Illinois General Assembly - Full Text of HB0711
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Full Text of HB0711  102nd General Assembly

HB0711ham002 102ND GENERAL ASSEMBLY

Rep. Greg Harris

Filed: 4/20/2021

 

 


 

 


 
10200HB0711ham002LRB102 10190 BMS 25668 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

 

 

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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,
15employee, unit of local government, or school district health
16plans. This Act does not diminish a health care plan's duties
17and responsibilities under other federal or State law or rules
18promulgated thereunder. This Act is not intended to alter or
19impede the provisions of any consent decree or judicial order
20to which the State or any of its agencies is a party.
 
21    Section 15. Definitions. As used in this Act:
22    "Adverse determination" has the meaning given to that term
23in Section 10 of the Health Carrier External Review Act.
24    "Appeal" means a formal request, either orally or in

 

 

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1writing, to reconsider an adverse determination.
2    "Approval" means a determination by a health insurance
3issuer or its contracted utilization review organization that
4a health care service has been reviewed and, based on the
5information provided, satisfies the health insurance issuer's
6or its contracted utilization review organization's
7requirements for medical necessity and appropriateness.
8    "Clinical review criteria" has the meaning given to that
9term in Section 10 of the Health Carrier External Review Act.
10    "Department" means the Department of Insurance.
11    "Emergency medical condition" has the meaning given to
12that term in Section 10 of the Managed Care Reform and Patient
13Rights Act.
14    "Emergency services" has the meaning given to that term in
15federal health insurance reform requirements for the group and
16individual health insurance markets, 45 CFR 147.138.
17    "Enrollee" has the meaning given to that term in Section
1810 of the Managed Care Reform and Patient Rights Act.
19    "Health care professional" has the meaning given to that
20term in Section 10 of the Managed Care Reform and Patient
21Rights Act.
22    "Health care provider" has the meaning given to that term
23in Section 10 of the Managed Care Reform and Patient Rights
24Act, except that facilities licensed under the Nursing Home
25Care Act and long-term care facilities as defined in Section
261-113 of the Nursing Home Care Act are excluded from this Act.

 

 

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1    "Health care service" means any services or level of
2services included in the furnishing to an individual of
3medical care or the hospitalization incident to the furnishing
4of such care, as well as the furnishing to any person of any
5other services for the purpose of preventing, alleviating,
6curing, or healing human illness or injury, including
7behavioral health, mental health, home health, and
8pharmaceutical services and products.
9    "Health insurance issuer" has the meaning given to that
10term in Section 5 of the Illinois Health Insurance Portability
11and Accountability Act.
12    "Medically necessary" means a health care professional
13exercising prudent clinical judgment would provide care to a
14patient for the purpose of preventing, diagnosing, or treating
15an illness, injury, disease, or its symptoms and that are: (i)
16in accordance with generally accepted standards of medical
17practice; (ii) clinically appropriate in terms of type,
18frequency, extent, site, and duration and are considered
19effective for the patient's illness, injury, or disease; and
20(iii) not primarily for the convenience of the patient,
21treating physician, other health care professional, caregiver,
22family member, or other interested party, but focused on what
23is best for the patient's health outcome.
24    "Physician" means a person licensed under the Medical
25Practice Act of 1987 or licensed under the laws of another
26state to practice medicine in all its branches.

 

 

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1    "Prior authorization" means the process by which health
2insurance issuers or their contracted utilization review
3organizations determine the medical necessity and medical
4appropriateness of otherwise covered health care services
5before the rendering of such health care services. "Prior
6authorization" includes any health insurance issuer's or its
7contracted utilization review organization's requirement that
8an enrollee, health care professional, or health care provider
9notify the health insurance issuer or its contracted
10utilization review organization before, at the time of, or
11concurrent to providing a health care service.
12    "Urgent health care service" means a health care service
13with respect to which the application of the time periods for
14making a non-expedited prior authorization that in the opinion
15of a health care professional with knowledge of the enrollee's
16medical condition:
17        (1) could seriously jeopardize the life or health of
18    the enrollee or the ability of the enrollee to regain
19    maximum function; or
20        (2) could subject the enrollee to severe pain that
21    cannot be adequately managed without the care or treatment
22    that is the subject of the utilization review.
23    "Urgent health care service" does not include emergency
24services.
25    "Utilization review organization" has the meaning given to
26that term in 50 Ill. Adm. Code 4520.30.
 

 

 

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1    Section 20. Disclosure and review of prior authorization
2requirements.
3    (a) A health insurance issuer shall maintain a complete
4list of services for which prior authorization is required,
5including for all services where prior authorization is
6performed by an entity under contract with the health
7insurance issuer.
8    (b) A health insurance issuer shall make any current prior
9authorization requirements and restrictions, including the
10written clinical review criteria, readily accessible and
11conspicuously posted on its website to enrollees, health care
12professionals, and health care providers. Content published by
13a third party and licensed for use by a health insurance issuer
14or its contracted utilization review organization may be made
15available through the health insurance issuer's or its
16contracted utilization review organization's secure,
17password-protected website so long as the access requirements
18of the website do not unreasonably restrict access.
19Requirements shall be described in detail, written in easily
20understandable language, and readily available to the health
21care professional and health care provider at the point of
22care. The website shall indicate for each service subject to
23prior authorization:
24        (1) when prior authorization became required for
25    policies issued or delivered in Illinois, including the

 

 

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1    effective date or dates and the termination date or dates,
2    if applicable, in Illinois;
3        (2) the date the Illinois-specific requirement was
4    listed on the health insurance issuer's or its contracted
5    utilization review organization's website;
6        (3) where applicable, the date that prior
7    authorization was removed for Illinois; and
8        (4) where applicable, access to a standardized
9    electronic prior authorization request transaction
10    process.
11    (c) The clinical review criteria must:
12        (1) be based on nationally recognized, generally
13    accepted standards except where State law provides its own
14    standard;
15        (2) be developed in accordance with the current
16    standards of a national medical accreditation entity;
17        (3) ensure quality of care and access to needed health
18    care services;
19        (4) be evidence-based;
20        (5) be sufficiently flexible to allow deviations from
21    norms when justified on a case-by-case basis; and
22        (6) be evaluated and updated, if necessary, at least
23    annually.
24    (d) A health insurance issuer shall not deny a claim for
25failure to obtain prior authorization if the prior
26authorization requirement was not in effect on the date of

 

 

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

 

 

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1statistics available regarding prior authorization approvals
2and denials on their website in a readily accessible format.
3The statistics must be updated annually and include all of the
4following information:
5        (1) a list of all health care services, including
6    medications, that are subject to prior authorization;
7        (2) the total number of prior authorization requests
8    received;
9        (3) the number of prior authorization requests denied
10    during the previous plan year by the health insurance
11    issuer or its contracted utilization review organization
12    with respect to each service described in paragraph (1)
13    and the top 5 reasons for denial;
14        (4) the number of requests described in paragraph (3)
15    that were appealed, the number of the appealed requests
16    that upheld the adverse determination, and the number of
17    appealed requests that reversed the adverse determination;
18        (5) the average time between submission and response;
19    and
20        (6) any other information as the Director determines
21    appropriate.
 
22    Section 25. Health insurance issuer's and its contracted
23utilization review organization's obligations with respect to
24prior authorizations in nonurgent circumstances.
25Notwithstanding any other provision of law, if a health

 

 

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1insurance issuer requires prior authorization of a health care
2service, the health insurance issuer or its contracted
3utilization review organization must make an approval or
4adverse determination and notify the enrollee, the enrollee's
5health care professional, and the enrollee's health care
6provider of the approval or adverse determination as required
7by applicable law, but no later than 5 calendar days after
8obtaining all necessary information to make the approval or
9adverse determination. As used in this Section, "necessary
10information" includes the results of any face-to-face clinical
11evaluation, second opinion, or other clinical information that
12is directly applicable to the requested service that may be
13required.
 
14    Section 30. Health insurance issuer's and its contracted
15utilization review organization's obligations with respect to
16prior authorizations concerning urgent health care services.
17    (a) Notwithstanding any other provision of law, a health
18insurance issuer or its contracted utilization review
19organization must render an approval or adverse determination
20concerning urgent care services and notify the enrollee, the
21enrollee's health care professional, and the enrollee's health
22care provider of that approval or adverse determination as
23required by law, but not later than 48 hours after receiving
24all information needed to complete the review of the requested
25health care services.

 

 

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1    (b) To facilitate the rendering of a prior authorization
2determination in conformance with this Section, a health
3insurance issuer or its contracted utilization review
4organization must establish a mechanism to ensure health care
5professionals have access to appropriately trained and
6licensed clinical personnel who have access to physicians for
7consultation, designated by the plan to make such
8determinations for prior authorization concerning urgent care
9services.
 
10    Section 35. Personnel qualified to make adverse
11determinations of a prior authorization request. A health
12insurance issuer or its contracted utilization review
13organization must ensure that all adverse determinations are
14made by a physician when the request is by a physician or a
15representative of a physician. The physician must:
16        (1) possess a current and valid nonrestricted license
17    in any United States jurisdiction; and
18        (2) have experience treating and managing patients
19    with the medical condition or disease for which the health
20    care service is being requested.
21    Notwithstanding the foregoing, a licensed health care
22professional who satisfies the requirements of this Section
23may make an adverse determination of a prior authorization
24request submitted by a health care professional licensed in
25the same profession.
 

 

 

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1    Section 40. Requirements for adverse determination. If a
2health insurance issuer or its contracted utilization review
3organization makes an adverse determination, the health
4insurance issuer or its contracted utilization review
5organization shall include the following in the notification
6to the enrollee, the enrollee's health care professional, and
7the enrollee's health care provider:
8        (1) the reasons for the adverse determination and
9    related evidence-based criteria, including a description
10    of any missing or insufficient documentation;
11        (2) the right to appeal the adverse determination;
12        (3) instructions on how to file the appeal; and
13        (4) additional documentation necessary to support the
14    appeal.
 
15    Section 45. Requirements applicable to the personnel who
16can review appeals. A health insurance issuer or its
17contracted utilization review organization must ensure that
18all appeals are reviewed by a physician when the request is by
19a physician or a representative of a physician. The physician
20must:
21        (1) possess a current and valid nonrestricted license
22    to practice medicine in any United States jurisdiction;
23        (2) be in the same or similar specialty as a physician
24    who typically manages the medical condition or disease;

 

 

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1        (3) be knowledgeable of, and have experience
2    providing, the health care services under appeal;
3        (4) not have been directly involved in making the
4    adverse determination; and
5        (5) consider all known clinical aspects of the health
6    care service under review, including, but not limited to,
7    a review of all pertinent medical records provided to the
8    health insurance issuer or its contracted utilization
9    review organization by the enrollee's health care
10    professional or health care provider and any medical
11    literature provided to the health insurance issuer or its
12    contracted utilization review organization by the health
13    care professional or health care provider.
14    Notwithstanding the foregoing, a licensed health care
15professional who satisfies the requirements in this Section
16may review appeal requests submitted by a health care
17professional licensed in the same profession.
 
18    Section 50. Review of prior authorization requirements. A
19health insurance issuer shall periodically review its prior
20authorization requirements and consider removal of prior
21authorization requirements:
22        (1) where a medication or procedure prescribed is
23    customary and properly indicated or is a treatment for the
24    clinical indication as supported by peer-reviewed medical
25    publications; or

 

 

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

 

 

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1    health insurance issuer or its contracted utilization
2    review organization or delegated reviewer if contact was
3    made between those parties before the service being
4    rendered;
5        (4) it is timely determined that the enrollee
6    receiving such health care services was not an enrollee of
7    the health care plan; or
8        (5) the approval was based upon a material
9    misrepresentation by the enrollee, health care
10    professional, or health care provider; as used in this
11    paragraph (5), "material" means a fact or situation that
12    is not merely technical in nature and results or could
13    result in a substantial change in the situation.
14    (c) Nothing in this Section shall preclude a utilization
15review organization or a health insurance issuer from
16performing post-service reviews of health care claims for
17purposes of payment integrity or for the prevention of fraud,
18waste, or abuse.
 
19    Section 60. Length of prior authorization approval. A
20prior authorization approval shall be valid for the lesser of
216 months after the date the health care professional or health
22care provider receives the prior authorization approval or the
23length of treatment as determined by the patient's health care
24professional or the renewal of the plan, and the approval
25period shall be effective regardless of any changes, including

 

 

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1any changes in dosage for a prescription drug prescribed by
2the health care professional. All dosage increases must be
3based on established evidentiary standards and nothing in this
4Section shall prohibit a health insurance issuer from having
5safety edits in place. This Section shall not apply to the
6prescription of benzodiazepines or Schedule II narcotic drugs,
7such as opioids. Except to the extent required by medical
8exceptions processes for prescription drugs set forth in
9Section 45.1 of the Managed Care Reform and Patient Rights
10Act, nothing in this Section shall require a policy to cover
11any care, treatment, or services for any health condition that
12the terms of coverage otherwise completely exclude from the
13policy's covered benefits without regard for whether the care,
14treatment, or services are medically necessary.
 
15    Section 65. Length of prior authorization approval for
16treatment for chronic or long-term conditions. If a health
17insurance issuer requires a prior authorization for a
18recurring health care service or maintenance medication for
19the treatment of a chronic or long-term condition, the
20approval shall remain valid for the lesser of 12 months from
21the date the health care professional or health care provider
22receives the prior authorization approval or the length of the
23treatment as determined by the patient's health care
24professional. This Section shall not apply to the prescription
25of benzodiazepines or Schedule II narcotic drugs, such as

 

 

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1opioids. Except to the extent required by medical exceptions
2processes for prescription drugs set forth in Section 45.1 of
3the Managed Care Reform and Patient Rights Act, nothing in
4this Section shall require a policy to cover any care,
5treatment, or services for any health condition that the terms
6of coverage otherwise completely exclude from the policy's
7covered benefits without regard for whether the care,
8treatment, or services are medically necessary.
 
9    Section 70. Continuity of care for enrollees.
10    (a) On receipt of information documenting a prior
11authorization approval from the enrollee or from the
12enrollee's health care professional or health care provider, a
13health insurance issuer shall honor a prior authorization
14granted to an enrollee from a previous health insurance issuer
15or its contracted utilization review organization for at least
16the initial 90 days of an enrollee's coverage under a new
17health plan, subject to the terms of the member's coverage
18agreement.
19    (b) During the time period described in subsection (a), a
20health insurance issuer or its contracted utilization review
21organization may perform its own review to grant a prior
22authorization approval subject to the terms of the member's
23coverage agreement.
24    (c) If there is a change in coverage of or approval
25criteria for a previously authorized health care service, the

 

 

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1change in coverage or approval criteria does not affect an
2enrollee who received prior authorization approval before the
3effective date of the change for the remainder of the
4enrollee's plan year.
5    (d) Except to the extent required by medical exceptions
6processes for prescription drugs, nothing in this Section
7shall require a policy to cover any care, treatment, or
8services for any health condition that the terms of coverage
9otherwise completely exclude from the policy's covered
10benefits without regard for whether the care, treatment, or
11services are medically necessary.
 
12    Section 75. Health care services deemed authorized if a
13health insurance issuer or its contracted utilization review
14organization fails to comply with the requirements of this
15Act. A failure by a health insurance issuer or its contracted
16utilization review organization to comply with the deadlines
17and other requirements specified in this Act shall result in
18any health care services subject to review to be automatically
19deemed authorized by the health insurance issuer or its
20contracted utilization review organization.
 
21    Section 80. Severability. If any provision of this Act or
22its application to any person or circumstance is held invalid,
23the invalidity does not affect other provisions or
24applications of this Act that can be given effect without the

 

 

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1invalid provision or application, and to this end the
2provisions of this Act are declared to be severable.
 
3    Section 85. Administration and enforcement.
4    (a) The Department shall enforce the provisions of this
5Act pursuant to the enforcement powers granted to it by law. To
6enforce the provisions of this Act, the Director is hereby
7granted specific authority to issue a cease and desist order
8or require a utilization review organization or health
9insurance issuer to submit a plan of correction for violations
10of this Act, or both, in accordance with the requirements and
11authority set forth in Section 85 of the Managed Care Reform
12and Patient Rights Act. Subject to the provisions of the
13Illinois Administrative Procedure Act, the Director may,
14pursuant to Section 403A of the Illinois Insurance Code,
15impose upon a utilization review organization or health
16insurance issuer an administrative fine not to exceed $250,000
17for failure to submit a requested plan of correction, failure
18to comply with its plan of correction, or repeated violations
19of this Act.
20    (b) Any person who believes that his or her utilization
21review organization or health insurance issuer is in violation
22of the provisions of this Act may file a complaint with the
23Department. The Department shall review all complaints
24received and investigate all complaints that it deems to state
25a potential violation. The Department shall fairly,

 

 

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1efficiently, and timely review and investigate complaints.
2Health insurance issuers and utilization review organizations
3found to be in violation of this Act shall be penalized in
4accordance with this Section.
5    (c) The Department of Healthcare and Family Services shall
6enforce the provisions of this Act as it applies to persons
7enrolled under Article V of the Illinois Public Aid Code or
8under the Children's Health Insurance Program Act.
 
9    Section 900. The Illinois Insurance Code is amended by
10changing Sections 155.36 and 370g as follows:
 
11    (215 ILCS 5/155.36)
12    Sec. 155.36. Managed Care Reform and Patient Rights Act.
13Insurance companies that transact the kinds of insurance
14authorized under Class 1(b) or Class 2(a) of Section 4 of this
15Code shall comply with Sections 45, 45.1, 45.2, 65, 70, and 85,
16subsection (d) of Section 30, and the definition of the term
17"emergency medical condition" in Section 10 of the Managed
18Care Reform and Patient Rights Act.
19(Source: P.A. 101-608, eff. 1-1-20.)
 
20    (215 ILCS 5/370g)  (from Ch. 73, par. 982g)
21    Sec. 370g. Definitions. As used in this Article, the
22following definitions apply:
23    (a) "Health care services" means health care services or

 

 

10200HB0711ham002- 21 -LRB102 10190 BMS 25668 a

1products rendered or sold by a provider within the scope of the
2provider's license or legal authorization. The term includes,
3but is not limited to, hospital, medical, surgical, dental,
4vision and pharmaceutical services or products.
5    (b) "Insurer" means an insurance company or a health
6service corporation authorized in this State to issue policies
7or subscriber contracts which reimburse for expenses of health
8care services.
9    (c) "Insured" means an individual entitled to
10reimbursement for expenses of health care services under a
11policy or subscriber contract issued or administered by an
12insurer.
13    (d) "Provider" means an individual or entity duly licensed
14or legally authorized to provide health care services.
15    (e) "Noninstitutional provider" means any person licensed
16under the Medical Practice Act of 1987, as now or hereafter
17amended.
18    (f) "Beneficiary" means an individual entitled to
19reimbursement for expenses of or the discount of provider fees
20for health care services under a program where the beneficiary
21has an incentive to utilize the services of a provider which
22has entered into an agreement or arrangement with an
23administrator.
24    (g) "Administrator" means any person, partnership or
25corporation, other than an insurer or health maintenance
26organization holding a certificate of authority under the

 

 

10200HB0711ham002- 22 -LRB102 10190 BMS 25668 a

1"Health Maintenance Organization Act", as now or hereafter
2amended, that arranges, contracts with, or administers
3contracts with a provider whereby beneficiaries are provided
4an incentive to use the services of such provider.
5    (h) "Emergency medical condition" has the meaning given to
6that term in Section 10 of the Managed Care Reform and Patient
7Rights Act. means a medical condition manifesting itself by
8acute symptoms of sufficient severity (including severe pain)
9such that a prudent layperson, who possesses an average
10knowledge of health and medicine, could reasonably expect the
11absence of immediate medical attention to result in:
12        (1) placing the health of the individual (or, with
13    respect to a pregnant woman, the health of the woman or her
14    unborn child) in serious jeopardy;
15        (2) serious impairment to bodily functions; or
16        (3) serious dysfunction of any bodily organ or part.
17(Source: P.A. 91-617, eff. 1-1-00.)
 
18    Section 905. The Managed Care Reform and Patient Rights
19Act is amended by changing Section 10 as follows:
 
20    (215 ILCS 134/10)
21    Sec. 10. Definitions.
22    "Adverse determination" means a determination by a health
23care plan under Section 45 or by a utilization review program
24under Section 85 that a health care service is not medically

 

 

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1necessary.
2    "Clinical peer" means a health care professional who is in
3the same profession and the same or similar specialty as the
4health care provider who typically manages the medical
5condition, procedures, or treatment under review.
6    "Department" means the Department of Insurance.
7    "Emergency medical condition" means a medical condition
8manifesting itself by acute symptoms of sufficient severity,
9regardless of the final diagnosis given, such that a prudent
10layperson, who possesses an average knowledge of health and
11medicine, could reasonably expect the absence of immediate
12medical attention to result in:
13        (1) placing the health of the individual (or, with
14    respect to a pregnant woman, the health of the woman or her
15    unborn child) in serious jeopardy;
16        (2) serious impairment to bodily functions;
17        (3) serious dysfunction of any bodily organ or part;
18        (4) inadequately controlled pain; or
19        (5) with respect to a pregnant woman who is having
20    contractions:
21            (A) inadequate time to complete a safe transfer to
22        another hospital before delivery; or
23            (B) a transfer to another hospital may pose a
24        threat to the health or safety of the woman or unborn
25        child.
26    "Emergency medical screening examination" means a medical

 

 

10200HB0711ham002- 24 -LRB102 10190 BMS 25668 a

1screening examination and evaluation by a physician licensed
2to practice medicine in all its branches, or to the extent
3permitted by applicable laws, by other appropriately licensed
4personnel under the supervision of or in collaboration with a
5physician licensed to practice medicine in all its branches to
6determine whether the need for emergency services exists.
7    "Emergency services" means, with respect to an enrollee of
8a health care plan, transportation services, including but not
9limited to ambulance services, and covered inpatient and
10outpatient hospital services furnished by a provider qualified
11to furnish those services that are needed to evaluate or
12stabilize an emergency medical condition. "Emergency services"
13does not refer to post-stabilization medical services.
14    "Enrollee" means any person and his or her dependents
15enrolled in or covered by a health care plan.
16    "Health care plan" means a plan, including, but not
17limited to, a health maintenance organization, a managed care
18community network as defined in the Illinois Public Aid Code,
19or an accountable care entity as defined in the Illinois
20Public Aid Code that receives capitated payments to cover
21medical services from the Department of Healthcare and Family
22Services, that establishes, operates, or maintains a network
23of health care providers that has entered into an agreement
24with the plan to provide health care services to enrollees to
25whom the plan has the ultimate obligation to arrange for the
26provision of or payment for services through organizational

 

 

10200HB0711ham002- 25 -LRB102 10190 BMS 25668 a

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

 

 

10200HB0711ham002- 26 -LRB102 10190 BMS 25668 a

1professional nurse, or other individual appropriately licensed
2or registered to provide health care services.
3    "Health care provider" means any physician, hospital
4facility, facility licensed under the Nursing Home Care Act,
5long-term care facility as defined in Section 1-113 of the
6Nursing Home Care Act, or other person that is licensed or
7otherwise authorized to deliver health care services. Nothing
8in this Act shall be construed to define Independent Practice
9Associations or Physician-Hospital Organizations as health
10care providers.
11    "Health care services" means any services included in the
12furnishing to any individual of medical care, or the
13hospitalization incident to the furnishing of such care, as
14well as the furnishing to any person of any and all other
15services for the purpose of preventing, alleviating, curing,
16or healing human illness or injury including behavioral
17health, mental health, home health, and pharmaceutical
18services and products.
19    "Medical director" means a physician licensed in any state
20to practice medicine in all its branches appointed by a health
21care plan.
22    "Person" means a corporation, association, partnership,
23limited liability company, sole proprietorship, or any other
24legal entity.
25    "Physician" means a person licensed under the Medical
26Practice Act of 1987.

 

 

10200HB0711ham002- 27 -LRB102 10190 BMS 25668 a

1    "Post-stabilization medical services" means health care
2services provided to an enrollee that are furnished in a
3licensed hospital by a provider that is qualified to furnish
4such services, and determined to be medically necessary and
5directly related to the emergency medical condition following
6stabilization.
7    "Stabilization" means, with respect to an emergency
8medical condition, to provide such medical treatment of the
9condition as may be necessary to assure, within reasonable
10medical probability, that no material deterioration of the
11condition is likely to result.
12    "Utilization review" means the evaluation of the medical
13necessity, appropriateness, and efficiency of the use of
14health care services, procedures, and facilities.
15    "Utilization review program" means a program established
16by a person to perform utilization review.
17(Source: P.A. 101-452, eff. 1-1-20.)
 
18    Section 910. The Illinois Public Aid Code is amended by
19adding Section 5-5.12d as follows:
 
20    (305 ILCS 5/5-5.12d new)
21    Sec. 5-5.12d. Managed care organization prior
22authorization of health care services.
23    (a) As used in this Section, "health care service" has the
24meaning given to that term in the Prior Authorization Reform

 

 

10200HB0711ham002- 28 -LRB102 10190 BMS 25668 a

1Act.
2    (b) Notwithstanding any other provision of law to the
3contrary, all managed care organizations shall comply with the
4requirements of the Prior Authorization Reform Act.
 
5    Section 999. Effective date. This Act takes effect January
61, 2022.".