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Rep. Laura Fine
Filed: 4/20/2015
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1 | | AMENDMENT TO HOUSE BILL 3549
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2 | | AMENDMENT NO. ______. Amend House Bill 3549 by replacing |
3 | | everything after the enacting clause with the following:
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4 | | "Section 5. The Managed Care Reform and Patient Rights Act |
5 | | is amended by changing Section 45.1 as follows: |
6 | | (215 ILCS 134/45.1) |
7 | | Sec. 45.1. Medical exceptions procedures required. |
8 | | (a) Notwithstanding any other provision of law, on or after |
9 | | the effective date of this amendatory Act of the 99th General |
10 | | Assembly, every insurer licensed in this State to sell a policy |
11 | | of group or individual accident and health insurance or a |
12 | | health benefits plan shall Every health carrier that offers a |
13 | | qualified health plan, as defined in the federal Patient |
14 | | Protection and Affordable Care Act of 2010 (Public Law |
15 | | 111-148), as amended by the federal Health Care and Education |
16 | | Reconciliation Act of 2010 (Public Law 111-152), and any |
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1 | | amendments thereto, or regulations or guidance issued under |
2 | | those Acts (collectively, "the Federal Act"), directly to |
3 | | consumers in this State shall establish and maintain a medical |
4 | | exceptions process that allows covered persons or their |
5 | | authorized representatives to request any clinically |
6 | | appropriate prescription drug when (1) the drug is not covered |
7 | | based on the health benefit plan's formulary; (2) the health |
8 | | benefit plan is discontinuing coverage of the drug on the |
9 | | plan's formulary for reasons other than safety or other than |
10 | | because the prescription drug has been withdrawn from the |
11 | | market by the drug's manufacturer; (3) the prescription drug |
12 | | alternatives required to be used in accordance with a step |
13 | | therapy requirement (A) has been ineffective in the treatment |
14 | | of the enrollee's disease or medical condition or, based on |
15 | | both sound clinical evidence and medical and scientific |
16 | | evidence, the known relevant physical or mental |
17 | | characteristics of the enrollee, and the known characteristics |
18 | | of the drug regimen, is likely to be ineffective or adversely |
19 | | affect the drug's effectiveness or patient compliance or (B) |
20 | | has caused or, based on sound medical evidence, is likely to |
21 | | cause an adverse reaction or harm to the enrollee; or (4) the |
22 | | number of doses available under a dose restriction for the |
23 | | prescription drug (A) has been ineffective in the treatment of |
24 | | the enrollee's disease or medical condition or (B) based on |
25 | | both sound clinical evidence and medical and scientific |
26 | | evidence, the known relevant physical and mental |
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1 | | characteristics of the enrollee, and known characteristics of |
2 | | the drug regimen, is likely to be ineffective or adversely |
3 | | affect the drug's effective or patient compliance. |
4 | | (b) The health carrier's established medical exceptions |
5 | | procedures must require, at a minimum, the following: |
6 | | (1) Any request for approval of coverage made verbally |
7 | | or in writing (regardless of whether made using a paper or |
8 | | electronic form or some other writing) at any time shall be |
9 | | reviewed by appropriate health care professionals. |
10 | | (2) The health carrier must, within 72 hours after |
11 | | receipt of a request made under subsection (a) of this |
12 | | Section, either approve or deny the request. In the case of |
13 | | a denial, the health carrier shall provide the covered |
14 | | person or the covered person's authorized representative |
15 | | and the covered person's prescribing provider with the |
16 | | reason for the denial, an alternative covered medication, |
17 | | if applicable, and information regarding the procedure for |
18 | | submitting an appeal to the denial. |
19 | | (3) In the case of an expedited coverage determination, |
20 | | the health carrier must either approve or deny the request |
21 | | within 24 hours after receipt of the request. In the case |
22 | | of a denial, the health carrier shall provide the covered |
23 | | person or the covered person's authorized representative |
24 | | and the covered person's prescribing provider with the |
25 | | reason for the denial, an alternative covered medication, |
26 | | if applicable, and information regarding the procedure for |