Full Text of HB3638 98th General Assembly
HB3638enr 98TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 1. Short title. This amendatory Act may be referred | 5 | | to as the Health Insurance Consumer Protection Act of 2014. | 6 | | Section 3. Findings and purpose. The General Assembly | 7 | | finds that the federal Patient Protection and Affordable Care | 8 | | Act and the federal regulations implementing that Act give the | 9 | | State and its Department of Insurance primary responsibility | 10 | | for ensuring that all policies of health insurance and health | 11 | | care plans that are offered for sale directly to consumers in | 12 | | the State provide consumers with adequate information about the | 13 | | coverage offered to enable them to meaningfully compare plans | 14 | | and premiums and enroll in the appropriate policy or plan. The | 15 | | purpose of this amendatory Act of the 98th General Assembly is | 16 | | to build on the consumer protections provided in federal law | 17 | | for policies or qualified health plans offered for sale | 18 | | directly to consumers through the Health Insurance Marketplace | 19 | | in Illinois. | 20 | | Section 5. The Illinois Insurance Code is amended by | 21 | | changing Sections 155.36 and 355a as follows:
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| 1 | | (215 ILCS 5/155.36)
| 2 | | Sec. 155.36. Managed Care Reform and Patient Rights Act. | 3 | | Insurance
companies that transact the kinds of insurance | 4 | | authorized under Class 1(b) or
Class 2(a) of Section 4 of this | 5 | | Code shall comply
with Sections 45 , 45.1, 45.2, and 85 and the | 6 | | definition of the term "emergency medical
condition" in Section
| 7 | | 10 of the Managed Care Reform and Patient Rights Act.
| 8 | | (Source: P.A. 96-857, eff. 7-1-10 .)
| 9 | | (215 ILCS 5/355a) (from Ch. 73, par. 967a)
| 10 | | Sec. 355a. Standardization of terms and coverage.
| 11 | | (1) The purpose of this Section shall be (a) to provide
| 12 | | reasonable standardization and simplification of terms and | 13 | | coverages of
individual accident and health insurance policies | 14 | | to facilitate public
understanding and comparisons; (b) to | 15 | | eliminate provisions contained in
individual accident and | 16 | | health insurance policies which may be
misleading or | 17 | | unreasonably confusing in connection either with the
purchase | 18 | | of such coverages or with the settlement of claims; and (c) to
| 19 | | provide for reasonable disclosure in the sale of accident and | 20 | | health
coverages.
| 21 | | (2) Definitions applicable to this Section are as follows:
| 22 | | (a) "Policy" means all or any part of the forms | 23 | | constituting the
contract between the insurer and the | 24 | | insured, including the policy,
certificate, subscriber | 25 | | contract, riders, endorsements, and the
application if |
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| 1 | | attached, which are subject to filing with and approval
by | 2 | | the Director.
| 3 | | (b) "Service corporations" means
voluntary health and | 4 | | dental
corporations organized and operating respectively | 5 | | under
the Voluntary Health Services Plans Act and
the | 6 | | Dental Service Plan Act.
| 7 | | (c) "Accident and health insurance" means insurance | 8 | | written under
Article XX of the Insurance Code, other than | 9 | | credit accident and health
insurance, and coverages | 10 | | provided in subscriber contracts issued by
service | 11 | | corporations. For purposes of this Section such service
| 12 | | corporations shall be deemed to be insurers engaged in the | 13 | | business of
insurance.
| 14 | | (3) The Director shall issue such rules as he shall deem | 15 | | necessary
or desirable to establish specific standards, | 16 | | including standards of
full and fair disclosure that set forth | 17 | | the form and content and
required disclosure for sale, of | 18 | | individual policies of accident and
health insurance, which | 19 | | rules and regulations shall be in addition to
and in accordance | 20 | | with the applicable laws of this State, and which may
cover but | 21 | | shall not be limited to: (a) terms of renewability; (b)
initial | 22 | | and subsequent conditions of eligibility; (c) non-duplication | 23 | | of
coverage provisions; (d) coverage of dependents; (e) | 24 | | pre-existing
conditions; (f) termination of insurance; (g) | 25 | | probationary periods; (h)
limitation, exceptions, and | 26 | | reductions; (i) elimination periods; (j)
requirements |
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| 1 | | regarding replacements; (k) recurrent conditions; and (l)
the | 2 | | definition of terms including but not limited to the following:
| 3 | | hospital, accident, sickness, injury, physician, accidental | 4 | | means, total
disability, partial disability, nervous disorder, | 5 | | guaranteed renewable,
and non-cancellable.
| 6 | | The Director may issue rules that specify prohibited policy
| 7 | | provisions not otherwise specifically authorized by statute | 8 | | which in the
opinion of the Director are unjust, unfair or | 9 | | unfairly discriminatory to
the policyholder, any person | 10 | | insured under the policy, or beneficiary.
| 11 | | (4) The Director shall issue such rules as he shall deem | 12 | | necessary
or desirable to establish minimum standards for | 13 | | benefits under each
category of coverage in individual accident | 14 | | and health policies, other
than conversion policies issued | 15 | | pursuant to a contractual conversion
privilege under a group | 16 | | policy, including but not limited to the
following categories: | 17 | | (a) basic hospital expense coverage; (b) basic
| 18 | | medical-surgical expense coverage; (c) hospital confinement | 19 | | indemnity
coverage; (d) major medical expense coverage; (e) | 20 | | disability income
protection coverage; (f) accident only | 21 | | coverage; and (g) specified
disease or specified accident | 22 | | coverage.
| 23 | | Nothing in this subsection (4) shall preclude the issuance | 24 | | of any
policy which combines two or more of the categories of | 25 | | coverage
enumerated in subparagraphs (a) through (f) of this | 26 | | subsection.
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| 1 | | No policy shall be delivered or issued for delivery in this | 2 | | State
which does not meet the prescribed minimum standards for | 3 | | the categories
of coverage listed in this subsection unless the | 4 | | Director finds that
such policy is necessary to meet specific | 5 | | needs of individuals or groups
and such individuals or groups | 6 | | will be adequately informed that such
policy does not meet the | 7 | | prescribed minimum standards, and such policy
meets the | 8 | | requirement that the benefits provided therein are reasonable
| 9 | | in relation to the premium charged. The standards and criteria | 10 | | to be
used by the Director in approving such policies shall be | 11 | | included in the
rules required under this Section with as much | 12 | | specificity as
practicable.
| 13 | | The Director shall prescribe by rule the method of | 14 | | identification of
policies based upon coverages provided.
| 15 | | (5) (a) In order to provide for full and fair disclosure in | 16 | | the
sale of individual accident and health insurance policies, | 17 | | no such
policy shall be delivered or issued for delivery in | 18 | | this State unless
the outline of coverage described in | 19 | | paragraph (b) of this subsection
either accompanies the policy, | 20 | | or is delivered to the applicant at the
time the application is | 21 | | made, and an acknowledgment signed by the
insured, of receipt | 22 | | of delivery of such outline, is provided to the
insurer. In the | 23 | | event the policy is issued on a basis other than that
applied | 24 | | for, the outline of coverage properly describing the policy | 25 | | must
accompany the policy when it is delivered and such outline | 26 | | shall clearly
state that the policy differs, and to what |
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| 1 | | extent, from that for which
application was originally made. | 2 | | All policies, except single premium
nonrenewal policies, shall | 3 | | have a notice prominently printed on the
first page of the | 4 | | policy or attached thereto stating in substance, that
the | 5 | | policyholder shall have the right to return the policy within | 6 | | 10 days of its delivery and to have the premium refunded if | 7 | | after
examination of the policy the policyholder is not | 8 | | satisfied for any
reason.
| 9 | | (b) The Director shall issue such rules as he shall deem | 10 | | necessary
or desirable to prescribe the format and content of | 11 | | the outline of
coverage required by paragraph (a) of this | 12 | | subsection. "Format" means
style, arrangement, and overall | 13 | | appearance, including such items as the
size, color, and | 14 | | prominence of type and the arrangement of text and
captions. | 15 | | "Content" shall include without limitation thereto,
statements | 16 | | relating to the particular policy as to the applicable
category | 17 | | of coverage prescribed under subsection 4; principal benefits;
| 18 | | exceptions, reductions and limitations; and renewal | 19 | | provisions,
including any reservation by the insurer of a right | 20 | | to change premiums.
Such outline of coverage shall clearly | 21 | | state that it constitutes a
summary of the policy issued or | 22 | | applied for and that the policy should
be consulted to | 23 | | determine governing contractual provisions.
| 24 | | (c) Without limiting the generality of paragraph (b) of | 25 | | this subsection (5), no qualified health plans shall be offered | 26 | | for sale directly to consumers through the health insurance |
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| 1 | | marketplace operating in the State in accordance with Sections | 2 | | 1311 and
1321 of the federal Patient Protection and Affordable | 3 | | Care Act of 2010 (Public Law 111-148), as amended by the | 4 | | federal Health Care and Education Reconciliation Act of 2010 | 5 | | (Public Law 111-152), and any amendments thereto, or | 6 | | regulations or guidance issued thereunder (collectively, "the | 7 | | Federal Act"), unless the following information is made | 8 | | available to the consumer at the time he or she is comparing | 9 | | policies and their premiums: | 10 | | (i) With respect to prescription drug benefits, the | 11 | | most recently published formulary where a consumer can view | 12 | | in one location covered prescription drugs; information on | 13 | | tiering and the cost-sharing structure for each tier; and | 14 | | information about how a consumer can obtain specific | 15 | | copayment amounts or coinsurance percentages for a | 16 | | specific qualified health plan before enrolling in that | 17 | | plan. This information shall clearly identify the | 18 | | qualified health plan to which it applies. | 19 | | (ii) The most recently published provider directory | 20 | | where a consumer can view the provider network that applies | 21 | | to each qualified health plan and information about each | 22 | | provider, including location, contact information, | 23 | | specialty, medical group, if any, any institutional | 24 | | affiliation, and whether the provider is accepting new | 25 | | patients. The information shall clearly identify the | 26 | | qualified health plan to which it applies. |
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| 1 | | (d) Each company that offers qualified health plans for | 2 | | sale directly to consumers through the health insurance | 3 | | marketplace operating in the State shall make the information | 4 | | in paragraph (c) of this subsection (5), for each qualified | 5 | | health plan that it offers, available and accessible to the | 6 | | general public on the company's Internet website and through | 7 | | other means for individuals without access to the Internet. | 8 | | (e) The Department shall ensure that State-operated | 9 | | Internet websites, in addition to the Internet website for the | 10 | | health insurance marketplace established in this State in | 11 | | accordance with the Federal Act, prominently provide links to | 12 | | Internet-based materials and tools to help consumers be | 13 | | informed purchasers of health insurance. | 14 | | (f) Nothing in this Section shall be interpreted or | 15 | | implemented in a manner not consistent with the Federal Act. | 16 | | This Section shall apply to all qualified health plans offered | 17 | | for sale directly to consumers through the health insurance | 18 | | marketplace operating in this State for any coverage year | 19 | | beginning on or after January 1, 2015. | 20 | | (6) Prior to the issuance of rules pursuant to this | 21 | | Section, the
Director shall afford the public, including the | 22 | | companies affected
thereby, reasonable opportunity for | 23 | | comment. Such rulemaking is subject
to the provisions of the | 24 | | Illinois Administrative Procedure Act.
| 25 | | (7) When a rule has been adopted, pursuant to this Section, | 26 | | all
policies of insurance or subscriber contracts which are not |
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| 1 | | in
compliance with such rule shall, when so provided in such | 2 | | rule, be
deemed to be disapproved as of a date specified in | 3 | | such rule not less
than 120 days following its effective date, | 4 | | without any further or
additional notice other than the | 5 | | adoption of the rule.
| 6 | | (8) When a rule adopted pursuant to this Section so | 7 | | provides, a
policy of insurance or subscriber contract which | 8 | | does not comply with
the rule shall not less than 120 days from | 9 | | the effective date of such
rule, be construed, and the insurer | 10 | | or service corporation shall be
liable, as if the policy or | 11 | | contract did comply with the rule.
| 12 | | (9) Violation of any rule adopted pursuant to this Section | 13 | | shall be
a violation of the insurance law for purposes of | 14 | | Sections 370 and 446 of
the Insurance Code.
| 15 | | (Source: P.A. 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; | 16 | | 90-655, eff.
7-30-98.)
| 17 | | Section 10. The Managed Care Reform and Patient Rights Act | 18 | | is amended by changing Section 15 and by adding Sections 45.1 | 19 | | and 45.2 as follows:
| 20 | | (215 ILCS 134/15)
| 21 | | Sec. 15. Provision of information.
| 22 | | (a) A health care plan shall provide annually to enrollees | 23 | | and prospective
enrollees, upon request, a complete list of | 24 | | participating health care providers
in the
health care plan's |
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| 1 | | service area and a description of the following terms of
| 2 | | coverage:
| 3 | | (1) the service area;
| 4 | | (2) the covered benefits and services with all | 5 | | exclusions, exceptions, and
limitations;
| 6 | | (3) the pre-certification and other utilization review | 7 | | procedures
and requirements;
| 8 | | (4) a description of the process for the selection of a | 9 | | primary care
physician,
any limitation on access to | 10 | | specialists, and the plan's standing referral
policy;
| 11 | | (5) the emergency coverage and benefits, including any | 12 | | restrictions on
emergency
care services;
| 13 | | (6) the out-of-area coverage and benefits, if any;
| 14 | | (7) the enrollee's financial responsibility for | 15 | | copayments, deductibles,
premiums, and any other | 16 | | out-of-pocket expenses;
| 17 | | (8) the provisions for continuity of treatment in the | 18 | | event a health care
provider's
participation terminates | 19 | | during the course of an enrollee's treatment by that
| 20 | | provider;
| 21 | | (9) the appeals process, forms, and time frames for | 22 | | health care services
appeals, complaints, and external | 23 | | independent reviews, administrative
complaints,
and | 24 | | utilization review complaints, including a phone
number
to | 25 | | call to receive more information from the health care plan | 26 | | concerning the
appeals process; and
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| 1 | | (10) a statement of all basic health care services and | 2 | | all specific
benefits and
services mandated to be provided | 3 | | to enrollees by any State law or
administrative
rule.
| 4 | | (a-5) Without limiting the generality of subsection (a) of | 5 | | this Section, no qualified health plans shall be offered for | 6 | | sale directly to consumers through the health insurance | 7 | | marketplace operating in the State in accordance with Sections | 8 | | 1311 and
1321 of the federal Patient Protection and Affordable | 9 | | Care Act of 2010 (Public Law 111-148), as amended by the | 10 | | federal Health Care and Education Reconciliation Act of 2010 | 11 | | (Public Law 111-152), and any amendments thereto, or | 12 | | regulations or guidance issued thereunder (collectively, "the | 13 | | Federal Act"), unless, in addition to the information required | 14 | | under subsection (a) of this Section, the following information | 15 | | is available to the consumer at the time he or she is comparing | 16 | | health care plans and their premiums: | 17 | | (1) With respect to prescription drug benefits, the | 18 | | most recently published formulary where a consumer can view | 19 | | in one location covered prescription drugs; information on | 20 | | tiering and the cost-sharing structure for each tier; and | 21 | | information about how a consumer can obtain specific | 22 | | copayment amounts or coinsurance percentages for a | 23 | | specific qualified health plan before enrolling in that | 24 | | plan. This information shall clearly identify the | 25 | | qualified health plan to which it applies. | 26 | | (2) The most recently published provider directory |
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| 1 | | where a consumer can view the provider network that applies | 2 | | to each qualified health plan and information about each | 3 | | provider, including location, contact information, | 4 | | specialty, medical group, if any, any institutional | 5 | | affiliation, and whether the provider is accepting new | 6 | | patients. The information shall clearly identify the | 7 | | qualified health plan to which it applies. | 8 | | In the event of an inconsistency between any separate | 9 | | written disclosure
statement and the enrollee contract or | 10 | | certificate, the terms of the enrollee
contract or certificate | 11 | | shall control.
| 12 | | (b) Upon written request, a health care plan shall provide | 13 | | to enrollees a
description of the financial relationships | 14 | | between the health care plan and any
health care provider
and, | 15 | | if requested, the percentage
of copayments, deductibles, and | 16 | | total premiums spent on healthcare related
expenses and the | 17 | | percentage of
copayments, deductibles, and total premiums | 18 | | spent on other expenses, including
administrative expenses,
| 19 | | except that no health care plan shall be required to disclose | 20 | | specific provider
reimbursement.
| 21 | | (c) A participating health care provider shall provide all | 22 | | of the
following, where applicable, to enrollees upon request:
| 23 | | (1) Information related to the health care provider's | 24 | | educational
background,
experience, training, specialty, | 25 | | and board certification, if applicable.
| 26 | | (2) The names of licensed facilities on the provider |
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| 1 | | panel where
the health
care provider presently has | 2 | | privileges for the treatment, illness, or
procedure
that is | 3 | | the subject of the request.
| 4 | | (3) Information regarding the health care provider's | 5 | | participation
in
continuing education programs and | 6 | | compliance with any licensure,
certification, or | 7 | | registration requirements, if applicable.
| 8 | | (d) A health care plan shall provide the information | 9 | | required to be
disclosed under this Act upon enrollment and | 10 | | annually thereafter in a legible
and understandable format. The | 11 | | Department
shall promulgate rules to establish the format | 12 | | based, to the extent
practical,
on
the standards developed for | 13 | | supplemental insurance coverage under Title XVIII
of
the | 14 | | federal Social Security Act as a guide, so that a person can | 15 | | compare the
attributes of the various health care plans.
| 16 | | (e) The written disclosure requirements of this Section may | 17 | | be met by
disclosure to one enrollee in a household.
| 18 | | (f) Each issuer of qualified health plans for sale directly | 19 | | to consumers through the health insurance marketplace | 20 | | operating in the State shall make the information described in | 21 | | subsection (a) of this Section, for each qualified health plan | 22 | | that it offers, available and accessible to the general public | 23 | | on the company's Internet website and through other means for | 24 | | individuals without access to the Internet. | 25 | | (g) The Department shall ensure that State-operated | 26 | | Internet websites, in addition to the Internet website for the |
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| 1 | | health insurance marketplace established in this State in | 2 | | accordance with the Federal Act and its implementing | 3 | | regulations, prominently provide links to Internet-based | 4 | | materials and tools to help consumers be informed purchasers of | 5 | | health care plans. | 6 | | (h) Nothing in this Section shall be interpreted or | 7 | | implemented in a manner not consistent with the Federal Act. | 8 | | This Section shall apply to all qualified health plans offered | 9 | | for sale directly to consumers through the health insurance | 10 | | marketplace operating in this State for any coverage year | 11 | | beginning on or after January 1, 2015. | 12 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 13 | | (215 ILCS 134/45.1 new) | 14 | | Sec. 45.1. Medical exceptions procedures required. | 15 | | (a) Every health carrier that offers a qualified health | 16 | | plan, as defined in the federal Patient Protection and | 17 | | Affordable Care Act of 2010 (Public Law 111-148), as amended by | 18 | | the federal Health Care and Education Reconciliation Act of | 19 | | 2010 (Public Law 111-152), and any amendments thereto, or | 20 | | regulations or guidance issued under those Acts (collectively, | 21 | | "the Federal Act"), directly to consumers in this State shall | 22 | | establish and maintain a medical exceptions process that allows | 23 | | covered persons or their authorized representatives to request | 24 | | any clinically appropriate prescription drug when (1) the drug | 25 | | is not covered based on the health benefit plan's formulary; |
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| 1 | | (2) the health benefit plan is discontinuing coverage of the | 2 | | drug on the plan's formulary for reasons other than safety or | 3 | | other than because the prescription drug has been withdrawn | 4 | | from the market by the drug's manufacturer; (3) the | 5 | | prescription drug alternatives required to be used in | 6 | | accordance with a step therapy requirement (A) has been | 7 | | ineffective in the treatment of the enrollee's disease or | 8 | | medical condition or, based on both sound clinical evidence and | 9 | | medical and scientific evidence, the known relevant physical or | 10 | | mental characteristics of the enrollee, and the known | 11 | | characteristics of the drug regimen, is likely to be | 12 | | ineffective or adversely affect the drug's effectiveness or | 13 | | patient compliance or (B) has caused or, based on sound medical | 14 | | evidence, is likely to cause an adverse reaction or harm to the | 15 | | enrollee; or (4) the number of doses available under a dose | 16 | | restriction for the prescription drug (A) has been ineffective | 17 | | in the treatment of the enrollee's disease or medical condition | 18 | | or (B) based on both sound clinical evidence and medical and | 19 | | scientific evidence, the known relevant physical and mental | 20 | | characteristics of the enrollee, and known characteristics of | 21 | | the drug regimen, is likely to be ineffective or adversely | 22 | | affect the drug's effective or patient compliance. | 23 | | (b) The health carrier's established medical exceptions | 24 | | procedures must require, at a minimum, the following: | 25 | | (1) Any request for approval of coverage made verbally | 26 | | or in writing (regardless of whether made using a paper or |
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| 1 | | electronic form or some other writing) at any time shall be | 2 | | reviewed by appropriate health care professionals. | 3 | | (2) The health carrier must, within 72 hours after | 4 | | receipt of a request made under subsection (a) of this | 5 | | Section, either approve or deny the request. In the case of | 6 | | a denial, the health carrier shall provide the covered | 7 | | person or the covered person's authorized representative | 8 | | and the covered person's prescribing provider with the | 9 | | reason for the denial, an alternative covered medication, | 10 | | if applicable, and information regarding the procedure for | 11 | | submitting an appeal to the denial. | 12 | | (3) In the case of an expedited coverage determination, | 13 | | the health carrier must either approve or deny the request | 14 | | within 24 hours after receipt of the request. In the case | 15 | | of a denial, the health carrier shall provide the covered | 16 | | person or the covered person's authorized representative | 17 | | and the covered person's prescribing provider with the | 18 | | reason for the denial, an alternative covered medication, | 19 | | if applicable, and information regarding the procedure for | 20 | | submitting an appeal to the denial. | 21 | | (c) Notwithstanding any other provision of this Section, | 22 | | nothing in this Section shall be interpreted or implemented in | 23 | | a manner not consistent with the Federal Act. | 24 | | (215 ILCS 134/45.2 new) | 25 | | Sec. 45.2. Prior authorization form; prescription |
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| 1 | | benefits. | 2 | | (a) Notwithstanding any other provision of law, on and | 3 | | after January 1, 2015, a health insurer that provides | 4 | | prescription drug benefits must, within 72 hours after receipt | 5 | | of a paper or electronic prior authorization form from a | 6 | | prescribing provider or pharmacist, either approve or deny the | 7 | | prior authorization. In the case of a denial, the insurer shall | 8 | | provide the prescriber with the reason for the denial, an | 9 | | alternative covered medication, if applicable, and information | 10 | | regarding the denial. | 11 | | In the case of an expedited coverage determination, the | 12 | | health insurer must either approve or deny the prior | 13 | | authorization within 24 hours after receipt of the paper or | 14 | | electronic prior authorization form. In the case of a denial, | 15 | | the health insurer shall provide the prescriber with the reason | 16 | | for the denial, an alternative covered medication, if | 17 | | applicable, and information regarding the procedure for | 18 | | submitting an appeal to the denial. | 19 | | (b) This Section does not apply to plans for beneficiaries | 20 | | of Medicare or Medicaid. | 21 | | (c) For the purposes of this Section: | 22 | | "Pharmacist" has the same meaning as set forth in the | 23 | | Pharmacy Practice Act. | 24 | | "Prescribing provider" includes a provider authorized to | 25 | | write a prescription, as described in subsection (e) of Section | 26 | | 3 of the Pharmacy Practice Act, to treat a medical condition of |
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| 1 | | an insured.
| 2 | | Section 99. Effective date. This Act takes effect upon | 3 | | becoming law.
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