Illinois General Assembly - Full Text of HB0711
Illinois General Assembly

  Bills & Resolutions  
  Compiled Statutes  
  Public Acts  
  Legislative Reports  
  IL Constitution  
  Legislative Guide  
  Legislative Glossary  

 Search By Number
 (example: HB0001)
Search Tips

Search By Keyword

Full Text of HB0711  102nd General Assembly

HB0711ham001 102ND GENERAL ASSEMBLY

Rep. Greg Harris

Filed: 4/7/2021

 

 


 

 


 
10200HB0711ham001LRB102 10190 BMS 24729 a

1
AMENDMENT TO HOUSE BILL 711

2    AMENDMENT NO. ______. Amend House Bill 711 by replacing
3everything after the enacting clause with the following:
 
4    "Section 1. Short title. This Act may be cited as the Prior
5Authorization Reform Act.
 
6    Section 5. Purpose. The General Assembly hereby finds and
7declares that:
8        (1) the health care professional-patient relationship
9    is paramount and should not be subject to third-party
10    intrusion;
11        (2) prior authorization programs shall be subject to
12    member coverage agreements and medical policies but shall
13    not hinder the independent medical judgment of a physician
14    or health care provider; and
15        (3) prior authorization programs must be transparent
16    to ensure a fair and consistent process for health care

 

 

10200HB0711ham001- 2 -LRB102 10190 BMS 24729 a

1    providers and patients.
 
2    Section 10. Applicability; scope. This Act applies to
3health insurance coverage as defined in the Illinois Health
4Insurance Portability and Accountability Act, and policies
5issued or delivered in this State to the Department of
6Healthcare and Family Services and providing coverage to
7persons who are enrolled under Article V of the Illinois
8Public Aid Code or under the Children's Health Insurance
9Program Act, amended, delivered, issued, or renewed on or
10after the effective date of this Act, with the exception of
11employee or employer self-insured health benefit plans under
12the federal Employee Retirement Income Security Act of 1974,
13health care provided pursuant to the Workers' Compensation Act
14or the Workers' Occupational Diseases Act, and State employee
15health plans. This Act does not diminish a health care plan's
16duties and responsibilities under other federal or State law
17or rules promulgated thereunder.
 
18    Section 15. Definitions. As used in this Act:
19    "Adverse determination" has the meaning given to that term
20in Section 10 of the Health Carrier External Review Act.
21    "Appeal" means a formal request, either orally or in
22writing, to reconsider an adverse determination.
23    "Approval" means a determination by a utilization review
24organization that a health care service has been reviewed and,

 

 

10200HB0711ham001- 3 -LRB102 10190 BMS 24729 a

1based on the information provided, satisfies the utilization
2review organization's requirements for medical necessity and
3appropriateness.
4    "Clinical review criteria" has the meaning given to that
5term in Section 10 of the Health Carrier External Review Act.
6    "Department" means the Department of Insurance.
7    "Emergency medical condition" has the meaning given to
8that term in Section 10 of the Managed Care Reform and Patient
9Rights Act.
10    "Emergency services" has the meaning given to that term in
11federal health insurance reform requirements for the group and
12individual health insurance markets, 45 CFR 147.138.
13    "Enrollee" has the meaning given to that term in Section
1410 of the Managed Care Reform and Patient Rights Act.
15    "Health care professional" has the meaning given to that
16term in Section 10 of the Managed Care Reform and Patient
17Rights Act.
18    "Health care provider" has the meaning given to that term
19in Section 10 of the Managed Care Reform and Patient Rights
20Act.
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

 

 

10200HB0711ham001- 4 -LRB102 10190 BMS 24729 a

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" means a health care professional
7exercising prudent clinical judgment would provide care to a
8patient for the purpose of preventing, diagnosing, or treating
9an illness, injury, disease, or its symptoms and that are: (i)
10in accordance with generally accepted standards of medical
11practice; (ii) clinically appropriate in terms of type,
12frequency, extent, site, and duration and are considered
13effective for the patient's illness, injury, or disease; and
14(iii) not primarily for the convenience of the patient,
15treating physician, other health care professional, caregiver,
16family member, or other interested party, but focused on what
17is best for the patient's health outcome.
18    "Physician" means a person licensed under the Medical
19Practice Act of 1987 to practice medicine in all its branches.
20    "Prior authorization" means the process by which
21utilization review organizations determine the medical
22necessity and medical appropriateness of otherwise covered
23health care services before the rendering of such health care
24services. "Prior authorization" includes any utilization
25review organization's requirement that an enrollee, health
26care professional, or health care provider notify the

 

 

10200HB0711ham001- 5 -LRB102 10190 BMS 24729 a

1utilization review organization before, at the time of, or
2concurrent to providing a health care service.
3    "Urgent health care service" means a health care service
4with respect to which the application of the time periods for
5making a non-expedited prior authorization that in the opinion
6of a health care professional with knowledge of the enrollee's
7medical condition:
8        (1) could seriously jeopardize the life or health of
9    the enrollee or the ability of the enrollee to regain
10    maximum function; or
11        (2) could subject the enrollee to severe pain that
12    cannot be adequately managed without the care or treatment
13    that is the subject of the utilization review.
14    "Urgent health care service" does not include emergency
15services.
16    "Utilization review organization" has the meaning given to
17that term in 50 Ill. Adm. Code 4520.30.
 
18    Section 20. Disclosure and review of prior authorization
19requirements.
20    (a) A health insurance issuer shall maintain a complete
21list of services for which prior authorization is required,
22including for all services where prior authorization is
23performed by an entity under contract with the health
24insurance issuer.
25    (b) A health insurance issuer shall make any current prior

 

 

10200HB0711ham001- 6 -LRB102 10190 BMS 24729 a

1authorization requirements and restrictions, including the
2written clinical review criteria, readily accessible and
3conspicuously posted on its website to enrollees, health care
4professionals, and health care providers. Content published by
5a third party and licensed for use by a health insurance issuer
6or its contracted utilization review organization may be made
7available through the health insurance issuer's or its
8contracted utilization review organization's secure,
9password-protected website so long as the access requirements
10of the website do not unreasonably restrict access.
11Requirements shall be described in detail, written in easily
12understandable language, and readily available to the health
13care professional and health care provider at the point of
14care. The website shall indicate for each service subject to
15prior authorization:
16        (1) when prior authorization became required for
17    policies issued or delivered in Illinois, including the
18    effective date or dates and the termination date or dates,
19    if applicable, in Illinois;
20        (2) the date the Illinois-specific requirement was
21    listed on the health insurance issuer's or its contracted
22    utilization review organization's website; and
23        (3) where applicable, the date that prior
24    authorization was removed for Illinois.
25    (c) The clinical review criteria must:
26        (1) be based on nationally recognized, generally

 

 

10200HB0711ham001- 7 -LRB102 10190 BMS 24729 a

1    accepted standards except where State law provides its own
2    standard;
3        (2) be developed in accordance with the current
4    standards of a national medical accreditation entity;
5        (3) ensure quality of care and access to needed health
6    care services;
7        (4) be evidence-based;
8        (5) be sufficiently flexible to allow deviations from
9    norms when justified on a case-by-case basis; and
10        (6) be evaluated and updated, if necessary, at least
11    annually.
12    (d) A health insurance issuer shall not deny a claim for
13failure to obtain prior authorization if the prior
14authorization requirement was not in effect on the date of
15service on the claim.
16    (e) Neither a health insurance issuer nor a contracted
17utilization review organization shall deny prior authorization
18of a health care service solely based on the grounds that:
19        (1) no independently developed, evidence-based
20    standards can be derived from reliable scientific evidence
21    or documents published by professional societies;
22        (2) evidence-based standards conflict; or
23        (3) evidence-based standards from expert consensus
24    panels do not exist.
25    (f) A health insurance issuer or its contracted
26utilization review organization shall not deem as incidental

 

 

10200HB0711ham001- 8 -LRB102 10190 BMS 24729 a

1or deny supplies or health care services that are routinely
2used as part of a health care service when:
3        (1) an associated health care service has received
4    prior authorization; or
5        (2) prior authorization for the health care service is
6    not required.
7    (g) If a health insurance issuer intends either to
8implement a new prior authorization requirement or restriction
9or amend an existing requirement or restriction, the health
10insurance issuer shall provide enrollees, contracted health
11care professionals, and contracted health care providers of
12enrollees written notice of the new or amended requirement or
13amendment no less than 60 days before the requirement or
14restriction is implemented. The written notice may be provided
15in an electronic format, including email or facsimile, if the
16enrollee, health care professional, or health care provider
17has agreed in advance to receive notices electronically. The
18health insurance issuer shall ensure that the new or amended
19requirement is not implemented unless the health insurance
20issuer's or its contracted utilization review organization's
21website has been updated to reflect the new or amended
22requirement or restriction.
23    (h) Entities utilizing prior authorization shall make
24statistics available regarding prior authorization approvals
25and denials on their website in a readily accessible format.
26The categories must be updated quarterly and include all of

 

 

10200HB0711ham001- 9 -LRB102 10190 BMS 24729 a

1the following information:
2        (1) a list of all health care services, including
3    medications, that are subject to prior authorization;
4        (2) the total number of prior authorization requests
5    received;
6        (3) the number of prior authorization requests denied
7    during the previous plan year by the health insurance
8    issuer or its contracted utilization review organization
9    with respect to each service described in paragraph (1)
10    and the top 5 reasons for denial;
11        (4) the number of requests described in paragraph (3)
12    that were appealed, the number of the appealed requests
13    that upheld the adverse determination, and the number of
14    appealed requests that reversed the adverse determination;
15        (5) the average time between submission and response;
16    and
17        (6) any other information as the Director determines
18    appropriate.
 
19    Section 25. Health insurance issuer's and its contracted
20utilization review organization's obligations with respect to
21prior authorizations in nonurgent circumstances. If a health
22insurance issuer requires prior authorization of a health care
23service, the health insurance issuer or its contracted
24utilization review organization must make an approval or
25adverse determination and notify the enrollee, the enrollee's

 

 

10200HB0711ham001- 10 -LRB102 10190 BMS 24729 a

1health care professional, and the enrollee's health care
2provider of the approval or adverse determination as required
3by applicable law, but no later than 72 hours after obtaining
4all necessary information to make the approval or adverse
5determination. As used in this Section, "necessary
6information" includes the results of any face-to-face clinical
7evaluation or second opinion that may be required.
 
8    Section 30. Health insurance issuer's and its contracted
9utilization review organization's obligations with respect to
10prior authorizations concerning urgent health care services.
11    (a) A health insurance issuer or its contracted
12utilization review organization must render an approval or
13adverse determination concerning urgent care services and any
14services for any current or prospective resident of a skilled
15nursing facility and notify the enrollee, the enrollee's
16health care professional, and the enrollee's health care
17provider of that approval or adverse determination not later
18than 24 hours after receiving all information needed to
19complete the review of the requested health care services.
20    (b) To facilitate the rendering of a prior authorization
21determination in conformance with this Section, a health
22insurance issuer or its contracted utilization review
23organization must establish and provide access to a hotline
24that is staffed 24 hours per day, 7 days per week by
25appropriately trained and licensed clinical personnel who have

 

 

10200HB0711ham001- 11 -LRB102 10190 BMS 24729 a

1access to physicians for consultation, designated by the plan
2to make such determinations for prior authorization concerning
3urgent care services.
 
4    Section 35. Health insurance issuer's and its contracted
5utilization review organization's obligations with respect to
6prior authorization concerning emergency health care services.
7    (a) A health insurance issuer shall cover emergency health
8care services necessary to screen and stabilize an enrollee.
9If a health care professional or health care provider
10certifies in writing to a health insurance issuer within 72
11hours after an enrollee's admission that the enrollee's
12condition required emergency health care services, that
13certification shall create a presumption that the emergency
14health care services were medically necessary and such
15presumption may be rebutted only if the health insurance
16issuer or its contracted utilization review organization can
17establish, with clear and convincing evidence, that the
18emergency health care services were not medically necessary.
19    (b) If an enrollee receives an emergency health care
20service that requires immediate post-evaluation or
21post-stabilization services, a health insurance issuer or its
22contracted utilization review organization shall make a prior
23authorization determination within 60 minutes after receiving
24a request; if the prior authorization determination is not
25made within 60 minutes, the services shall be deemed approved.
 

 

 

10200HB0711ham001- 12 -LRB102 10190 BMS 24729 a

1    Section 40. Personnel qualified to make adverse
2determinations of a prior authorization request. A health
3insurance issuer or its contracted utilization review
4organization must ensure that all adverse determinations are
5made by a physician when the request is by a physician or a
6representative of a physician. The physician must:
7        (1) possess a current and valid nonrestricted license
8    to practice medicine in all its branches in any United
9    States jurisdiction;
10        (2) practice in the same or similar specialty as the
11    physician who typically manages the medical condition or
12    disease or provides the health care service involved in
13    the request; and
14        (3) have experience treating patients with the medical
15    condition or disease for which the health care service is
16    being requested.
17    Notwithstanding the foregoing, a licensed health care
18professional who satisfies the requirements of this Section
19may make an adverse determination of a prior authorization
20request submitted by a health care professional licensed in
21the same profession.
 
22    Section 45. Consultation before issuing an adverse
23determination of a prior authorization. If a health insurance
24issuer or its contracted utilization review organization is

 

 

10200HB0711ham001- 13 -LRB102 10190 BMS 24729 a

1questioning the medical necessity of a health care service,
2the health insurance issuer or its contracted utilization
3review organization must notify the enrollee's health care
4professional and health care provider that medical necessity
5is being questioned. Before issuing an adverse determination,
6the enrollee's health care professional and health care
7provider must have the opportunity to discuss the medical
8necessity of the health care service on the telephone or by
9other agreeable method with the health care professional who
10will be responsible for issuing the prior authorization
11determination of the health care service under review.
 
12    Section 50. Requirements applicable to the physician who
13can review consultations and appeals. A health insurance
14issuer or its contracted utilization review organization must
15ensure that all appeals are reviewed by a physician. The
16physician must:
17        (1) possess a current and valid nonrestricted license
18    to practice medicine in any United States jurisdiction;
19        (2) be currently in active practice in the same or
20    similar specialty as a physician who typically manages the
21    medical condition or disease;
22        (3) be knowledgeable of, and have experience
23    providing, the health care services under appeal;
24        (4) not have been directly involved in making the
25    adverse determination; and

 

 

10200HB0711ham001- 14 -LRB102 10190 BMS 24729 a

1        (5) consider all known clinical aspects of the health
2    care service under review, including, but not limited to,
3    a review of all pertinent medical records provided to the
4    health insurance issuer or its contracted utilization
5    review organization by the enrollee's health care
6    professional or health care provider and any medical
7    literature provided to the health insurance issuer or its
8    contracted utilization review organization by the health
9    care professional or health care provider.
 
10    Section 55. Review of prior authorization requirements. A
11health insurance issuer shall periodically review its prior
12authorization requirements and consider removal of prior
13authorization requirements:
14        (1) where a medication or procedure prescribed is
15    customary and properly indicated or is a treatment for the
16    clinical indication as supported by peer-reviewed medical
17    publications; or
18        (2) for patients currently managed with an established
19    treatment regimen.
 
20    Section 60. Denial.
21    (a) The health insurance issuer or its contracted
22utilization review organization may not revoke, limit,
23condition, or restrict a previously issued prior authorization
24approval.

 

 

10200HB0711ham001- 15 -LRB102 10190 BMS 24729 a

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

 

 

10200HB0711ham001- 16 -LRB102 10190 BMS 24729 a

1    as used in this paragraph (5), "material" means a fact or
2    situation that is not merely technical in nature and
3    results or could result in a substantial change in the
4    situation.
 
5    Section 65. Length of prior authorization approval. A
6prior authorization approval shall be valid for the lesser of
712 months after the date the health care professional or
8health care provider receives the prior authorization approval
9or the length of treatment as determined by the patient's
10health care professional, and the approval period shall be
11effective regardless of any changes, including any changes in
12dosage for a prescription drug prescribed by the health care
13professional. This Section shall not apply to the prescription
14of benzodiazepines or Schedule II narcotic drugs, such as
15opioids. Except to the extent required by medical exceptions
16processes for prescription drugs, nothing in this Section
17shall require a policy to cover any care, treatment, or
18services for any health condition that the terms of coverage
19otherwise completely exclude from the policy's covered
20benefits without regard for whether the care, treatment, or
21services are medically necessary.
 
22    Section 70. Length of prior authorization approval for
23treatment for chronic or long-term conditions. If a health
24insurance issuer requires a prior authorization for a

 

 

10200HB0711ham001- 17 -LRB102 10190 BMS 24729 a

1recurring health care service or maintenance medication for
2the treatment of a chronic or long-term condition, the
3approval shall remain valid for the lesser of 12 months from
4the date the health care professional or health care provider
5receives the prior authorization approval or the length of the
6treatment as determined by the patient's health care
7professional. Except to the extent required by medical
8exceptions processes for prescription drugs, nothing in this
9Section shall require a policy to cover any care, treatment,
10or services for any health condition that the terms of
11coverage otherwise completely exclude from the policy's
12covered benefits without regard for whether the care,
13treatment, or services are medically necessary.
 
14    Section 75. Continuity of care for enrollees.
15    (a) On receipt of information documenting a prior
16authorization approval from the enrollee or from the
17enrollee's health care professional or health care provider, a
18health insurance issuer shall honor a prior authorization
19granted to an enrollee from a previous health insurance issuer
20or its contracted utilization review organization for at least
21the initial 90 days of an enrollee's coverage under a new
22health plan.
23    (b) During the time period described in subsection (a), a
24health insurance issuer or its contracted utilization review
25organization may perform its own review to grant a prior

 

 

10200HB0711ham001- 18 -LRB102 10190 BMS 24729 a

1authorization approval subject to the terms of the member's
2coverage agreement.
3    (c) If there is a change in coverage of or approval
4criteria for a previously authorized health care service, the
5change in coverage or approval criteria does not affect an
6enrollee who received prior authorization approval before the
7effective date of the change for the remainder of the
8enrollee's plan year.
9    (d) Except to the extent required by medical exceptions
10processes for prescription drugs, nothing in this Section
11shall require a policy to cover any care, treatment, or
12services for any health condition that the terms of coverage
13otherwise completely exclude from the policy's covered
14benefits without regard for whether the care, treatment, or
15services are medically necessary.
 
16    Section 80. Health care services deemed authorized if a
17health insurance issuer or its contracted utilization review
18organization fails to comply with the requirements of this
19Act. A failure by a health insurance issuer or its contracted
20utilization review organization to comply with the deadlines
21and other requirements specified in this Act shall result in
22any health care services subject to review to be automatically
23deemed authorized by the health insurance issuer or its
24contracted utilization review organization.
 

 

 

10200HB0711ham001- 19 -LRB102 10190 BMS 24729 a

1    Section 85. Severability. If any provision of this Act or
2its application to any person or circumstance is held invalid,
3the invalidity does not affect other provisions or
4applications of this Act that can be given effect without the
5invalid provision or application, and to this end the
6provisions of this Act are declared to be severable.
 
7    Section 90. Administration and enforcement.
8    (a) The Department shall enforce the provisions of this
9Act pursuant to the enforcement powers granted to it by law. To
10enforce the provisions of this Act, the Director is hereby
11granted specific authority to issue a cease and desist order
12or require a utilization review organization or health
13insurance issuer to submit a plan of correction for violations
14of this Act, or both, in accordance with the requirements and
15authority set forth in Section 85 of the Managed Care Reform
16and Patient Rights Act. Subject to the provisions of the
17Illinois Administrative Procedure Act, the Director may,
18pursuant to Section 403A of the Illinois Insurance Code,
19impose upon a utilization review organization or health
20insurance issuer an administrative fine not to exceed $250,000
21for failure to submit a requested plan of correction, failure
22to comply with its plan of correction, or repeated violations
23of this Act.
24    (b) Any person who believes that his or her utilization
25review organization or health insurance issuer is in violation

 

 

10200HB0711ham001- 20 -LRB102 10190 BMS 24729 a

1of the provisions of this Act may file a complaint with the
2Department. The Department shall review all complaints
3received and investigate all complaints that it deems to state
4a potential violation. The Department shall fairly,
5efficiently, and timely review and investigate complaints.
6Utilization review organizations found to be in violation of
7this Act shall be penalized in accordance with this Section.
8    (c) The Department of Healthcare and Family Services shall
9enforce the provisions of this Act as it applies to persons
10enrolled under Article V of the Illinois Public Aid Code or
11under the Children's Health Insurance Program Act.
 
12    Section 900. The Illinois Insurance Code is amended by
13changing Section 370g as follows:
 
14    (215 ILCS 5/370g)  (from Ch. 73, par. 982g)
15    Sec. 370g. Definitions. As used in this Article, the
16following definitions apply:
17    (a) "Health care services" means health care services or
18products rendered or sold by a provider within the scope of the
19provider's license or legal authorization. The term includes,
20but is not limited to, hospital, medical, surgical, dental,
21vision and pharmaceutical services or products.
22    (b) "Insurer" means an insurance company or a health
23service corporation authorized in this State to issue policies
24or subscriber contracts which reimburse for expenses of health

 

 

10200HB0711ham001- 21 -LRB102 10190 BMS 24729 a

1care services.
2    (c) "Insured" means an individual entitled to
3reimbursement for expenses of health care services under a
4policy or subscriber contract issued or administered by an
5insurer.
6    (d) "Provider" means an individual or entity duly licensed
7or legally authorized to provide health care services.
8    (e) "Noninstitutional provider" means any person licensed
9under the Medical Practice Act of 1987, as now or hereafter
10amended.
11    (f) "Beneficiary" means an individual entitled to
12reimbursement for expenses of or the discount of provider fees
13for health care services under a program where the beneficiary
14has an incentive to utilize the services of a provider which
15has entered into an agreement or arrangement with an
16administrator.
17    (g) "Administrator" means any person, partnership or
18corporation, other than an insurer or health maintenance
19organization holding a certificate of authority under the
20"Health Maintenance Organization Act", as now or hereafter
21amended, that arranges, contracts with, or administers
22contracts with a provider whereby beneficiaries are provided
23an incentive to use the services of such provider.
24    (h) "Emergency medical condition" has the meaning given to
25that term in Section 10 of the Managed Care Reform and Patient
26Rights Act. means a medical condition manifesting itself by

 

 

10200HB0711ham001- 22 -LRB102 10190 BMS 24729 a

1acute symptoms of sufficient severity (including severe pain)
2such that a prudent layperson, who possesses an average
3knowledge of health and medicine, could reasonably expect the
4absence of immediate medical attention to result in:
5        (1) placing the health of the individual (or, with
6    respect to a pregnant woman, the health of the woman or her
7    unborn child) in serious jeopardy;
8        (2) serious impairment to bodily functions; or
9        (3) serious dysfunction of any bodily organ or part.
10(Source: P.A. 91-617, eff. 1-1-00.)
 
11    Section 905. The Managed Care Reform and Patient Rights
12Act is amended by changing Sections 10 and 65 as follows:
 
13    (215 ILCS 134/10)
14    Sec. 10. Definitions.
15    "Adverse determination" means a determination by a health
16care plan under Section 45 or by a utilization review program
17under Section 85 that a health care service is not medically
18necessary.
19    "Clinical peer" means a health care professional who is in
20the same profession and the same or similar specialty as the
21health care provider who typically manages the medical
22condition, procedures, or treatment under review.
23    "Department" means the Department of Insurance.
24    "Emergency medical condition" means a medical condition

 

 

10200HB0711ham001- 23 -LRB102 10190 BMS 24729 a

1manifesting itself by acute symptoms of sufficient severity,
2regardless of the final diagnosis given, such that a prudent
3layperson, who possesses an average knowledge of health and
4medicine, could reasonably expect the absence of immediate
5medical attention to result in:
6        (1) placing the health of the individual (or, with
7    respect to a pregnant woman, the health of the woman or her
8    unborn child) in serious jeopardy;
9        (2) serious impairment to bodily functions;
10        (3) serious dysfunction of any bodily organ or part;
11        (4) inadequately controlled pain; or
12        (5) with respect to a pregnant woman who is having
13    contractions:
14            (A) inadequate time to complete a safe transfer to
15        another hospital before delivery; or
16            (B) a transfer to another hospital may pose a
17        threat to the health or safety of the woman or unborn
18        child.
19    "Emergency medical screening examination" means a medical
20screening examination and evaluation by a physician licensed
21to practice medicine in all its branches, or to the extent
22permitted by applicable laws, by other appropriately licensed
23personnel under the supervision of or in collaboration with a
24physician licensed to practice medicine in all its branches to
25determine whether the need for emergency services exists.
26    "Emergency services" means, with respect to an enrollee of

 

 

10200HB0711ham001- 24 -LRB102 10190 BMS 24729 a

1a health care plan, transportation services, including but not
2limited to ambulance services, and covered inpatient and
3outpatient hospital services furnished by a provider qualified
4to furnish those services that are needed to evaluate or
5stabilize an emergency medical condition. "Emergency services"
6does not refer to post-stabilization medical services.
7    "Enrollee" means any person and his or her dependents
8enrolled in or covered by a health care plan.
9    "Health care plan" means a plan, including, but not
10limited to, a health maintenance organization, a managed care
11community network as defined in the Illinois Public Aid Code,
12or an accountable care entity as defined in the Illinois
13Public Aid Code that receives capitated payments to cover
14medical services from the Department of Healthcare and Family
15Services, that establishes, operates, or maintains a network
16of health care providers that has entered into an agreement
17with the plan to provide health care services to enrollees to
18whom the plan has the ultimate obligation to arrange for the
19provision of or payment for services through organizational
20arrangements for ongoing quality assurance, utilization review
21programs, or dispute resolution. Nothing in this definition
22shall be construed to mean that an independent practice
23association or a physician hospital organization that
24subcontracts with a health care plan is, for purposes of that
25subcontract, a health care plan.
26    For purposes of this definition, "health care plan" shall

 

 

10200HB0711ham001- 25 -LRB102 10190 BMS 24729 a

1not include the following:
2        (1) indemnity health insurance policies including
3    those using a contracted provider network;
4        (2) health care plans that offer only dental or only
5    vision coverage;
6        (3) preferred provider administrators, as defined in
7    Section 370g(g) of the Illinois Insurance Code;
8        (4) employee or employer self-insured health benefit
9    plans under the federal Employee Retirement Income
10    Security Act of 1974;
11        (5) health care provided pursuant to the Workers'
12    Compensation Act or the Workers' Occupational Diseases
13    Act; and
14        (6) not-for-profit voluntary health services plans
15    with health maintenance organization authority in
16    existence as of January 1, 1999 that are affiliated with a
17    union and that only extend coverage to union members and
18    their dependents.
19    "Health care professional" means a physician, a registered
20professional nurse, or other individual appropriately licensed
21or registered to provide health care services.
22    "Health care provider" means any physician, hospital
23facility, facility licensed under the Nursing Home Care Act,
24long-term care facility as defined in Section 1-113 of the
25Nursing Home Care Act, or other person that is licensed or
26otherwise authorized to deliver health care services. Nothing

 

 

10200HB0711ham001- 26 -LRB102 10190 BMS 24729 a

1in this Act shall be construed to define Independent Practice
2Associations or Physician-Hospital Organizations as health
3care providers.
4    "Health care services" means any services included in the
5furnishing to any individual of medical care, or the
6hospitalization incident to the furnishing of such care, as
7well as the furnishing to any person of any and all other
8services for the purpose of preventing, alleviating, curing,
9or healing human illness or injury including behavioral
10health, mental health, home health, and pharmaceutical
11services and products.
12    "Medical director" means a physician licensed in any state
13to practice medicine in all its branches appointed by a health
14care plan.
15    "Person" means a corporation, association, partnership,
16limited liability company, sole proprietorship, or any other
17legal entity.
18    "Physician" means a person licensed under the Medical
19Practice Act of 1987.
20    "Post-stabilization medical services" means health care
21services provided to an enrollee that are furnished in a
22licensed hospital by a provider that is qualified to furnish
23such services, and determined to be medically necessary and
24directly related to the emergency medical condition following
25stabilization.
26    "Stabilization" means, with respect to an emergency

 

 

10200HB0711ham001- 27 -LRB102 10190 BMS 24729 a

1medical condition, to provide such medical treatment of the
2condition as may be necessary to assure, within reasonable
3medical probability, that no material deterioration of the
4condition is likely to result.
5    "Utilization review" means the evaluation of the medical
6necessity, appropriateness, and efficiency of the use of
7health care services, procedures, and facilities.
8    "Utilization review program" means a program established
9by a person to perform utilization review.
10(Source: P.A. 101-452, eff. 1-1-20.)
 
11    (215 ILCS 134/65)
12    Sec. 65. Emergency services prior to stabilization.
13    (a) A health care plan that provides or that is required by
14law to provide coverage for emergency services shall provide
15coverage such that payment under this coverage is not
16dependent upon whether the services are performed by a plan or
17non-plan health care provider and without regard to prior
18authorization. This coverage shall be at the same benefit
19level as if the services or treatment had been rendered by the
20health care plan physician licensed to practice medicine in
21all its branches or health care provider.
22    (b) Prior authorization or approval by the plan shall not
23be required for emergency services.
24    (c) Coverage and payment shall only be retrospectively
25denied under the following circumstances:

 

 

10200HB0711ham001- 28 -LRB102 10190 BMS 24729 a

1        (1) upon reasonable determination that the emergency
2    services claimed were never performed;
3        (2) upon timely determination that the emergency
4    evaluation and treatment were rendered to an enrollee who
5    sought emergency services and whose circumstance did not
6    meet the definition of emergency medical condition;
7        (3) upon determination that the patient receiving such
8    services was not an enrollee of the health care plan; or
9        (4) upon material misrepresentation by the enrollee or
10    health care provider; "material" means a fact or situation
11    that is not merely technical in nature and results or
12    could result in a substantial change in the situation.
13    (d) When an enrollee presents to a hospital seeking
14emergency services, the determination as to whether the need
15for those services exists shall be made for purposes of
16treatment by a physician licensed to practice medicine in all
17its branches or, to the extent permitted by applicable law, by
18other appropriately licensed personnel under the supervision
19of or in collaboration with a physician licensed to practice
20medicine in all its branches. The physician or other
21appropriate personnel shall indicate in the patient's chart
22the results of the emergency medical screening examination.
23    (e) The appropriate use of the 911 emergency telephone
24system or its local equivalent shall not be discouraged or
25penalized by the health care plan when an emergency medical
26condition exists. This provision shall not imply that the use

 

 

10200HB0711ham001- 29 -LRB102 10190 BMS 24729 a

1of 911 or its local equivalent is a factor in determining the
2existence of an emergency medical condition.
3    (f) The medical director's or his or her designee's
4determination of whether the enrollee meets the standard of an
5emergency medical condition shall be based solely upon the
6presenting symptoms documented in the medical record at the
7time care was sought. Only a clinical peer may make an adverse
8determination.
9    (g) Nothing in this Section shall prohibit the imposition
10of deductibles, copayments, and co-insurance. Nothing in this
11Section alters the prohibition on billing enrollees contained
12in the Health Maintenance Organization Act.
13    (h) This Section shall apply to the types of companies
14subject to Section 155.36 of the Illinois Insurance Code.
15(Source: P.A. 91-617, eff. 1-1-00.)
 
16    Section 910. The Illinois Public Aid Code is amended by
17adding Section 5-5.12d as follows:
 
18    (305 ILCS 5/5-5.12d new)
19    Sec. 5-5.12d. Managed care organization prior
20authorization of health care services.
21    (a) As used in this Section, "health care service" has the
22meaning given to that term in the Prior Authorization Reform
23Act.
24    (b) Notwithstanding any other provision of law to the

 

 

10200HB0711ham001- 30 -LRB102 10190 BMS 24729 a

1contrary, all managed care organizations shall comply with the
2requirements of the Prior Authorization Reform Act.
 
3    Section 999. Effective date. This Act takes effect January
41, 2022.".