or substance use disorders or
7    conditions benefits in the case of any participant or
8    beneficiary must be made available within a reasonable
9    time and in a reasonable manner and in readily
10    understandable language by the plan administrator (or the
11    health insurance issuer offering such coverage) to the
12    participant or beneficiary upon request.
13    (f) As used in this Section, "group policy of accident and
14health insurance" and "group health benefit plan" includes (1)
15State-regulated employer-sponsored group health insurance
16plans written in Illinois or which purport to provide coverage
17for a resident of this State; and (2) State employee health
18plans.
19    (g) (1) As used in this subsection:
20    "Benefits", with respect to insurers, means the benefits
21provided for treatment services for inpatient and outpatient
22treatment of substance use disorders or conditions at American
23Society of Addiction Medicine levels of treatment 2.1
24(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
25(Clinically Managed Low-Intensity Residential), 3.3
26(Clinically Managed Population-Specific High-Intensity

 

 

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1Residential), 3.5 (Clinically Managed High-Intensity
2Residential), and 3.7 (Medically Monitored Intensive
3Inpatient) and OMT (Opioid Maintenance Therapy) services.
4    "Benefits", with respect to managed care organizations,
5means the benefits provided for treatment services for
6inpatient and outpatient treatment of substance use disorders
7or conditions at American Society of Addiction Medicine levels
8of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
9Hospitalization), 3.5 (Clinically Managed High-Intensity
10Residential), and 3.7 (Medically Monitored Intensive
11Inpatient) and OMT (Opioid Maintenance Therapy) services.
12    "Substance use disorder treatment provider or facility"
13means a licensed physician, licensed psychologist, licensed
14psychiatrist, licensed advanced practice registered nurse, or
15licensed, certified, or otherwise State-approved facility or
16provider of substance use disorder treatment.
17    (2) A group health insurance policy, an individual health
18benefit plan, or qualified health plan that is offered through
19the health insurance marketplace, small employer group health
20plan, and large employer group health plan that is amended,
21delivered, issued, executed, or renewed in this State, or
22approved for issuance or renewal in this State, on or after
23January 1, 2019 (the effective date of Public Act 100-1023)
24shall comply with the requirements of this Section and Section
25370c.1. The services for the treatment and the ongoing
26assessment of the patient's progress in treatment shall follow

 

 

HB5395 Engrossed- 113 -LRB103 37071 RPS 67189 b

1the requirements of 77 Ill. Adm. Code 2060.
2    (3) Prior authorization shall not be utilized for the
3benefits under this subsection. The substance use disorder
4treatment provider or facility shall notify the insurer of the
5initiation of treatment. For an insurer that is not a managed
6care organization, the substance use disorder treatment
7provider or facility notification shall occur for the
8initiation of treatment of the covered person within 2
9business days. For managed care organizations, the substance
10use disorder treatment provider or facility notification shall
11occur in accordance with the protocol set forth in the
12provider agreement for initiation of treatment within 24
13hours. If the managed care organization is not capable of
14accepting the notification in accordance with the contractual
15protocol during the 24-hour period following admission, the
16substance use disorder treatment provider or facility shall
17have one additional business day to provide the notification
18to the appropriate managed care organization. Treatment plans
19shall be developed in accordance with the requirements and
20timeframes established in 77 Ill. Adm. Code 2060. If the
21substance use disorder treatment provider or facility fails to
22notify the insurer of the initiation of treatment in
23accordance with these provisions, the insurer may follow its
24normal prior authorization processes.
25    (4) For an insurer that is not a managed care
26organization, if an insurer determines that benefits are no

 

 

HB5395 Engrossed- 114 -LRB103 37071 RPS 67189 b

1longer medically necessary, the insurer shall notify the
2covered person, the covered person's authorized
3representative, if any, and the covered person's health care
4provider in writing of the covered person's right to request
5an external review pursuant to the Health Carrier External
6Review Act. The notification shall occur within 24 hours
7following the adverse determination.
8    Pursuant to the requirements of the Health Carrier
9External Review Act, the covered person or the covered
10person's authorized representative may request an expedited
11external review. An expedited external review may not occur if
12the substance use disorder treatment provider or facility
13determines that continued treatment is no longer medically
14necessary.
15    If an expedited external review request meets the criteria
16of the Health Carrier External Review Act, an independent
17review organization shall make a final determination of
18medical necessity within 72 hours. If an independent review
19organization upholds an adverse determination, an insurer
20shall remain responsible to provide coverage of benefits
21through the day following the determination of the independent
22review organization. A decision to reverse an adverse
23determination shall comply with the Health Carrier External
24Review Act.
25    (5) The substance use disorder treatment provider or
26facility shall provide the insurer with 7 business days'

 

 

HB5395 Engrossed- 115 -LRB103 37071 RPS 67189 b

1advance notice of the planned discharge of the patient from
2the substance use disorder treatment provider or facility and
3notice on the day that the patient is discharged from the
4substance use disorder treatment provider or facility.
5    (6) The benefits required by this subsection shall be
6provided to all covered persons with a diagnosis of substance
7use disorder or conditions. The presence of additional related
8or unrelated diagnoses shall not be a basis to reduce or deny
9the benefits required by this subsection.
10    (7) Nothing in this subsection shall be construed to
11require an insurer to provide coverage for any of the benefits
12in this subsection.
13    (h) As used in this Section:
14    "Generally accepted standards of mental, emotional,
15nervous, or substance use disorder or condition care" means
16standards of care and clinical practice that are generally
17recognized by health care providers practicing in relevant
18clinical specialties such as psychiatry, psychology, clinical
19sociology, social work, addiction medicine and counseling, and
20behavioral health treatment. Valid, evidence-based sources
21reflecting generally accepted standards of mental, emotional,
22nervous, or substance use disorder or condition care include
23peer-reviewed scientific studies and medical literature,
24recommendations of nonprofit health care provider professional
25associations and specialty societies, including, but not
26limited to, patient placement criteria and clinical practice

 

 

HB5395 Engrossed- 116 -LRB103 37071 RPS 67189 b

1guidelines, recommendations of federal government agencies,
2and drug labeling approved by the United States Food and Drug
3Administration.
4    "Medically necessary treatment of mental, emotional,
5nervous, or substance use disorders or conditions" means a
6service or product addressing the specific needs of that
7patient, for the purpose of screening, preventing, diagnosing,
8managing, or treating an illness, injury, or condition or its
9symptoms and comorbidities, including minimizing the
10progression of an illness, injury, or condition or its
11symptoms and comorbidities in a manner that is all of the
12following:
13        (1) in accordance with the generally accepted
14    standards of mental, emotional, nervous, or substance use
15    disorder or condition care;
16        (2) clinically appropriate in terms of type,
17    frequency, extent, site, and duration; and
18        (3) not primarily for the economic benefit of the
19    insurer, purchaser, or for the convenience of the patient,
20    treating physician, or other health care provider.
21    "Utilization review" means either of the following:
22        (1) prospectively, retrospectively, or concurrently
23    reviewing and approving, modifying, delaying, or denying,
24    based in whole or in part on medical necessity, requests
25    by health care providers, insureds, or their authorized
26    representatives for coverage of health care services

 

 

HB5395 Engrossed- 117 -LRB103 37071 RPS 67189 b

1    before, retrospectively, or concurrently with the
2    provision of health care services to insureds.
3        (2) evaluating the medical necessity, appropriateness,
4    level of care, service intensity, efficacy, or efficiency
5    of health care services, benefits, procedures, or
6    settings, under any circumstances, to determine whether a
7    health care service or benefit subject to a medical
8    necessity coverage requirement in an insurance policy is
9    covered as medically necessary for an insured.
10    "Utilization review criteria" means patient placement
11criteria or any criteria, standards, protocols, or guidelines
12used by an insurer to conduct utilization review.
13    (i)(1) Every insurer that amends, delivers, issues, or
14renews a group or individual policy of accident and health
15insurance or a qualified health plan offered through the
16health insurance marketplace in this State and Medicaid
17managed care organizations providing coverage for hospital or
18medical treatment on or after January 1, 2023 shall, pursuant
19to subsections (h) through (s), provide coverage for medically
20necessary treatment of mental, emotional, nervous, or
21substance use disorders or conditions.
22    (2) An insurer shall not set a specific limit on the
23duration of benefits or coverage of medically necessary
24treatment of mental, emotional, nervous, or substance use
25disorders or conditions or limit coverage only to alleviation
26of the insured's current symptoms.

 

 

HB5395 Engrossed- 118 -LRB103 37071 RPS 67189 b

1    (3) All utilization review conducted medical necessity
2determinations made by the insurer concerning diagnosis,
3prevention, and treatment service intensity, level of care
4placement, continued stay, and transfer or discharge of
5insureds diagnosed with mental, emotional, nervous, or
6substance use disorders or conditions shall be conducted in
7accordance with the requirements of subsections (k) through
8(w) (u).
9    (4) An insurer that authorizes a specific type of
10treatment by a provider pursuant to this Section shall not
11rescind or modify the authorization after that provider
12renders the health care service in good faith and pursuant to
13this authorization for any reason, including, but not limited
14to, the insurer's subsequent cancellation or modification of
15the insured's or policyholder's contract, or the insured's or
16policyholder's eligibility. Nothing in this Section shall
17require the insurer to cover a treatment when the
18authorization was granted based on a material
19misrepresentation by the insured, the policyholder, or the
20provider. Nothing in this Section shall require Medicaid
21managed care organizations to pay for services if the
22individual was not eligible for Medicaid at the time the
23service was rendered. Nothing in this Section shall require an
24insurer to pay for services if the individual was not the
25insurer's enrollee at the time services were rendered. As used
26in this paragraph, "material" means a fact or situation that

 

 

HB5395 Engrossed- 119 -LRB103 37071 RPS 67189 b

1is not merely technical in nature and results in or could
2result in a substantial change in the situation.
3    (j) An insurer shall not limit benefits or coverage for
4medically necessary services on the basis that those services
5should be or could be covered by a public entitlement program,
6including, but not limited to, special education or an
7individualized education program, Medicaid, Medicare,
8Supplemental Security Income, or Social Security Disability
9Insurance, and shall not include or enforce a contract term
10that excludes otherwise covered benefits on the basis that
11those services should be or could be covered by a public
12entitlement program. Nothing in this subsection shall be
13construed to require an insurer to cover benefits that have
14been authorized and provided for a covered person by a public
15entitlement program. Medicaid managed care organizations are
16not subject to this subsection.
17    (k) An insurer shall base any medical necessity
18determination or the utilization review criteria that the
19insurer, and any entity acting on the insurer's behalf,
20applies to determine the medical necessity of health care
21services and benefits for the diagnosis, prevention, and
22treatment of mental, emotional, nervous, or substance use
23disorders or conditions on current generally accepted
24standards of mental, emotional, nervous, or substance use
25disorder or condition care. All denials and appeals shall be
26reviewed by a professional with experience or expertise

 

 

HB5395 Engrossed- 120 -LRB103 37071 RPS 67189 b

1comparable to the provider requesting the authorization.
2    (l) In conducting utilization review of all covered health
3care services for the diagnosis, prevention, and treatment of
4For medical necessity determinations relating to level of care
5placement, continued stay, and transfer or discharge of
6insureds diagnosed with mental, emotional, and nervous
7disorders or conditions, an insurer shall apply the patient
8placement criteria and guidelines set forth in the most recent
9version of the treatment criteria developed by an unaffiliated
10nonprofit professional association for the relevant clinical
11specialty or, for Medicaid managed care organizations, patient
12placement criteria and guidelines determined by the Department
13of Healthcare and Family Services that are consistent with
14generally accepted standards of mental, emotional, nervous or
15substance use disorder or condition care. Pursuant to
16subsection (b), in conducting utilization review of all
17covered services and benefits for the diagnosis, prevention,
18and treatment of substance use disorders an insurer shall use
19the most recent edition of the patient placement criteria
20established by the American Society of Addiction Medicine.
21    (m) In conducting utilization review For medical necessity
22determinations relating to level of care placement, continued
23stay, and transfer, or discharge, or any other patient care
24decisions that are within the scope of the sources specified
25in subsection (l), an insurer shall not apply different,
26additional, conflicting, or more restrictive utilization

 

 

HB5395 Engrossed- 121 -LRB103 37071 RPS 67189 b

1review criteria than the criteria set forth in those sources.
2For all level of care placement decisions, the insurer shall
3authorize placement at the level of care consistent with the
4assessment of the insured using the relevant patient placement
5criteria as specified in subsection (l). If that level of
6placement is not available, the insurer shall authorize the
7next higher level of care. In the event of disagreement, the
8insurer shall provide full detail of its assessment using the
9relevant criteria as specified in subsection (l) to the
10provider of the service and the patient.
11    Nothing in this subsection or subsection (l) prohibits an
12insurer from applying utilization review criteria that were
13developed in accordance with subsection (k) to health care
14services and benefits for mental, emotional, and nervous
15disorders or conditions that are not related to medical
16necessity determinations for level of care placement,
17continued stay, and transfer or discharge. If an insurer
18purchases or licenses utilization review criteria pursuant to
19this subsection, the insurer shall verify and document before
20use that the criteria were developed in accordance with
21subsection (k).
22    (n) In conducting utilization review that is outside the
23scope of the criteria as specified in subsection (l) or
24relates to the advancements in technology or in the types or
25levels of care that are not addressed in the most recent
26versions of the sources specified in subsection (l), an

 

 

HB5395 Engrossed- 122 -LRB103 37071 RPS 67189 b

1insurer shall conduct utilization review in accordance with
2subsection (k).
3    (o) This Section does not in any way limit the rights of a
4patient under the Medical Patient Rights Act.
5    (p) This Section does not in any way limit early and
6periodic screening, diagnostic, and treatment benefits as
7defined under 42 U.S.C. 1396d(r).
8    (q) To ensure the proper use of the criteria described in
9subsection (l), every insurer shall do all of the following:
10        (1) Educate the insurer's staff, including any third
11    parties contracted with the insurer to review claims,
12    conduct utilization reviews, or make medical necessity
13    determinations about the utilization review criteria.
14        (2) Make the educational program available to other
15    stakeholders, including the insurer's participating or
16    contracted providers and potential participants,
17    beneficiaries, or covered lives. The education program
18    must be provided at least once a year, in-person or
19    digitally, or recordings of the education program must be
20    made available to the aforementioned stakeholders.
21        (3) Provide, at no cost, the utilization review
22    criteria and any training material or resources to
23    providers and insured patients upon request. For
24    utilization review criteria not concerning level of care
25    placement, continued stay, and transfer, or discharge, or
26    other patient care decisions used by the insurer pursuant

 

 

HB5395 Engrossed- 123 -LRB103 37071 RPS 67189 b

1    to subsection (m), the insurer may place the criteria on a
2    secure, password-protected website so long as the access
3    requirements of the website do not unreasonably restrict
4    access to insureds or their providers. No restrictions
5    shall be placed upon the insured's or treating provider's
6    access right to utilization review criteria obtained under
7    this paragraph at any point in time, including before an
8    initial request for authorization.
9        (4) Track, identify, and analyze how the utilization
10    review criteria are used to certify care, deny care, and
11    support the appeals process.
12        (5) Conduct interrater reliability testing to ensure
13    consistency in utilization review decision making that
14    covers how medical necessity decisions are made; this
15    assessment shall cover all aspects of utilization review
16    as defined in subsection (h).
17        (6) Run interrater reliability reports about how the
18    clinical guidelines are used in conjunction with the
19    utilization review process and parity compliance
20    activities.
21        (7) Achieve interrater reliability pass rates of at
22    least 90% and, if this threshold is not met, immediately
23    provide for the remediation of poor interrater reliability
24    and interrater reliability testing for all new staff
25    before they can conduct utilization review without
26    supervision.

 

 

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1        (8) Maintain documentation of interrater reliability
2    testing and the remediation actions taken for those with
3    pass rates lower than 90% and submit to the Department of
4    Insurance or, in the case of Medicaid managed care
5    organizations, the Department of Healthcare and Family
6    Services the testing results and a summary of remedial
7    actions as part of parity compliance reporting set forth
8    in subsection (k) of Section 370c.1.
9    (r) This Section applies to all health care services and
10benefits for the diagnosis, prevention, and treatment of
11mental, emotional, nervous, or substance use disorders or
12conditions covered by an insurance policy, including
13prescription drugs.
14    (s) This Section applies to an insurer that amends,
15delivers, issues, or renews a group or individual policy of
16accident and health insurance or a qualified health plan
17offered through the health insurance marketplace in this State
18providing coverage for hospital or medical treatment and
19conducts utilization review as defined in this Section,
20including Medicaid managed care organizations, and any entity
21or contracting provider that performs utilization review or
22utilization management functions on an insurer's behalf.
23    (t) If the Director determines that an insurer has
24violated this Section, the Director may, after appropriate
25notice and opportunity for hearing, by order, assess a civil
26penalty between $1,000 and $5,000 for each violation. Moneys

 

 

HB5395 Engrossed- 125 -LRB103 37071 RPS 67189 b

1collected from penalties shall be deposited into the Parity
2Advancement Fund established in subsection (i) of Section
3370c.1.
4    (u) An insurer shall not adopt, impose, or enforce terms
5in its policies or provider agreements, in writing or in
6operation, that undermine, alter, or conflict with the
7requirements of this Section.
8    (v) The provisions of this Section are severable. If any
9provision of this Section or its application is held invalid,
10that invalidity shall not affect other provisions or
11applications that can be given effect without the invalid
12provision or application.
13    (w) Beginning January 1, 2026, coverage for inpatient
14mental health treatment at participating hospitals shall
15comply with the following requirements:
16        (1) Subject to paragraphs (2) and (3) of this
17    subsection, no policy shall require prior authorization
18    for admission for such treatment at any participating
19    hospital.
20        (2) Coverage provided under this subsection also shall
21    not be subject to concurrent review for the first 72
22    hours, provided that the hospital must notify the insurer
23    of both the admission and the initial treatment plan
24    within 48 hours of admission. A discharge plan must be
25    fully developed and continuity services prepared to meet
26    the patient's needs and the patient's community preference

 

 

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1    upon release. Nothing in this paragraph supersedes a
2    health maintenance organization's referral requirement for
3    services from nonparticipating providers upon a patient's
4    discharge from a hospital.
5        (3) Treatment provided under this subsection may be
6    reviewed retrospectively. If coverage is denied
7    retrospectively, neither the insurer nor the participating
8    hospital shall bill, and the insured shall not be liable,
9    for any treatment under this subsection through the date
10    the adverse determination is issued, other than any
11    copayment, coinsurance, or deductible for the stay through
12    that date as applicable under the policy. Coverage shall
13    not be retrospectively denied for the first 72 hours of
14    treatment at a participating hospital except:
15            (A) upon reasonable determination that the
16        inpatient mental health treatment was not provided;
17            (B) upon determination that the patient receiving
18        the treatment was not an insured, enrollee, or
19        beneficiary under the policy;
20            (C) upon material misrepresentation by the patient
21        or health care provider. In this item (C), "material"
22        means a fact or situation that is not merely technical
23        in nature and results or could result in a substantial
24        change in the situation; or
25            (D) upon determination that a service was excluded
26        under the terms of coverage. In that case, the

 

 

HB5395 Engrossed- 127 -LRB103 37071 RPS 67189 b

1        limitation to billing for a copayment, coinsurance, or
2        deductible shall not apply.
3        (4) Nothing in this subsection shall be construed to
4    require a policy to cover any health care service excluded
5    under the terms of coverage.
6    (x) Notwithstanding any provision of this Section, nothing
7shall require the medical assistance program under Article V
8of the Illinois Public Aid Code to violate any applicable
9federal laws, regulations, or grant requirements or any State
10or federal consent decrees. Nothing in subsection (w) shall
11prevent the Department of Healthcare and Family Services from
12requiring a health care provider to use specified level of
13care, admission, continued stay, or discharge criteria,
14including, but not limited to, those under Section 5-5.23 of
15the Illinois Public Aid Code, as long as the Department of
16Healthcare and Family Services does not require a health care
17provider to seek prior authorization or concurrent review from
18the Department of Healthcare and Family Services, a Medicaid
19managed care organization, or a utilization review
20organization under the circumstances expressly prohibited by
21subsection (w).
22    (y) Children's Mental Health. Nothing in this Section
23shall suspend the screening and assessment requirements for
24mental health services for children participating in the
25State's medical assistance program as required in Section
265-5.23 of the Illinois Public Aid Code.

 

 

HB5395 Engrossed- 128 -LRB103 37071 RPS 67189 b

1(Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22;
2102-813, eff. 5-13-22; 103-426, eff. 8-4-23.)
 
3    Section 6-10. The Managed Care Reform and Patient Rights
4Act is amended by changing Sections 10, 45.1, and 85 and by
5adding Section 87 as follows:
 
6    (215 ILCS 134/10)
7    Sec. 10. Definitions. In this Act:
8    "Adverse determination" means a determination by a health
9care plan under Section 45 or by a utilization review program
10under Section 85 that a health care service is not medically
11necessary.
12    "Clinical peer" means a health care professional who is in
13the same profession and the same or similar specialty as the
14health care provider who typically manages the medical
15condition, procedures, or treatment under review.
16    "Department" means the Department of Insurance.
17    "Emergency medical condition" means a medical condition
18manifesting itself by acute symptoms of sufficient severity,
19regardless of the final diagnosis given, such that a prudent
20layperson, who possesses an average knowledge of health and
21medicine, could reasonably expect the absence of immediate
22medical attention to result in:
23        (1) placing the health of the individual (or, with
24    respect to a pregnant woman, the health of the woman or her

 

 

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

 

 

HB5395 Engrossed- 130 -LRB103 37071 RPS 67189 b

1enrolled in or covered by a health care plan.
2    "Generally accepted standards of care" means standards of
3care and clinical practice that are generally recognized by
4health care providers practicing in relevant clinical
5specialties for the illness, injury, or condition or its
6symptoms and comorbidities. Valid, evidence-based sources
7reflecting generally accepted standards of care include
8peer-reviewed scientific studies and medical literature,
9recommendations of nonprofit health care provider professional
10associations and specialty societies, including, but not
11limited to, patient placement criteria and clinical practice
12guidelines, recommendations of federal government agencies,
13and drug labeling approved by the United States Food and Drug
14Administration.
15    "Health care plan" means a plan, including, but not
16limited to, a health maintenance organization, a managed care
17community network as defined in the Illinois Public Aid Code,
18or an accountable care entity as defined in the Illinois
19Public Aid Code that receives capitated payments to cover
20medical services from the Department of Healthcare and Family
21Services, that establishes, operates, or maintains a network
22of health care providers that has entered into an agreement
23with the plan to provide health care services to enrollees to
24whom the plan has the ultimate obligation to arrange for the
25provision of or payment for services through organizational
26arrangements for ongoing quality assurance, utilization review

 

 

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1programs, or dispute resolution. Nothing in this definition
2shall be construed to mean that an independent practice
3association or a physician hospital organization that
4subcontracts with a health care plan is, for purposes of that
5subcontract, a health care plan.
6    For purposes of this definition, "health care plan" shall
7not include the following:
8        (1) indemnity health insurance policies including
9    those using a contracted provider network;
10        (2) health care plans that offer only dental or only
11    vision coverage;
12        (3) preferred provider administrators, as defined in
13    Section 370g(g) of the Illinois Insurance Code;
14        (4) employee or employer self-insured health benefit
15    plans under the federal Employee Retirement Income
16    Security Act of 1974;
17        (5) health care provided pursuant to the Workers'
18    Compensation Act or the Workers' Occupational Diseases
19    Act; and
20        (6) except with respect to subsections (a) and (b) of
21    Section 65 and subsection (a-5) of Section 70,
22    not-for-profit voluntary health services plans with health
23    maintenance organization authority in existence as of
24    January 1, 1999 that are affiliated with a union and that
25    only extend coverage to union members and their
26    dependents.

 

 

HB5395 Engrossed- 132 -LRB103 37071 RPS 67189 b

1    "Health care professional" means a physician, a registered
2professional nurse, or other individual appropriately licensed
3or registered to provide health care services.
4    "Health care provider" means any physician, hospital
5facility, facility licensed under the Nursing Home Care Act,
6long-term care facility as defined in Section 1-113 of the
7Nursing Home Care Act, or other person that is licensed or
8otherwise authorized to deliver health care services. Nothing
9in this Act shall be construed to define Independent Practice
10Associations or Physician-Hospital Organizations as health
11care providers.
12    "Health care services" means any services included in the
13furnishing to any individual of medical care, or the
14hospitalization incident to the furnishing of such care, as
15well as the furnishing to any person of any and all other
16services for the purpose of preventing, alleviating, curing,
17or healing human illness or injury including behavioral
18health, mental health, home health, and pharmaceutical
19services and products.
20    "Medical director" means a physician licensed in any state
21to practice medicine in all its branches appointed by a health
22care plan.
23    "Medically necessary" means that a service or product
24addresses the specific needs of a patient for the purpose of
25screening, preventing, diagnosing, managing, or treating an
26illness, injury, or condition or its symptoms and

 

 

HB5395 Engrossed- 133 -LRB103 37071 RPS 67189 b

1comorbidities, including minimizing the progression of an
2illness, injury, or condition or its symptoms and
3comorbidities, in a manner that is all of the following:
4        (1) in accordance with generally accepted standards of
5    care;
6        (2) clinically appropriate in terms of type,
7    frequency, extent, site, and duration; and
8        (3) not primarily for the economic benefit of the
9    health care plan, purchaser, or utilization review
10    organization, or for the convenience of the patient,
11    treating physician, or other health care provider.
12    "Person" means a corporation, association, partnership,
13limited liability company, sole proprietorship, or any other
14legal entity.
15    "Physician" means a person licensed under the Medical
16Practice Act of 1987.
17    "Post-stabilization medical services" means health care
18services provided to an enrollee that are furnished in a
19licensed hospital by a provider that is qualified to furnish
20such services, and determined to be medically necessary and
21directly related to the emergency medical condition following
22stabilization.
23    "Stabilization" means, with respect to an emergency
24medical condition, to provide such medical treatment of the
25condition as may be necessary to assure, within reasonable
26medical probability, that no material deterioration of the

 

 

HB5395 Engrossed- 134 -LRB103 37071 RPS 67189 b

1condition is likely to result.
2    "Step therapy requirement" means a fail-first utilization
3review or formulary requirement that specifies, as a condition
4of coverage under a health care plan, the order in which
5certain health care services must be used to treat or manage an
6enrollee's health condition.
7    "Step therapy requirement" does not include:
8        (i) the use of utilization review to identify when a
9    treatment is contraindicated or to limit quantity or
10    dosage for an enrollee based on utilization review
11    criteria consistent with generally accepted standards of
12    care;
13        (ii) the removal of a drug from a formulary or
14    negatively changing a formulary drug's preferred or
15    cost-sharing tier;
16        (iii) the fact that an enrollee or the enrollee's
17    authorized representative must use the medical exceptions
18    process under Section 45.1 of this Act to obtain coverage
19    for a drug that is not concurrently listed on the
20    formulary for the enrollee's health care plan. However, if
21    a health care plan or utilization review program's medical
22    exceptions process requires an enrollee to fail first on a
23    formulary drug before approving coverage for an
24    off-formulary drug, that requirement is a step therapy
25    requirement;
26        (iv) a requirement that an enrollee or the enrollee's

 

 

HB5395 Engrossed- 135 -LRB103 37071 RPS 67189 b

1    authorized representative obtain prior authorization for
2    the requested treatment;
3        (v) for health care plans operated or overseen by the
4    Department of Healthcare and Family Services, including
5    Medicaid managed care plans, any utilization controls
6    mandated by 42 CFR 456.703;
7        (vi) the creation and maintenance by the Department of
8    Healthcare and Family Services of a Preferred Drug List,
9    and any requirement that Medicaid managed care
10    organizations comply with the Preferred Drug List
11    utilization control process, as described in Section
12    5-30.14 of the Illinois Public Aid Code; or
13        (vii) the use of utilization review criteria allowed
14    under subsections (c) through (e) of Section 87 of this
15    Act for any health care service other than prescription
16    drugs.
17    "Utilization review" means the evaluation of the medical
18necessity, appropriateness, and efficiency of the use of
19health care services, procedures, and facilities.
20    "Utilization review" includes either of the following:
21        (1) prospectively, retrospectively, or concurrently
22    reviewing and approving, modifying, delaying, or denying,
23    based, in whole or in part, on medical necessity, requests
24    by health care providers, enrollees, or their authorized
25    representatives for coverage of health care services
26    before, retrospectively, or concurrently with the

 

 

HB5395 Engrossed- 136 -LRB103 37071 RPS 67189 b

1    provision of health care services to enrollees; or
2        (2) evaluating the medical necessity, appropriateness,
3    level of care, service intensity, efficacy, or efficiency
4    of health care services, benefits, procedures, or
5    settings, under any circumstances, to determine whether a
6    health care service or benefit subject to a medical
7    necessity coverage requirement in a health care plan is
8    covered as medically necessary for an enrollee.
9    "Utilization review criteria" means criteria, standards,
10protocols, or guidelines used by a utilization review program
11to conduct utilization review to ensure that a patient's care
12is aligned with generally accepted standards of care and
13consistent with State law.
14    "Utilization review program" means a program established
15by a person to perform utilization review.
16(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
17    (215 ILCS 134/45.1)
18    Sec. 45.1. Medical exceptions procedures required.
19    (a) Notwithstanding any other provision of law, on or
20after January 1, 2018 (the effective date of Public Act
2199-761), every insurer licensed in this State to sell a policy
22of group or individual accident and health insurance or a
23health benefits plan shall establish and maintain a medical
24exceptions process that allows covered persons or their
25authorized representatives to request any clinically

 

 

HB5395 Engrossed- 137 -LRB103 37071 RPS 67189 b

1appropriate prescription drug when (1) the drug is not covered
2based on the health benefit plan's formulary; (2) the health
3benefit plan is discontinuing coverage of the drug on the
4plan's formulary for reasons other than safety or other than
5because the prescription drug has been withdrawn from the
6market by the drug's manufacturer; (3) (blank) the
7prescription drug alternatives required to be used in
8accordance with a step therapy requirement (A) has been
9ineffective in the treatment of the enrollee's disease or
10medical condition or, based on both sound clinical evidence
11and medical and scientific evidence, the known relevant
12physical or mental characteristics of the enrollee, and the
13known characteristics of the drug regimen, is likely to be
14ineffective or adversely affect the drug's effectiveness or
15patient compliance or (B) has caused or, based on sound
16medical evidence, is likely to cause an adverse reaction or
17harm to the enrollee; or (4) the number of doses available
18under a dose restriction for the prescription drug (A) has
19been ineffective in the treatment of the enrollee's disease or
20medical condition or (B) based on both sound clinical evidence
21and medical and scientific evidence, the known relevant
22physical and mental characteristics of the enrollee, and known
23characteristics of the drug regimen, is likely to be
24ineffective or adversely affect the drug's effective or
25patient compliance.
26    (b) The health carrier's established medical exceptions

 

 

HB5395 Engrossed- 138 -LRB103 37071 RPS 67189 b

1procedures must require, at a minimum, the following:
2        (1) Any request for approval of coverage made verbally
3    or in writing (regardless of whether made using a paper or
4    electronic form or some other writing) at any time shall
5    be reviewed by appropriate health care professionals.
6        (2) The health carrier must, within 72 hours after
7    receipt of a request made under subsection (a) of this
8    Section, either approve or deny the request. In the case
9    of a denial, the health carrier shall provide the covered
10    person or the covered person's authorized representative
11    and the covered person's prescribing provider with the
12    reason for the denial, an alternative covered medication,
13    if applicable, and information regarding the procedure for
14    submitting an appeal to the denial. A health carrier shall
15    not use the authorization of alternative covered
16    medications under this Section in a manner that
17    effectively creates a step therapy requirement.
18        (3) In the case of an expedited coverage
19    determination, the health carrier must either approve or
20    deny the request within 24 hours after receipt of the
21    request. In the case of a denial, the health carrier shall
22    provide the covered person or the covered person's
23    authorized representative and the covered person's
24    prescribing provider with the reason for the denial, an
25    alternative covered medication, if applicable, and
26    information regarding the procedure for submitting an

 

 

HB5395 Engrossed- 139 -LRB103 37071 RPS 67189 b

1    appeal to the denial.
2    (c) (Blank). A step therapy requirement exception request
3shall be approved if:
4        (1) the required prescription drug is contraindicated;
5        (2) the patient has tried the required prescription
6    drug while under the patient's current or previous health
7    insurance or health benefit plan and the prescribing
8    provider submits evidence of failure or intolerance; or
9        (3) the patient is stable on a prescription drug
10    selected by his or her health care provider for the
11    medical condition under consideration while on a current
12    or previous health insurance or health benefit plan.
13    (d) Upon the granting of an exception request, the
14insurer, health plan, utilization review organization, or
15other entity shall authorize the coverage for the drug
16prescribed by the enrollee's treating health care provider, to
17the extent the prescribed drug is a covered drug under the
18policy or contract up to the quantity covered.
19    (e) Any approval of a medical exception request made
20pursuant to this Section shall be honored for 12 months
21following the date of the approval or until renewal of the
22plan.
23    (f) Notwithstanding any other provision of this Section,
24nothing in this Section shall be interpreted or implemented in
25a manner not consistent with the federal Patient Protection
26and Affordable Care Act (Public Law 111-148), as amended by

 

 

HB5395 Engrossed- 140 -LRB103 37071 RPS 67189 b

1the federal Health Care and Education Reconciliation Act of
22010 (Public Law 111-152), and any amendments thereto, or
3regulations or guidance issued under those Acts.
4    (g) Nothing in this Section shall require or authorize the
5State agency responsible for the administration of the medical
6assistance program established under the Illinois Public Aid
7Code to approve, supply, or cover prescription drugs pursuant
8to the procedure established in this Section.
9(Source: P.A. 103-154, eff. 6-30-23.)
 
10    (215 ILCS 134/85)
11    Sec. 85. Utilization review program registration.
12    (a) No person may conduct a utilization review program in
13this State unless once every 2 years the person registers the
14utilization review program with the Department and certifies
15compliance with the Health Utilization Management Standards of
16the American Accreditation Healthcare Commission (URAC)
17sufficient to achieve American Accreditation Healthcare
18Commission (URAC) accreditation or submits evidence of
19accreditation by the American Accreditation Healthcare
20Commission (URAC) for its Health Utilization Management
21Standards. Nothing in this Act shall be construed to require a
22health care plan or its subcontractors to become American
23Accreditation Healthcare Commission (URAC) accredited.
24    (b) In addition, the Director of the Department, in
25consultation with the Director of the Department of Public

 

 

HB5395 Engrossed- 141 -LRB103 37071 RPS 67189 b

1Health, may certify alternative utilization review standards
2of national accreditation organizations or entities in order
3for plans to comply with this Section. Any alternative
4utilization review standards shall meet or exceed those
5standards required under subsection (a).
6    (b-5) The Department shall recognize the Accreditation
7Association for Ambulatory Health Care among the list of
8accreditors from which utilization organizations may receive
9accreditation and qualify for reduced registration and renewal
10fees.
11    (c) The provisions of this Section do not apply to:
12        (1) persons providing utilization review program
13    services only to the federal government;
14        (2) self-insured health plans under the federal
15    Employee Retirement Income Security Act of 1974, however,
16    this Section does apply to persons conducting a
17    utilization review program on behalf of these health
18    plans;
19        (3) hospitals and medical groups performing
20    utilization review activities for internal purposes unless
21    the utilization review program is conducted for another
22    person.
23    Nothing in this Act prohibits a health care plan or other
24entity from contractually requiring an entity designated in
25item (3) of this subsection to adhere to the utilization
26review program requirements of this Act.

 

 

HB5395 Engrossed- 142 -LRB103 37071 RPS 67189 b

1    (d) This registration shall include submission of all of
2the following information regarding utilization review program
3activities:
4        (1) The name, address, and telephone number of the
5    utilization review programs.
6        (2) The organization and governing structure of the
7    utilization review programs.
8        (3) The number of lives for which utilization review
9    is conducted by each utilization review program.
10        (4) Hours of operation of each utilization review
11    program.
12        (5) Description of the grievance process for each
13    utilization review program.
14        (6) Number of covered lives for which utilization
15    review was conducted for the previous calendar year for
16    each utilization review program.
17        (7) Written policies and procedures for protecting
18    confidential information according to applicable State and
19    federal laws for each utilization review program.
20    (e) (1) A utilization review program shall have written
21procedures for assuring that patient-specific information
22obtained during the process of utilization review will be:
23        (A) kept confidential in accordance with applicable
24    State and federal laws; and
25        (B) shared only with the enrollee, the enrollee's
26    designee, the enrollee's health care provider, and those

 

 

HB5395 Engrossed- 143 -LRB103 37071 RPS 67189 b

1    who are authorized by law to receive the information.
2    Summary data shall not be considered confidential if it
3does not provide information to allow identification of
4individual patients or health care providers.
5        (2) Only a health care professional may make
6    determinations regarding the medical necessity of health
7    care services during the course of utilization review.
8    Only a clinical peer may make an adverse determination.
9        (3) When making retrospective reviews, utilization
10    review programs shall base reviews solely on the medical
11    information available to the attending physician or
12    ordering provider at the time the health care services
13    were provided.
14        (4) When making prospective, concurrent, and
15    retrospective determinations, utilization review programs
16    shall collect only information that is necessary to make
17    the determination and shall not routinely require health
18    care providers to numerically code diagnoses or procedures
19    to be considered for certification, unless required under
20    State or federal Medicare or Medicaid rules or
21    regulations, but may request such code if available, or
22    routinely request copies of medical records of all
23    enrollees reviewed. During prospective or concurrent
24    review, copies of medical records shall only be required
25    when necessary to verify that the health care services
26    subject to review are medically necessary. In these cases,

 

 

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1    only the necessary or relevant sections of the medical
2    record shall be required.
3    (f) If the Department finds that a utilization review
4program is not in compliance with this Section, the Department
5shall issue a corrective action plan and allow a reasonable
6amount of time for compliance with the plan. If the
7utilization review program does not come into compliance, the
8Department may issue a cease and desist order. Before issuing
9a cease and desist order under this Section, the Department
10shall provide the utilization review program with a written
11notice of the reasons for the order and allow a reasonable
12amount of time to supply additional information demonstrating
13compliance with requirements of this Section and to request a
14hearing. The hearing notice shall be sent by certified mail,
15return receipt requested, and the hearing shall be conducted
16in accordance with the Illinois Administrative Procedure Act.
17    (g) A utilization review program subject to a corrective
18action may continue to conduct business until a final decision
19has been issued by the Department.
20    (h) Any adverse determination made by a health care plan
21or its subcontractors may be appealed in accordance with
22subsection (f) of Section 45.
23    (i) The Director may by rule establish a registration fee
24for each person conducting a utilization review program. All
25fees paid to and collected by the Director under this Section
26shall be deposited into the Insurance Producer Administration

 

 

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1Fund.
2(Source: P.A. 99-111, eff. 1-1-16.)
 
3    (215 ILCS 134/87 new)
4    Sec. 87. General standards for use of utilization review
5criteria.
6    (a) Except as provided in subsections (g) and (h),
7beginning January 1, 2026, all medical necessity
8determinations made by a utilization review program shall be
9conducted in accordance with the requirements of this Section.
10No policy, contract, certificate, or evidence of coverage
11issued to any enrollee, nor any formulary, may contain terms
12or conditions to the contrary.
13    (b) A utilization review program shall base any medical
14necessity determination or the utilization review criteria
15that the program applies to determine the medical necessity of
16health care services and benefits on current generally
17accepted standards of care.
18    (c) Subject to subsection (i), a utilization review
19program shall apply the most recent version of:
20        (1) the treatment criteria, at the time the service or
21    treatment was delivered, developed by an unaffiliated
22    nonprofit professional association for the relevant
23    clinical specialty;
24        (2) nationally recognized, evidence-based treatment
25    criteria reflecting current generally accepted standards

 

 

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1    of care when:
2            (A) such national criteria are developed and
3        updated annually by a third-party entity that does not
4        receive direct payments based on the outcome of the
5        clinical care decisions; and
6            (B) for utilization review programs with respect
7        to health care plans subject to this Act, neither the
8        developing entity nor the utilization review program
9        customizes or adapts such national criteria, and the
10        developing entity does not offer the utilization
11        review program a choice the among more than one
12        distinct set of criteria for the same health care
13        service, except to the extent necessary for all
14        utilization review programs subject to this Section to
15        comply with State or federal requirements applicable
16        to each health care plan that they offer or administer
17        as provided in subsection (i); or
18        (3) for health care plans operated or overseen by the
19    Department of Healthcare and Family Services, including
20    Medicaid managed care plans, when neither of the preceding
21    types of sources offers treatment criteria for a covered
22    item or service, treatment criteria determined by the
23    Department of Healthcare and Family Services that are not
24    inconsistent with generally accepted standards of care.
25    (d) For medical necessity determinations that are within
26the scope of the sources specified in subsection (c), a

 

 

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1utilization review program shall not apply different,
2additional, conflicting, or more restrictive utilization
3review criteria than the criteria set forth in those sources.
4For all level of care placement decisions, the utilization
5review program or health care plan shall authorize placement
6at the level of care consistent with the assessment of the
7enrollee using the relevant patient placement criteria as
8specified in subsection (c). If that level of placement is not
9available, the utilization review program or health care plan
10shall authorize the next highest level of care. In the event of
11disagreement, the utilization review program shall provide
12full detail of its assessment using the relevant criteria as
13specified in subsection (c) to the provider of the service and
14the patient.
15    (e) In conducting utilization review that is outside the
16scope of the criteria specified in subsection (c) or that
17relates to the advancements in technology or in the types or
18levels of care that are not addressed in the most recent
19versions of the sources specified in subsection (c), a
20utilization review program shall conduct utilization review in
21accordance with subsection (b). If a utilization review
22program purchases or licenses utilization review criteria
23pursuant to this subsection, the utilization review program
24shall verify and document before use that the criteria were
25developed in accordance with subsection (b).
26    (f) To ensure the proper use of utilization review

 

 

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1criteria that were not developed under or that diverge from
2those developed under subsection (c), every health care plan
3shall do all of the following:
4        (1) Make an educational program available to the
5    health care plan's staff, as well as the staff of any other
6    utilization review program contracted to review claims,
7    conduct utilization reviews, or make medical necessity
8    determinations about the utilization review criteria.
9        (2) Make the educational program available, at no
10    cost, to other stakeholders, including the health care
11    plan's participating or contracted providers and potential
12    enrollees. The education program must be provided at least
13    once a year, in person or digitally, or recordings of the
14    education program must be made available to those
15    stakeholders.
16        (3) Provide, at no cost, the utilization review
17    criteria and any training material or resources to
18    providers and enrollees upon request. The health care plan
19    may place the criteria on a secure, password-protected
20    website so long as the access requirements of the website
21    do not unreasonably restrict access to enrollees or their
22    providers. No restrictions shall be placed upon the
23    enrollee's or treating provider's access right to
24    utilization review criteria obtained under this paragraph
25    at any point in time, including before an initial request
26    for authorization.

 

 

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1        (4) Track, identify, and analyze how the utilization
2    review criteria are used to certify care, deny care, and
3    support the appeals process.
4        (5) Conduct interrater reliability testing to ensure
5    consistency in utilization review decision-making that
6    covers how medical necessity decisions are made. This
7    assessment shall cover all aspects of utilization review
8    as defined in Section 10.
9        (6) Run interrater reliability reports about how the
10    clinical guidelines are used in conjunction with the
11    utilization review process.
12        (7) Achieve interrater reliability pass rates of at
13    least 90% and, if this threshold is not met, immediately
14    provide for the remediation of poor interrater reliability
15    and interrater reliability testing for all new staff
16    before they can conduct utilization review without
17    supervision.
18        (8) Maintain documentation of interrater reliability
19    testing and the remediation actions taken for those with
20    pass rates lower than 90% and submit to the Department of
21    Insurance or, in the case of Medicaid managed care
22    organizations, the Department of Healthcare and Family
23    Services the testing results and a summary of remedial
24    actions.
25    (g) Beginning January 1, 2025, no utilization review
26program or any policy, contract, certificate, evidence of

 

 

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1coverage, or formulary shall impose step therapy requirements.
2Nothing in this subsection prohibits a health care plan, by
3contract, written policy or procedure, or any other agreement
4or course of conduct, from requiring a pharmacist to effect
5substitutions of prescription drugs consistent with Section
619.5 of the Pharmacy Practice Act, under which a pharmacist
7may substitute an interchangeable biologic for a prescribed
8biologic product, and Section 25 of the Pharmacy Practice Act,
9under which a pharmacist may select a generic drug determined
10to be therapeutically equivalent by the United States Food and
11Drug Administration and in accordance with the Illinois Food,
12Drug and Cosmetic Act. For health care plans operated or
13overseen by the Department of Healthcare and Family Services,
14including Medicaid managed care plans, the prohibition in this
15subsection does not apply to step therapy requirements for
16drugs that do not appear on the most recent Preferred Drug List
17published by the Department of Healthcare and Family Services.
18    (h) Except for subsection (g), this Section does not apply
19to utilization review concerning diagnosis, prevention, and
20treatment of mental, emotional, nervous, or substance use
21disorders or conditions, which shall be governed by Section
22370c of the Illinois Insurance Code.
23    (i) Nothing in this Section shall be construed to
24supersede or waive requirements provided under any other State
25or federal law or federal regulation that any coverage subject
26to this Section comply with specific utilization review

 

 

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

 

 

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1        (3) a rescission of coverage determination, which does
2    not include a cancellation or discontinuance of coverage
3    that is attributable to a failure to timely pay required
4    premiums or contributions towards the cost of coverage.
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

 

 

HB5395 Engrossed- 153 -LRB103 37071 RPS 67189 b

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"Clinical review criteria" includes all utilization review
10criteria as defined in Section 10 of the Managed Care Reform
11and Patient Rights Act.
12    "Cohort study" means a prospective evaluation of 2 groups
13of patients with only one group of patients receiving specific
14intervention.
15    "Concurrent review" means a review conducted during a
16patient's stay or course of treatment in a facility, the
17office of a health care professional, or other inpatient or
18outpatient health care setting.
19    "Covered benefits" or "benefits" means those health care
20services to which a covered person is entitled under the terms
21of a health benefit plan.
22    "Covered person" means a policyholder, subscriber,
23enrollee, or other individual participating in a health
24benefit plan.
25    "Director" means the Director of the Department of
26Insurance.

 

 

HB5395 Engrossed- 154 -LRB103 37071 RPS 67189 b

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

 

 

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1by a health carrier, or its designee utilization review
2organization, at the completion of the health carrier's
3internal grievance process procedures as set forth by the
4Managed Care Reform and Patient Rights Act.
5    "Health benefit plan" means a policy, contract,
6certificate, plan, or agreement offered or issued by a health
7carrier to provide, deliver, arrange for, pay for, or
8reimburse any of the costs of health care services.
9    "Health care provider" or "provider" means a physician,
10hospital facility, or other health care practitioner licensed,
11accredited, or certified to perform specified health care
12services consistent with State law, responsible for
13recommending health care services on behalf of a covered
14person.
15    "Health care services" means services for the diagnosis,
16prevention, treatment, cure, or relief of a health condition,
17illness, injury, or disease.
18    "Health carrier" means an entity subject to the insurance
19laws and regulations of this State, or subject to the
20jurisdiction of the Director, that contracts or offers to
21contract to provide, deliver, arrange for, pay for, or
22reimburse any of the costs of health care services, including
23a sickness and accident insurance company, a health
24maintenance organization, or any other entity providing a plan
25of health insurance, health benefits, or health care services.
26"Health carrier" also means Limited Health Service

 

 

HB5395 Engrossed- 156 -LRB103 37071 RPS 67189 b

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

 

 

HB5395 Engrossed- 157 -LRB103 37071 RPS 67189 b

1    criteria of the National Institutes of Health's Library of
2    Medicine for indexing in Index Medicus (Medline) and
3    Elsevier Science Ltd. for indexing in Excerpta Medicus
4    (EMBASE);
5        (3) medical journals recognized by the Secretary of
6    Health and Human Services under Section 1861(t)(2) of the
7    federal Social Security Act;
8        (4) the following standard reference compendia:
9            (a) The American Hospital Formulary Service-Drug
10        Information;
11            (b) Drug Facts and Comparisons;
12            (c) The American Dental Association Accepted
13        Dental Therapeutics; and
14            (d) The United States Pharmacopoeia-Drug
15        Information;
16        (5) findings, studies, or research conducted by or
17    under the auspices of federal government agencies and
18    nationally recognized federal research institutes,
19    including:
20            (a) the federal Agency for Healthcare Research and
21        Quality;
22            (b) the National Institutes of Health;
23            (c) the National Cancer Institute;
24            (d) the National Academy of Sciences;
25            (e) the Centers for Medicare & Medicaid Services;
26            (f) the federal Food and Drug Administration; and

 

 

HB5395 Engrossed- 158 -LRB103 37071 RPS 67189 b

1            (g) any national board recognized by the National
2        Institutes of Health for the purpose of evaluating the
3        medical value of health care services; or
4        (6) any other medical or scientific evidence that is
5    comparable to the sources listed in items (1) through (5).
6    "Person" means an individual, a corporation, a
7partnership, an association, a joint venture, a joint stock
8company, a trust, an unincorporated organization, any similar
9entity, or any combination of the foregoing.
10    "Prospective review" means a review conducted prior to an
11admission or the provision of a health care service or a course
12of treatment in accordance with a health carrier's requirement
13that the health care service or course of treatment, in whole
14or in part, be approved prior to its provision.
15    "Protected health information" means health information
16(i) that identifies an individual who is the subject of the
17information; or (ii) with respect to which there is a
18reasonable basis to believe that the information could be used
19to identify an individual.
20    "Randomized clinical trial" means a controlled prospective
21study of patients that have been randomized into an
22experimental group and a control group at the beginning of the
23study with only the experimental group of patients receiving a
24specific intervention, which includes study of the groups for
25variables and anticipated outcomes over time.
26    "Retrospective review" means any review of a request for a

 

 

HB5395 Engrossed- 159 -LRB103 37071 RPS 67189 b

1benefit that is not a concurrent or prospective review
2request. "Retrospective review" does not include the review of
3a claim that is limited to veracity of documentation or
4accuracy of coding.
5    "Utilization review" has the meaning provided by the
6Managed Care Reform and Patient Rights Act.
7    "Utilization review organization" means a utilization
8review program as defined in the Managed Care Reform and
9Patient Rights Act.
10(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12;
1198-756, eff. 7-16-14.)
 
12    Section 6-20. The Prior Authorization Reform Act is
13amended by changing Sections 15 and 20 as follows:
 
14    (215 ILCS 200/15)
15    Sec. 15. Definitions. As used in this Act:
16    "Adverse determination" has the meaning given to that term
17in Section 10 of the Health Carrier External Review Act.
18    "Appeal" means a formal request, either orally or in
19writing, to reconsider an adverse determination.
20    "Approval" means a determination by a health insurance
21issuer or its contracted utilization review organization that
22a health care service has been reviewed and, based on the
23information provided, satisfies the health insurance issuer's
24or its contracted utilization review organization's

 

 

HB5395 Engrossed- 160 -LRB103 37071 RPS 67189 b

1requirements for medical necessity and appropriateness.
2    "Clinical review criteria" has the meaning given to that
3term in Section 10 of the Health Carrier External Review Act.
4    "Department" means the Department of Insurance.
5    "Emergency medical condition" has the meaning given to
6that term in Section 10 of the Managed Care Reform and Patient
7Rights Act.
8    "Emergency services" has the meaning given to that term in
9federal health insurance reform requirements for the group and
10individual health insurance markets, 45 CFR 147.138.
11    "Enrollee" has the meaning given to that term in Section
1210 of the Managed Care Reform and Patient Rights Act.
13    "Health care professional" has the meaning given to that
14term in Section 10 of the Managed Care Reform and Patient
15Rights Act.
16    "Health care provider" has the meaning given to that term
17in Section 10 of the Managed Care Reform and Patient Rights
18Act, except that facilities licensed under the Nursing Home
19Care Act and long-term care facilities as defined in Section
201-113 of the Nursing Home Care Act are excluded from this Act.
21    "Health care service" means any services or level of
22services included in the furnishing to an individual of
23medical care or the hospitalization incident to the furnishing
24of such care, as well as the furnishing to any person of any
25other services for the purpose of preventing, alleviating,
26curing, or healing human illness or injury, including

 

 

HB5395 Engrossed- 161 -LRB103 37071 RPS 67189 b

1behavioral health, mental health, home health, and
2pharmaceutical services and products.
3    "Health insurance issuer" has the meaning given to that
4term in Section 5 of the Illinois Health Insurance Portability
5and Accountability Act.
6    "Medically necessary" has the meaning given to that term
7in Section 10 of the Managed Care Reform and Patient Rights
8Act. means a health care professional exercising prudent
9clinical judgment would provide care to a patient for the
10purpose of preventing, diagnosing, or treating an illness,
11injury, disease, or its symptoms and that are: (i) in
12accordance with generally accepted standards of medical
13practice; (ii) clinically appropriate in terms of type,
14frequency, extent, site, and duration and are considered
15effective for the patient's illness, injury, or disease; and
16(iii) not primarily for the convenience of the patient,
17treating physician, other health care professional, caregiver,
18family member, or other interested party, but focused on what
19is best for the patient's health outcome.
20    "Physician" means a person licensed under the Medical
21Practice Act of 1987 or licensed under the laws of another
22state to practice medicine in all its branches.
23    "Prior authorization" means the process by which health
24insurance issuers or their contracted utilization review
25organizations determine the medical necessity and medical
26appropriateness of otherwise covered health care services

 

 

HB5395 Engrossed- 162 -LRB103 37071 RPS 67189 b

1before the rendering of such health care services. "Prior
2authorization" includes any health insurance issuer's or its
3contracted utilization review organization's requirement that
4an enrollee, health care professional, or health care provider
5notify the health insurance issuer or its contracted
6utilization review organization before, at the time of, or
7concurrent to providing a health care service.
8    "Urgent health care service" means a health care service
9with respect to which the application of the time periods for
10making a non-expedited prior authorization that in the opinion
11of a health care professional with knowledge of the enrollee's
12medical condition:
13        (1) could seriously jeopardize the life or health of
14    the enrollee or the ability of the enrollee to regain
15    maximum function; or
16        (2) could subject the enrollee to severe pain that
17    cannot be adequately managed without the care or treatment
18    that is the subject of the utilization review.
19    "Urgent health care service" does not include emergency
20services.
21    "Utilization review organization" has the meaning given to
22that term in 50 Ill. Adm. Code 4520.30.
23(Source: P.A. 102-409, eff. 1-1-22.)
 
24    (215 ILCS 200/20)
25    Sec. 20. Disclosure and review of prior authorization

 

 

HB5395 Engrossed- 163 -LRB103 37071 RPS 67189 b

1requirements.
2    (a) A health insurance issuer shall maintain a complete
3list of services for which prior authorization is required,
4including for all services where prior authorization is
5performed by an entity under contract with the health
6insurance issuer. The health insurance issuer shall publish
7this list on its public website without requiring a member of
8the general public to create any account or enter any
9credentials to access it. The list described in this
10subsection is not required to contain the clinical review
11criteria applicable to these services.
12    (b) A health insurance issuer shall make any current prior
13authorization requirements and restrictions, including the
14written clinical review criteria, readily accessible and
15conspicuously posted on its website to enrollees, health care
16professionals, and health care providers. Content published by
17a third party and licensed for use by a health insurance issuer
18or its contracted utilization review organization may be made
19available through the health insurance issuer's or its
20contracted utilization review organization's secure,
21password-protected website so long as the access requirements
22of the website do not unreasonably restrict access.
23Requirements shall be described in detail, written in easily
24understandable language, and readily available to the health
25care professional and health care provider at the point of
26care. The website shall indicate for each service subject to

 

 

HB5395 Engrossed- 164 -LRB103 37071 RPS 67189 b

1prior authorization:
2        (1) when prior authorization became required for
3    policies issued or delivered in Illinois, including the
4    effective date or dates and the termination date or dates,
5    if applicable, in Illinois;
6        (2) the date the Illinois-specific requirement was
7    listed on the health insurance issuer's or its contracted
8    utilization review organization's website;
9        (3) where applicable, the date that prior
10    authorization was removed for Illinois; and
11        (4) where applicable, access to a standardized
12    electronic prior authorization request transaction
13    process.
14    (c) The clinical review criteria must:
15        (1) be based on nationally recognized, generally
16    accepted standards except where State law provides its own
17    standard;
18        (2) be developed in accordance with the current
19    standards of a national medical accreditation entity;
20        (3) ensure quality of care and access to needed health
21    care services;
22        (4) be evidence-based;
23        (5) be sufficiently flexible to allow deviations from
24    norms when justified on a case-by-case basis; and
25        (6) be evaluated and updated, if necessary, at least
26    annually.

 

 

HB5395 Engrossed- 165 -LRB103 37071 RPS 67189 b

1    (d) A health insurance issuer shall not deny a claim for
2failure to obtain prior authorization if the prior
3authorization requirement was not in effect on the date of
4service on the claim.
5    (e) A health insurance issuer or its contracted
6utilization review organization shall not deem as incidental
7or deny supplies or health care services that are routinely
8used as part of a health care service when:
9        (1) an associated health care service has received
10    prior authorization; or
11        (2) prior authorization for the health care service is
12    not required.
13    (f) If a health insurance issuer intends either to
14implement a new prior authorization requirement or restriction
15or amend an existing requirement or restriction, the health
16insurance issuer shall provide contracted health care
17professionals and contracted health care providers of
18enrollees written notice of the new or amended requirement or
19amendment no less than 60 days before the requirement or
20restriction is implemented. The written notice may be provided
21in an electronic format, including email or facsimile, if the
22health care professional or health care provider has agreed in
23advance to receive notices electronically. The health
24insurance issuer shall ensure that the new or amended
25requirement is not implemented unless the health insurance
26issuer's or its contracted utilization review organization's

 

 

HB5395 Engrossed- 166 -LRB103 37071 RPS 67189 b

1website has been updated to reflect the new or amended
2requirement or restriction.
3    (g) Entities using prior authorization shall make
4statistics available regarding prior authorization approvals
5and denials on their website in a readily accessible format.
6The statistics must be updated annually and include all of the
7following information:
8        (1) a list of all health care services, including
9    medications, that are subject to prior authorization;
10        (2) the total number of prior authorization requests
11    received;
12        (3) the number of prior authorization requests denied
13    during the previous plan year by the health insurance
14    issuer or its contracted utilization review organization
15    with respect to each service described in paragraph (1)
16    and the top 5 reasons for denial;
17        (4) the number of requests described in paragraph (3)
18    that were appealed, the number of the appealed requests
19    that upheld the adverse determination, and the number of
20    appealed requests that reversed the adverse determination;
21        (5) the average time between submission and response;
22    and
23        (6) any other information as the Director determines
24    appropriate.
25(Source: P.A. 102-409, eff. 1-1-22.)
 

 

 

HB5395 Engrossed- 167 -LRB103 37071 RPS 67189 b

1    Section 6-25. The Illinois Public Aid Code is amended by
2changing Section 5-16.12 as follows:
 
3    (305 ILCS 5/5-16.12)
4    Sec. 5-16.12. Managed Care Reform and Patient Rights Act.
5The medical assistance program and other programs administered
6by the Department are subject to the provisions of the Managed
7Care Reform and Patient Rights Act. The Department may adopt
8rules to implement those provisions. These rules shall require
9compliance with that Act in the medical assistance managed
10care programs and other programs administered by the
11Department. The medical assistance fee-for-service program is
12not subject to the provisions of the Managed Care Reform and
13Patient Rights Act, except for Sections 85 and 87 of the
14Managed Care Reform and Patient Rights Act and for any
15definition in Section 10 of the Managed Care Reform and
16Patient Rights Act that applies to Sections 85 and 87 of the
17Managed Care Reform and Patient Rights Act.
18    Nothing in the Managed Care Reform and Patient Rights Act
19shall be construed to mean that the Department is a health care
20plan as defined in that Act simply because the Department
21enters into contractual relationships with health care plans;
22provided that this clause shall not defeat the applicability
23of Sections 10, 85, and 87 of the Managed Care Reform and
24Patient Rights Act to the fee-for-service program.
25(Source: P.A. 91-617, eff. 1-1-00.)
 

 

 

HB5395 Engrossed- 168 -LRB103 37071 RPS 67189 b

1
Article 99.

 
2    Section 99-95. No acceleration or delay. Where this Act
3makes changes in a statute that is represented in this Act by
4text that is not yet or no longer in effect (for example, a
5Section represented by multiple versions), the use of that
6text does not accelerate or delay the taking effect of (i) the
7changes made by this Act or (ii) provisions derived from any
8other Public Act.
 
9    Section 99-99. Effective date. This Act takes effect
10January 1, 2025.