Bill Amendment: IL HB0711 | 2021-2022 | 102nd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: PRIOR AUTHORIZATION REFORM ACT
Status: 2021-08-19 - Public Act . . . . . . . . . 102-0409 [HB0711 Detail]
Download: Illinois-2021-HB0711-House_Amendment_002.html
Bill Title: PRIOR AUTHORIZATION REFORM ACT
Status: 2021-08-19 - Public Act . . . . . . . . . 102-0409 [HB0711 Detail]
Download: Illinois-2021-HB0711-House_Amendment_002.html
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1 | AMENDMENT TO HOUSE BILL 711
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2 | AMENDMENT NO. ______. Amend House Bill 711 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 1. Short title. This Act may be cited as the Prior | ||||||
5 | Authorization Reform Act.
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6 | Section 5. Purpose. The General Assembly hereby finds and | ||||||
7 | declares that:
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8 | (1) the health care professional-patient relationship | ||||||
9 | is paramount and should not be subject to third-party | ||||||
10 | intrusion;
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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
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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.
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2 | Section 10. Applicability; scope. This Act applies to | ||||||
3 | health insurance coverage as defined in the Illinois Health | ||||||
4 | Insurance Portability and Accountability Act, and policies | ||||||
5 | issued or delivered in this State to the Department of | ||||||
6 | Healthcare and Family Services and providing coverage to | ||||||
7 | persons who are enrolled under Article V of the Illinois | ||||||
8 | Public Aid Code or under the Children's Health Insurance | ||||||
9 | Program Act, amended, delivered, issued, or renewed on or | ||||||
10 | after the effective date of this Act, with the exception of | ||||||
11 | employee or employer self-insured health benefit plans under | ||||||
12 | the federal Employee Retirement Income Security Act of 1974, | ||||||
13 | health care provided pursuant to the Workers' Compensation Act | ||||||
14 | or the Workers' Occupational Diseases Act, and State, | ||||||
15 | employee, unit of local government, or school district health | ||||||
16 | plans. This Act does not diminish a health care plan's duties | ||||||
17 | and responsibilities under other federal or State law or rules | ||||||
18 | promulgated thereunder. This Act is not intended to alter or | ||||||
19 | impede the provisions of any consent decree or judicial order | ||||||
20 | to which the State or any of its agencies is a party.
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21 | Section 15. Definitions. As used in this Act:
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22 | "Adverse determination" has the meaning given to that term | ||||||
23 | in Section 10 of the Health Carrier External Review Act.
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24 | "Appeal" means a formal request, either orally or in |
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1 | writing, to reconsider an adverse determination.
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2 | "Approval" means a determination by a health insurance | ||||||
3 | issuer or its contracted utilization review organization that | ||||||
4 | a health care service has been reviewed and, based on the | ||||||
5 | information provided, satisfies the health insurance issuer's | ||||||
6 | or its contracted utilization review organization's | ||||||
7 | requirements for medical necessity and appropriateness.
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8 | "Clinical review criteria" has the meaning given to that | ||||||
9 | term in Section 10 of the Health Carrier External Review Act.
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10 | "Department" means the Department of Insurance.
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11 | "Emergency medical condition" has the meaning given to | ||||||
12 | that term in Section 10 of the Managed Care Reform and Patient | ||||||
13 | Rights Act.
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14 | "Emergency services" has the meaning given to that term in | ||||||
15 | federal health insurance reform requirements for the group and | ||||||
16 | individual health insurance markets, 45 CFR 147.138.
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17 | "Enrollee" has the meaning given to that term in Section | ||||||
18 | 10 of the Managed Care Reform and Patient Rights Act.
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19 | "Health care professional" has the meaning given to that | ||||||
20 | term in Section 10 of the Managed Care Reform and Patient | ||||||
21 | Rights Act.
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22 | "Health care provider" has the meaning given to that term | ||||||
23 | in Section 10 of the Managed Care Reform and Patient Rights | ||||||
24 | Act, except that facilities licensed under the Nursing Home | ||||||
25 | Care Act and long-term care facilities as defined in Section | ||||||
26 | 1-113 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 | ||||||
2 | services included in the furnishing to an individual of | ||||||
3 | medical care or the hospitalization incident to the furnishing | ||||||
4 | of such care, as well as the furnishing to any person of any | ||||||
5 | other services for the purpose of preventing, alleviating, | ||||||
6 | curing, or healing human illness or injury, including | ||||||
7 | behavioral health, mental health, home health, and | ||||||
8 | pharmaceutical services and products.
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9 | "Health insurance issuer" has the meaning given to that | ||||||
10 | term in Section 5 of the Illinois Health Insurance Portability | ||||||
11 | and Accountability Act.
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12 | "Medically necessary" means a health care professional | ||||||
13 | exercising prudent clinical judgment would provide care to a | ||||||
14 | patient for the purpose of preventing, diagnosing, or treating | ||||||
15 | an illness, injury, disease, or its symptoms and that are: (i) | ||||||
16 | in accordance with generally accepted standards of medical | ||||||
17 | practice; (ii) clinically appropriate in terms of type, | ||||||
18 | frequency, extent, site, and duration and are considered | ||||||
19 | effective for the patient's illness, injury, or disease; and | ||||||
20 | (iii) not primarily for the convenience of the patient, | ||||||
21 | treating physician, other health care professional, caregiver, | ||||||
22 | family member, or other interested party, but focused on what | ||||||
23 | is best for the patient's health outcome.
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24 | "Physician" means a person licensed under the Medical | ||||||
25 | Practice Act of 1987 or licensed under the laws of another | ||||||
26 | state to practice medicine in all its branches.
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1 | "Prior authorization" means the process by which health | ||||||
2 | insurance issuers or their contracted utilization review | ||||||
3 | organizations determine the medical necessity and medical | ||||||
4 | appropriateness of otherwise covered health care services | ||||||
5 | before the rendering of such health care services. "Prior | ||||||
6 | authorization" includes any health insurance issuer's or its | ||||||
7 | contracted utilization review organization's requirement that | ||||||
8 | an enrollee, health care professional, or health care provider | ||||||
9 | notify the health insurance issuer or its contracted | ||||||
10 | utilization review organization before, at the time of, or | ||||||
11 | concurrent to providing a health care service.
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12 | "Urgent health care service" means a health care service | ||||||
13 | with respect to which the application of the time periods for | ||||||
14 | making a non-expedited prior authorization that in the opinion | ||||||
15 | of a health care professional with knowledge of the enrollee's | ||||||
16 | medical condition:
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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
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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.
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23 | "Urgent health care service" does not include emergency | ||||||
24 | services.
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25 | "Utilization review organization" has the meaning given to | ||||||
26 | that term in 50 Ill. Adm. Code 4520.30.
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1 | Section 20. Disclosure and review of prior authorization | ||||||
2 | requirements.
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3 | (a) A health insurance issuer shall maintain a complete | ||||||
4 | list of services for which prior authorization is required, | ||||||
5 | including for all services where prior authorization is | ||||||
6 | performed by an entity under contract with the health | ||||||
7 | insurance issuer.
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8 | (b) A health insurance issuer shall make any current prior | ||||||
9 | authorization requirements and restrictions, including the | ||||||
10 | written clinical review criteria, readily accessible and | ||||||
11 | conspicuously posted on its website to enrollees, health care | ||||||
12 | professionals, and health care providers. Content published by | ||||||
13 | a third party and licensed for use by a health insurance issuer | ||||||
14 | or its contracted utilization review organization may be made | ||||||
15 | available through the health insurance issuer's or its | ||||||
16 | contracted utilization review organization's secure, | ||||||
17 | password-protected website so long as the access requirements | ||||||
18 | of the website do not unreasonably restrict access. | ||||||
19 | Requirements shall be described in detail, written in easily | ||||||
20 | understandable language, and readily available to the health | ||||||
21 | care professional and health care provider at the point of | ||||||
22 | care. The website shall indicate for each service subject to | ||||||
23 | prior authorization:
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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;
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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
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8 | (4) where applicable, access to a standardized | ||||||
9 | electronic prior authorization request transaction | ||||||
10 | process. | ||||||
11 | (c) The clinical review criteria must:
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12 | (1) be based on nationally recognized, generally | ||||||
13 | accepted standards except where State law provides its own | ||||||
14 | standard;
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15 | (2) be developed in accordance with the current | ||||||
16 | standards of a national medical accreditation entity;
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17 | (3) ensure quality of care and access to needed health | ||||||
18 | care services;
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19 | (4) be evidence-based;
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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 | ||||||
25 | failure to obtain prior authorization if the prior | ||||||
26 | authorization requirement was not in effect on the date of |
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1 | service on the claim.
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2 | (e) A health insurance issuer or its contracted | ||||||
3 | utilization review organization shall not deem as incidental | ||||||
4 | or deny supplies or health care services that are routinely | ||||||
5 | used as part of a health care service when:
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6 | (1) an associated health care service has received | ||||||
7 | prior authorization; or
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8 | (2) prior authorization for the health care service is | ||||||
9 | not required.
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10 | (f) If a health insurance issuer intends either to | ||||||
11 | implement a new prior authorization requirement or restriction | ||||||
12 | or amend an existing requirement or restriction, the health | ||||||
13 | insurance issuer shall provide contracted health care | ||||||
14 | professionals and contracted health care providers of | ||||||
15 | enrollees written notice of the new or amended requirement or | ||||||
16 | amendment no less than 60 days before the requirement or | ||||||
17 | restriction is implemented. The written notice may be provided | ||||||
18 | in an electronic format, including email or facsimile, if the | ||||||
19 | health care professional or health care provider has agreed in | ||||||
20 | advance to receive notices electronically. The health | ||||||
21 | insurance issuer shall ensure that the new or amended | ||||||
22 | requirement is not implemented unless the health insurance | ||||||
23 | issuer's or its contracted utilization review organization's | ||||||
24 | website has been updated to reflect the new or amended | ||||||
25 | requirement or restriction.
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26 | (g) Entities using prior authorization shall make |
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1 | statistics available regarding prior authorization approvals | ||||||
2 | and denials on their website in a readily accessible format. | ||||||
3 | The statistics must be updated annually and include all of the | ||||||
4 | following information:
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5 | (1) a list of all health care services, including | ||||||
6 | medications, that are subject to prior authorization;
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7 | (2) the total number of prior authorization requests | ||||||
8 | received;
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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;
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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;
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18 | (5) the average time between submission and response;
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19 | and | ||||||
20 | (6) any other information as the Director determines | ||||||
21 | appropriate.
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22 | Section 25. Health insurance issuer's and its contracted | ||||||
23 | utilization review organization's obligations with respect to | ||||||
24 | prior authorizations in nonurgent circumstances. | ||||||
25 | Notwithstanding any other provision of law, if a health |
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1 | insurance issuer requires prior authorization of a health care | ||||||
2 | service, the health insurance issuer or its contracted | ||||||
3 | utilization review organization must make an approval or | ||||||
4 | adverse determination and notify the enrollee, the enrollee's | ||||||
5 | health care professional, and the enrollee's health care | ||||||
6 | provider of the approval or adverse determination as required | ||||||
7 | by applicable law, but no later than 5 calendar days after | ||||||
8 | obtaining all necessary information to make the approval or | ||||||
9 | adverse determination. As used in this Section, "necessary | ||||||
10 | information" includes the results of any face-to-face clinical | ||||||
11 | evaluation, second opinion, or other clinical information that | ||||||
12 | is directly applicable to the requested service that may be | ||||||
13 | required.
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14 | Section 30. Health insurance issuer's and its contracted | ||||||
15 | utilization review organization's obligations with respect to | ||||||
16 | prior authorizations concerning urgent health care services.
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17 | (a) Notwithstanding any other provision of law, a health | ||||||
18 | insurance issuer or its contracted utilization review | ||||||
19 | organization must render an approval or adverse determination | ||||||
20 | concerning urgent care services and notify the enrollee, the | ||||||
21 | enrollee's health care professional, and the enrollee's health | ||||||
22 | care provider of that approval or adverse determination as | ||||||
23 | required by law, but not later than 48 hours after receiving | ||||||
24 | all information needed to complete the review of the requested | ||||||
25 | health care services.
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1 | (b) To facilitate the rendering of a prior authorization | ||||||
2 | determination in conformance with this Section, a health | ||||||
3 | insurance issuer or its contracted utilization review | ||||||
4 | organization must establish a mechanism to ensure health care | ||||||
5 | professionals have access to appropriately trained and | ||||||
6 | licensed clinical personnel who have access to physicians for | ||||||
7 | consultation, designated by the plan to make such | ||||||
8 | determinations for prior authorization concerning urgent care | ||||||
9 | services.
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10 | Section 35. Personnel qualified to make adverse | ||||||
11 | determinations of a prior authorization request. A health | ||||||
12 | insurance issuer or its contracted utilization review | ||||||
13 | organization must ensure that all adverse determinations are | ||||||
14 | made by a physician when the request is by a physician or a | ||||||
15 | representative of a physician. The physician must:
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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.
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21 | Notwithstanding the foregoing, a licensed health care | ||||||
22 | professional who satisfies the requirements of this Section | ||||||
23 | may make an adverse determination of a prior authorization | ||||||
24 | request submitted by a health care professional licensed in | ||||||
25 | the same profession.
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1 | Section 40. Requirements for adverse determination. If a | ||||||
2 | health insurance issuer or its contracted utilization review | ||||||
3 | organization makes an adverse determination, the health | ||||||
4 | insurance issuer or its contracted utilization review | ||||||
5 | organization shall include the following in the notification | ||||||
6 | to the enrollee, the enrollee's health care professional, and | ||||||
7 | the 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.
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15 | Section 45. Requirements applicable to the personnel who | ||||||
16 | can review appeals. A health insurance issuer or its | ||||||
17 | contracted utilization review organization must ensure that | ||||||
18 | all appeals are reviewed by a physician when the request is by | ||||||
19 | a physician or a representative of a physician. The physician | ||||||
20 | must:
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21 | (1) possess a current and valid nonrestricted license | ||||||
22 | to practice medicine in any United States jurisdiction;
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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;
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3 | (4) not have been directly involved in making the | ||||||
4 | adverse determination; and
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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.
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14 | Notwithstanding the foregoing, a licensed health care | ||||||
15 | professional who satisfies the requirements in this Section | ||||||
16 | may review appeal requests submitted by a health care | ||||||
17 | professional licensed in the same profession.
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18 | Section 50. Review of prior authorization requirements. A | ||||||
19 | health insurance issuer shall periodically review its prior | ||||||
20 | authorization requirements and consider removal of prior | ||||||
21 | authorization requirements:
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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.
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3 | Section 55. Denial.
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4 | (a) The health insurance issuer or its contracted | ||||||
5 | utilization review organization may not revoke or further | ||||||
6 | limit, condition, or restrict a previously issued prior | ||||||
7 | authorization approval while it remains valid under this Act.
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8 | (b) Notwithstanding any other provision of law, if a claim | ||||||
9 | is properly coded and submitted timely to a health insurance | ||||||
10 | issuer, the health insurance issuer shall make payment | ||||||
11 | according to the terms of coverage on claims for health care | ||||||
12 | services for which prior authorization was required and | ||||||
13 | approval received before the rendering of health care | ||||||
14 | services, unless one of the following occurs:
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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;
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22 | (2) it is timely determined that the health care | ||||||
23 | services claimed were not performed;
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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;
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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
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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.
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14 | (c) Nothing in this Section shall preclude a utilization | ||||||
15 | review organization or a health insurance issuer from | ||||||
16 | performing post-service reviews of health care claims for | ||||||
17 | purposes of payment integrity or for the prevention of fraud, | ||||||
18 | waste, or abuse.
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19 | Section 60. Length of prior authorization approval. A | ||||||
20 | prior authorization approval shall be valid for the lesser of | ||||||
21 | 6 months after the date the health care professional or health | ||||||
22 | care provider receives the prior authorization approval or the | ||||||
23 | length of treatment as determined by the patient's health care | ||||||
24 | professional or the renewal of the plan, and the approval | ||||||
25 | period shall be effective regardless of any changes, including |
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1 | any changes in dosage for a prescription drug prescribed by | ||||||
2 | the health care professional. All dosage increases must be | ||||||
3 | based on established evidentiary standards and nothing in this | ||||||
4 | Section shall prohibit a health insurance issuer from having | ||||||
5 | safety edits in place. This Section shall not apply to the | ||||||
6 | prescription of benzodiazepines or Schedule II narcotic drugs, | ||||||
7 | such as opioids. Except to the extent required by medical | ||||||
8 | exceptions processes for prescription drugs set forth in | ||||||
9 | Section 45.1 of the Managed Care Reform and Patient Rights | ||||||
10 | Act, nothing in this Section shall require a policy to cover | ||||||
11 | any care, treatment, or services for any health condition that | ||||||
12 | the terms of coverage otherwise completely exclude from the | ||||||
13 | policy's covered benefits without regard for whether the care, | ||||||
14 | treatment, or services are medically necessary.
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15 | Section 65. Length of prior authorization approval for | ||||||
16 | treatment for chronic or long-term conditions. If a health | ||||||
17 | insurance issuer requires a prior authorization for a | ||||||
18 | recurring health care service or maintenance medication for | ||||||
19 | the treatment of a chronic or long-term condition, the | ||||||
20 | approval shall remain valid for the lesser of 12 months from | ||||||
21 | the date the health care professional or health care provider | ||||||
22 | receives the prior authorization approval or the length of the | ||||||
23 | treatment as determined by the patient's health care | ||||||
24 | professional. This Section shall not apply to the prescription | ||||||
25 | of benzodiazepines or Schedule II narcotic drugs, such as |
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1 | opioids. Except to the extent required by medical exceptions | ||||||
2 | processes for prescription drugs set forth in Section 45.1 of | ||||||
3 | the Managed Care Reform and Patient Rights Act, nothing in | ||||||
4 | this Section shall require a policy to cover any care, | ||||||
5 | treatment, or services for any health condition that the terms | ||||||
6 | of coverage otherwise completely exclude from the policy's | ||||||
7 | covered benefits without regard for whether the care, | ||||||
8 | treatment, or services are medically necessary.
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9 | Section 70. Continuity of care for enrollees.
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10 | (a) On receipt of information documenting a prior | ||||||
11 | authorization approval from the enrollee or from the | ||||||
12 | enrollee's health care professional or health care provider, a | ||||||
13 | health insurance issuer shall honor a prior authorization | ||||||
14 | granted to an enrollee from a previous health insurance issuer | ||||||
15 | or its contracted utilization review organization for at least | ||||||
16 | the initial 90 days of an enrollee's coverage under a new | ||||||
17 | health plan, subject to the terms of the member's coverage | ||||||
18 | agreement.
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19 | (b) During the time period described in subsection (a), a | ||||||
20 | health insurance issuer or its contracted utilization review | ||||||
21 | organization may perform its own review to grant a prior | ||||||
22 | authorization approval subject to the terms of the member's | ||||||
23 | coverage agreement.
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24 | (c) If there is a change in coverage of or approval | ||||||
25 | criteria for a previously authorized health care service, the |
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1 | change in coverage or approval criteria does not affect an | ||||||
2 | enrollee who received prior authorization approval before the | ||||||
3 | effective date of the change for the remainder of the | ||||||
4 | enrollee's plan year.
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5 | (d) Except to the extent required by medical exceptions | ||||||
6 | processes for prescription drugs, nothing in this Section | ||||||
7 | shall require a policy to cover any care, treatment, or | ||||||
8 | services for any health condition that the terms of coverage | ||||||
9 | otherwise completely exclude from the policy's covered | ||||||
10 | benefits without regard for whether the care, treatment, or | ||||||
11 | services are medically necessary.
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12 | Section 75. Health care services deemed authorized if a | ||||||
13 | health insurance issuer or its contracted utilization review | ||||||
14 | organization fails to comply with the requirements of this | ||||||
15 | Act. A failure by a health insurance issuer or its contracted | ||||||
16 | utilization review organization to comply with the deadlines | ||||||
17 | and other requirements specified in this Act shall result in | ||||||
18 | any health care services subject to review to be automatically | ||||||
19 | deemed authorized by the health insurance issuer or its | ||||||
20 | contracted utilization review organization.
| ||||||
21 | Section 80. Severability. If any provision of this Act or | ||||||
22 | its application to any person or circumstance is held invalid, | ||||||
23 | the invalidity does not affect other provisions or | ||||||
24 | applications of this Act that can be given effect without the |
| |||||||
| |||||||
1 | invalid provision or application, and to this end the | ||||||
2 | provisions of this Act are declared to be severable.
| ||||||
3 | Section 85. Administration and enforcement.
| ||||||
4 | (a) The Department shall enforce the provisions of this | ||||||
5 | Act pursuant to the enforcement powers granted to it by law. To | ||||||
6 | enforce the provisions of this Act, the Director is hereby | ||||||
7 | granted specific authority to issue a cease and desist order | ||||||
8 | or require a utilization review organization or health | ||||||
9 | insurance issuer to submit a plan of correction for violations | ||||||
10 | of this Act, or both, in accordance with the requirements and | ||||||
11 | authority set forth in Section 85 of the Managed Care Reform | ||||||
12 | and Patient Rights Act. Subject to the provisions of the | ||||||
13 | Illinois Administrative Procedure Act, the Director may, | ||||||
14 | pursuant to Section 403A of the Illinois Insurance Code, | ||||||
15 | impose upon a utilization review organization or health | ||||||
16 | insurance issuer an administrative fine not to exceed $250,000 | ||||||
17 | for failure to submit a requested plan of correction, failure | ||||||
18 | to comply with its plan of correction, or repeated violations | ||||||
19 | of this Act.
| ||||||
20 | (b) Any person who believes that his or her utilization | ||||||
21 | review organization or health insurance issuer is in violation | ||||||
22 | of the provisions of this Act may file a complaint with the | ||||||
23 | Department. The Department shall review all complaints | ||||||
24 | received and investigate all complaints that it deems to state | ||||||
25 | a potential violation. The Department shall fairly, |
| |||||||
| |||||||
1 | efficiently, and timely review and investigate complaints. | ||||||
2 | Health insurance issuers and utilization review organizations | ||||||
3 | found to be in violation of this Act shall be penalized in | ||||||
4 | accordance with this Section.
| ||||||
5 | (c) The Department of Healthcare and Family Services shall | ||||||
6 | enforce the provisions of this Act as it applies to persons | ||||||
7 | enrolled under Article V of the Illinois Public Aid Code or | ||||||
8 | under the Children's Health Insurance Program Act.
| ||||||
9 | Section 900. The Illinois Insurance Code is amended by | ||||||
10 | changing Sections 155.36 and 370g as follows:
| ||||||
11 | (215 ILCS 5/155.36)
| ||||||
12 | Sec. 155.36. Managed Care Reform and Patient Rights Act. | ||||||
13 | Insurance
companies that transact the kinds of insurance | ||||||
14 | authorized under Class 1(b) or
Class 2(a) of Section 4 of this | ||||||
15 | Code shall comply
with Sections 45, 45.1, 45.2, 65, 70, and 85, | ||||||
16 | subsection (d) of Section 30, and the definition of the term | ||||||
17 | "emergency medical
condition" in Section
10 of the Managed | ||||||
18 | Care 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 | ||||||
22 | following definitions
apply:
| ||||||
23 | (a) "Health care services" means health care services or |
| |||||||
| |||||||
1 | products
rendered or sold by a provider within the scope of the | ||||||
2 | provider's license
or legal authorization. The term includes, | ||||||
3 | but is not limited to, hospital,
medical, surgical, dental, | ||||||
4 | vision and pharmaceutical services or products.
| ||||||
5 | (b) "Insurer" means an insurance company or a health | ||||||
6 | service corporation
authorized in this State to issue policies | ||||||
7 | or subscriber contracts which
reimburse for expenses of health | ||||||
8 | care services.
| ||||||
9 | (c) "Insured" means an individual entitled to | ||||||
10 | reimbursement for expenses
of health care services under a | ||||||
11 | policy or subscriber contract issued or
administered by an | ||||||
12 | insurer.
| ||||||
13 | (d) "Provider" means an individual or entity duly licensed | ||||||
14 | or legally
authorized to provide health care services.
| ||||||
15 | (e) "Noninstitutional provider" means any person licensed | ||||||
16 | under the Medical
Practice Act of 1987, as now or hereafter | ||||||
17 | amended.
| ||||||
18 | (f) "Beneficiary" means an individual entitled to | ||||||
19 | reimbursement for
expenses of or the discount of provider fees | ||||||
20 | for health care services under
a program where the beneficiary | ||||||
21 | has an incentive to utilize the services of a
provider which | ||||||
22 | has entered into an agreement or arrangement with an
| ||||||
23 | administrator.
| ||||||
24 | (g) "Administrator" means any person, partnership or | ||||||
25 | corporation, other
than an insurer or health maintenance | ||||||
26 | organization holding a certificate of
authority under the |
| |||||||
| |||||||
1 | "Health Maintenance Organization Act", as now or hereafter
| ||||||
2 | amended, that arranges, contracts with, or administers | ||||||
3 | contracts with a
provider whereby beneficiaries are provided | ||||||
4 | an incentive to use the services of
such provider.
| ||||||
5 | (h) "Emergency medical condition" has the meaning given to | ||||||
6 | that term in Section 10 of the Managed Care Reform and Patient | ||||||
7 | Rights Act. means a medical condition manifesting
itself
by
| ||||||
8 | acute symptoms of sufficient severity (including severe
pain) | ||||||
9 | such that a prudent
layperson, who possesses an average | ||||||
10 | knowledge of health and medicine, could
reasonably expect the | ||||||
11 | absence 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 | ||||||
19 | Act 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 | ||||||
23 | care plan under
Section 45 or by a utilization review program | ||||||
24 | under Section
85 that
a health care service is not medically |
| |||||||
| |||||||
1 | necessary.
| ||||||
2 | "Clinical peer" means a health care professional who is in | ||||||
3 | the same
profession and the same or similar specialty as the | ||||||
4 | health care provider who
typically manages the medical | ||||||
5 | condition, procedures, or treatment under
review.
| ||||||
6 | "Department" means the Department of Insurance.
| ||||||
7 | "Emergency medical condition" means a medical condition | ||||||
8 | manifesting itself by
acute symptoms of sufficient severity, | ||||||
9 | regardless of the final diagnosis given, such that a prudent
| ||||||
10 | layperson, who possesses an average knowledge of health and | ||||||
11 | medicine, could
reasonably expect the absence of immediate | ||||||
12 | medical 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 |
| |||||||
| |||||||
1 | screening
examination and
evaluation by a physician licensed | ||||||
2 | to practice medicine in all its branches, or
to the extent | ||||||
3 | permitted
by applicable laws, by other appropriately licensed | ||||||
4 | personnel under the
supervision of or in
collaboration with a | ||||||
5 | physician licensed to practice medicine in all its
branches to | ||||||
6 | determine whether
the need for emergency services exists.
| ||||||
7 | "Emergency services" means, with respect to an enrollee of | ||||||
8 | a health care
plan,
transportation services, including but not | ||||||
9 | limited to ambulance services, and
covered inpatient and | ||||||
10 | outpatient hospital services
furnished by a provider
qualified | ||||||
11 | to furnish those services that are needed to evaluate or | ||||||
12 | stabilize an
emergency medical condition. "Emergency services" | ||||||
13 | does not
refer to post-stabilization medical services.
| ||||||
14 | "Enrollee" means any person and his or her dependents | ||||||
15 | enrolled in or covered
by a health care plan.
| ||||||
16 | "Health care plan" means a plan, including, but not | ||||||
17 | limited to, a health maintenance organization, a managed care | ||||||
18 | community network as defined in the Illinois Public Aid Code, | ||||||
19 | or an accountable care entity as defined in the Illinois | ||||||
20 | Public Aid Code that receives capitated payments to cover | ||||||
21 | medical services from the Department of Healthcare and Family | ||||||
22 | Services, that establishes, operates, or maintains a
network | ||||||
23 | of health care providers that has entered into an agreement | ||||||
24 | with the
plan to provide health care services to enrollees to | ||||||
25 | whom the plan has the
ultimate obligation to arrange for the | ||||||
26 | provision of or payment for services
through organizational |
| |||||||
| |||||||
1 | arrangements for ongoing quality assurance,
utilization review | ||||||
2 | programs, or dispute resolution.
Nothing in this definition | ||||||
3 | shall be construed to mean that an independent
practice | ||||||
4 | association or a physician hospital organization that | ||||||
5 | subcontracts
with
a health care plan is, for purposes of that | ||||||
6 | subcontract, a health care plan.
| ||||||
7 | For purposes of this definition, "health care plan" shall | ||||||
8 | not 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 |
| |||||||
| |||||||
1 | professional
nurse,
or other individual appropriately licensed | ||||||
2 | or registered
to provide health care services.
| ||||||
3 | "Health care provider" means any physician, hospital | ||||||
4 | facility, facility licensed under the Nursing Home Care Act, | ||||||
5 | long-term care facility as defined in Section 1-113 of the | ||||||
6 | Nursing Home Care Act, or other
person that is licensed or | ||||||
7 | otherwise authorized to deliver health care
services. Nothing | ||||||
8 | in this
Act shall be construed to define Independent Practice | ||||||
9 | Associations or
Physician-Hospital Organizations as health | ||||||
10 | care providers.
| ||||||
11 | "Health care services" means any services included in the | ||||||
12 | furnishing to any
individual of medical care, or the
| ||||||
13 | hospitalization incident to the furnishing of such care, as | ||||||
14 | well as the
furnishing to any person of
any and all other | ||||||
15 | services for the purpose of preventing,
alleviating, curing, | ||||||
16 | or healing human illness or injury including behavioral | ||||||
17 | health, mental health, home health ,
and pharmaceutical | ||||||
18 | services and products.
| ||||||
19 | "Medical director" means a physician licensed in any state | ||||||
20 | to practice
medicine in all its
branches appointed by a health | ||||||
21 | care plan.
| ||||||
22 | "Person" means a corporation, association, partnership,
| ||||||
23 | limited liability company, sole proprietorship, or any other | ||||||
24 | legal entity.
| ||||||
25 | "Physician" means a person licensed under the Medical
| ||||||
26 | Practice Act of 1987.
|
| |||||||
| |||||||
1 | "Post-stabilization medical services" means health care | ||||||
2 | services
provided to an enrollee that are furnished in a | ||||||
3 | licensed hospital by a provider
that is qualified to furnish | ||||||
4 | such services, and determined to be medically
necessary and | ||||||
5 | directly related to the emergency medical condition following
| ||||||
6 | stabilization.
| ||||||
7 | "Stabilization" means, with respect to an emergency | ||||||
8 | medical condition, to
provide such medical treatment of the | ||||||
9 | condition as may be necessary to assure,
within reasonable | ||||||
10 | medical probability, that no material deterioration
of the | ||||||
11 | condition is likely to result.
| ||||||
12 | "Utilization review" means the evaluation of the medical | ||||||
13 | necessity,
appropriateness, and efficiency of the use of | ||||||
14 | health care services, procedures,
and facilities.
| ||||||
15 | "Utilization review program" means a program established | ||||||
16 | by 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 | ||||||
19 | adding Section 5-5.12d as follows:
| ||||||
20 | (305 ILCS 5/5-5.12d new) | ||||||
21 | Sec. 5-5.12d. Managed care organization prior | ||||||
22 | authorization of health care services. | ||||||
23 | (a) As used in this Section, "health care service" has the | ||||||
24 | meaning given to that term in the Prior Authorization Reform |
| |||||||
| |||||||
1 | Act. | ||||||
2 | (b) Notwithstanding any other provision of law to the | ||||||
3 | contrary, all managed care organizations shall comply with the | ||||||
4 | requirements of the Prior Authorization Reform Act.
| ||||||
5 | Section 999. Effective date. This Act takes effect January | ||||||
6 | 1, 2022.".
|