Bill Amendment: IL HB2472 | 2023-2024 | 103rd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: INS-ADVERSE DETERMINATION
Status: 2024-07-19 - Public Act . . . . . . . . . 103-0656 [HB2472 Detail]
Download: Illinois-2023-HB2472-House_Amendment_001.html
Bill Title: INS-ADVERSE DETERMINATION
Status: 2024-07-19 - Public Act . . . . . . . . . 103-0656 [HB2472 Detail]
Download: Illinois-2023-HB2472-House_Amendment_001.html
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1 | AMENDMENT TO HOUSE BILL 2472 | ||||||
2 | AMENDMENT NO. ______. Amend House Bill 2472 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Illinois Insurance Code is amended by | ||||||
5 | changing Sections 143.31, 155.36, 315.6, and 370s as follows:
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6 | (215 ILCS 5/143.31) | ||||||
7 | Sec. 143.31. Uniform medical claim and billing forms. | ||||||
8 | (a) The Director shall prescribe by rule, after | ||||||
9 | consultation with providers of health care or treatment, | ||||||
10 | insurers, hospital, medical, and dental service corporations, | ||||||
11 | and other prepayment organizations, insurance claim and | ||||||
12 | billing forms that the Director determines will provide for | ||||||
13 | uniformity and simplicity in insurance claims handling. The | ||||||
14 | claim forms shall include, but need not be limited to, | ||||||
15 | information regarding the medical diagnosis, treatment, and | ||||||
16 | prognosis of the patient, together with the details of charges |
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1 | incident to the providing of care, treatment, or services, | ||||||
2 | sufficient for the purpose of meeting the proof requirements | ||||||
3 | of an insurance policy or a hospital, medical, or dental | ||||||
4 | service contract. | ||||||
5 | (b) An insurer or a provider of health care treatment may | ||||||
6 | not refuse to accept a claim or bill submitted on duly | ||||||
7 | promulgated uniform claim and billing forms. An insurer, | ||||||
8 | however, may accept claims and bills submitted on any other | ||||||
9 | form. | ||||||
10 | (c) After receipt and adjudication or readjudication of | ||||||
11 | any claim or bill with all required documentation from an | ||||||
12 | insured or provider, or a notification under 42 U.S.C. | ||||||
13 | 300gg-136, an accident Accident and health insurer shall send | ||||||
14 | explanation of benefits paid statements or claims summary | ||||||
15 | statements sent to an insured by the accident and health | ||||||
16 | insurer shall be in a format and written in a manner that | ||||||
17 | promotes understanding by the insured by setting forth all of | ||||||
18 | the following: | ||||||
19 | (1) The total dollar amount submitted to the insurer | ||||||
20 | for payment. | ||||||
21 | (2) Any reduction in the amount paid due to the | ||||||
22 | application of any co-payment , coinsurance, or deductible, | ||||||
23 | along with an explanation of the amount of the co-payment , | ||||||
24 | coinsurance, or deductible applied under the insured's | ||||||
25 | policy. | ||||||
26 | (3) Any reduction in the amount paid due to the |
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1 | application of any other policy limitation , penalty, or | ||||||
2 | exclusion set forth in the insured's policy, along with an | ||||||
3 | explanation thereof. | ||||||
4 | (4) The total dollar amount paid. | ||||||
5 | (5) The total dollar amount remaining unpaid. | ||||||
6 | (6) If applicable under 42 U.S.C. 300gg-111 or 42 | ||||||
7 | U.S.C. 300gg-115, other information required for any | ||||||
8 | explanation of benefits described in either of those | ||||||
9 | Sections. | ||||||
10 | (d) The Director may issue an order directing an accident | ||||||
11 | and health insurer to comply with subsection (c). | ||||||
12 | (e) An accident and health insurer does not violate | ||||||
13 | subsection (c) by using a document that the accident and | ||||||
14 | health insurer is required to use by the federal government or | ||||||
15 | the State. | ||||||
16 | (f) The adoption of uniform claim forms and uniform | ||||||
17 | billing forms by the Director under this Section does not | ||||||
18 | preclude an insurer, hospital, medical, or dental service | ||||||
19 | corporation, or other prepayment organization from obtaining | ||||||
20 | any necessary additional information regarding a claim from | ||||||
21 | the claimant, provider of health care or treatment, or | ||||||
22 | certifier of coverage, as may be required. | ||||||
23 | (g) On and after January 1, 1996 when billing insurers or | ||||||
24 | otherwise filing insurance claims with insurers subject to | ||||||
25 | this Section, providers of health care or treatment, medical | ||||||
26 | services, dental services, pharmaceutical services, or medical |
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1 | equipment must use the uniform claim and billing forms adopted | ||||||
2 | by the Director under this Section. | ||||||
3 | (Source: P.A. 91-357, eff. 7-29-99.)
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4 | (215 ILCS 5/155.36) | ||||||
5 | Sec. 155.36. Managed Care Reform and Patient Rights Act. | ||||||
6 | Insurance companies that transact the kinds of insurance | ||||||
7 | authorized under Class 1(b) or Class 2(a) of Section 4 of this | ||||||
8 | Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65, | ||||||
9 | 70, and 85, subsection (d) of Section 30, and the definition of | ||||||
10 | the term "emergency medical condition" in Section 10 of the | ||||||
11 | Managed Care Reform and Patient Rights Act. Except as provided | ||||||
12 | by Section 85 of the Managed Care Reform and Patient Rights | ||||||
13 | Act, no law or rule shall be construed to exempt any | ||||||
14 | utilization review program from the requirements of Section 85 | ||||||
15 | of the Managed Care Reform and Patient Rights Act with respect | ||||||
16 | to any insurance described in this Section. | ||||||
17 | (Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
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18 | (215 ILCS 5/315.6) (from Ch. 73, par. 927.6) | ||||||
19 | (Section scheduled to be repealed on January 1, 2027) | ||||||
20 | Sec. 315.6. Application of other Code provisions. Unless | ||||||
21 | otherwise provided in this amendatory Act, every fraternal | ||||||
22 | benefit society shall be governed by this amendatory Act and | ||||||
23 | shall be exempt from all other provisions of the insurance | ||||||
24 | laws of this State not only in governmental relations with the |
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1 | State but for every other purpose, except for those provisions | ||||||
2 | specified in this amendatory Act and except as follows: | ||||||
3 | (a) Sections 1, 2, 2.1, 3.1, 117, 118, 132, 132.1, | ||||||
4 | 132.2, 132.3, 132.4, 132.5, 132.6, 132.7, 133, 134, 136, | ||||||
5 | 138, 139, 140, 141, 141.01, 141.1, 141.2, 141.3, 143, | ||||||
6 | 143.31, 143c, 144.1, 147, 148, 149, 150, 151, 152, 153, | ||||||
7 | 154.5, 154.6, 154.7, 154.8, 155, 155.04, 155.05, 155.06, | ||||||
8 | 155.07, 155.08 and 408 of this Code; and | ||||||
9 | (b) Articles VIII 1/2, XII, XII 1/2, XIII, XXIV, and | ||||||
10 | XXVIII of this Code. | ||||||
11 | (Source: P.A. 98-814, eff. 1-1-15 .)
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12 | (215 ILCS 5/370s) | ||||||
13 | Sec. 370s. Managed Care Reform and Patient Rights Act. All | ||||||
14 | administrators shall comply with Sections 55 and 85 of the | ||||||
15 | Managed Care Reform and Patient Rights Act. Except as provided | ||||||
16 | by Section 85 of the Managed Care Reform and Patient Rights | ||||||
17 | Act, no law or rule shall be construed to exempt any | ||||||
18 | utilization review program from the requirements of Section 85 | ||||||
19 | of the Managed Care Reform and Patient Rights Act with respect | ||||||
20 | to any insured or beneficiary described in this Article. | ||||||
21 | (Source: P.A. 91-617, eff. 1-1-00.)
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22 | Section 10. The Dental Service Plan Act is amended by | ||||||
23 | changing Section 25 as follows:
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1 | (215 ILCS 110/25) (from Ch. 32, par. 690.25) | ||||||
2 | Sec. 25. Application of Insurance Code provisions. Dental | ||||||
3 | service plan corporations and all persons interested therein | ||||||
4 | or dealing therewith shall be subject to the provisions of | ||||||
5 | Articles IIA, XI, and XII 1/2 and Sections 3.1, 133, 136, 139, | ||||||
6 | 140, 143, 143.31, 143c, 149, 155.49, 355.2, 355.3, 367.2, 401, | ||||||
7 | 401.1, 402, 403, 403A, 408, 408.2, and 412, and subsection | ||||||
8 | (15) of Section 367 of the Illinois Insurance Code. | ||||||
9 | (Source: P.A. 103-426, eff. 8-4-23.)
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10 | Section 15. The Network Adequacy and Transparency Act is | ||||||
11 | amended by changing Section 10 as follows:
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12 | (215 ILCS 124/10) | ||||||
13 | Sec. 10. Network adequacy. | ||||||
14 | (a) An insurer providing a network plan shall file a | ||||||
15 | description of all of the following with the Director: | ||||||
16 | (1) The written policies and procedures for adding | ||||||
17 | providers to meet patient needs based on increases in the | ||||||
18 | number of beneficiaries, changes in the | ||||||
19 | patient-to-provider ratio, changes in medical and health | ||||||
20 | care capabilities, and increased demand for services. | ||||||
21 | (2) The written policies and procedures for making | ||||||
22 | referrals within and outside the network. | ||||||
23 | (3) The written policies and procedures on how the | ||||||
24 | network plan will provide 24-hour, 7-day per week access |
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1 | to network-affiliated primary care, emergency services, | ||||||
2 | and women's principal health care providers. | ||||||
3 | An insurer shall not prohibit a preferred provider from | ||||||
4 | discussing any specific or all treatment options with | ||||||
5 | beneficiaries irrespective of the insurer's position on those | ||||||
6 | treatment options or from advocating on behalf of | ||||||
7 | beneficiaries within the utilization review, grievance, or | ||||||
8 | appeals processes established by the insurer in accordance | ||||||
9 | with any rights or remedies available under applicable State | ||||||
10 | or federal law. | ||||||
11 | (b) Insurers must file for review a description of the | ||||||
12 | services to be offered through a network plan. The description | ||||||
13 | shall include all of the following: | ||||||
14 | (1) A geographic map of the area proposed to be served | ||||||
15 | by the plan by county service area and zip code, including | ||||||
16 | marked locations for preferred providers. | ||||||
17 | (2) As deemed necessary by the Department, the names, | ||||||
18 | addresses, phone numbers, and specialties of the providers | ||||||
19 | who have entered into preferred provider agreements under | ||||||
20 | the network plan. | ||||||
21 | (3) The number of beneficiaries anticipated to be | ||||||
22 | covered by the network plan. | ||||||
23 | (4) An Internet website and toll-free telephone number | ||||||
24 | for beneficiaries and prospective beneficiaries to access | ||||||
25 | current and accurate lists of preferred providers, | ||||||
26 | additional information about the plan, as well as any |
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1 | other information required by Department rule. | ||||||
2 | (5) A description of how health care services to be | ||||||
3 | rendered under the network plan are reasonably accessible | ||||||
4 | and available to beneficiaries. The description shall | ||||||
5 | address all of the following: | ||||||
6 | (A) the type of health care services to be | ||||||
7 | provided by the network plan; | ||||||
8 | (B) the ratio of physicians and other providers to | ||||||
9 | beneficiaries, by specialty and including primary care | ||||||
10 | physicians and facility-based physicians when | ||||||
11 | applicable under the contract, necessary to meet the | ||||||
12 | health care needs and service demands of the currently | ||||||
13 | enrolled population; | ||||||
14 | (C) the travel and distance standards for plan | ||||||
15 | beneficiaries in county service areas; and | ||||||
16 | (D) a description of how the use of telemedicine, | ||||||
17 | telehealth, or mobile care services may be used to | ||||||
18 | partially meet the network adequacy standards, if | ||||||
19 | applicable. | ||||||
20 | (6) A provision ensuring that whenever a beneficiary | ||||||
21 | has made a good faith effort, as evidenced by accessing | ||||||
22 | the provider directory, calling the network plan, and | ||||||
23 | calling the provider, to utilize preferred providers for a | ||||||
24 | covered service and it is determined the insurer does not | ||||||
25 | have the appropriate preferred providers due to | ||||||
26 | insufficient number, type, unreasonable travel distance or |
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1 | delay, or preferred providers refusing to provide a | ||||||
2 | covered service because it is contrary to the conscience | ||||||
3 | of the preferred providers, as protected by the Health | ||||||
4 | Care Right of Conscience Act, the insurer shall ensure, | ||||||
5 | directly or indirectly, by terms contained in the payer | ||||||
6 | contract, that the beneficiary will be provided the | ||||||
7 | covered service at no greater cost to the beneficiary than | ||||||
8 | if the service had been provided by a preferred provider. | ||||||
9 | This paragraph (6) does not apply to: (A) a beneficiary | ||||||
10 | who willfully chooses to access a non-preferred provider | ||||||
11 | for health care services available through the panel of | ||||||
12 | preferred providers, or (B) a beneficiary enrolled in a | ||||||
13 | health maintenance organization. In these circumstances, | ||||||
14 | the contractual requirements for non-preferred provider | ||||||
15 | reimbursements shall apply unless Section 356z.3a of the | ||||||
16 | Illinois Insurance Code requires otherwise. In no event | ||||||
17 | shall a beneficiary who receives care at a participating | ||||||
18 | health care facility be required to search for | ||||||
19 | participating providers under the circumstances described | ||||||
20 | in subsection (b) or (b-5) of Section 356z.3a of the | ||||||
21 | Illinois Insurance Code except under the circumstances | ||||||
22 | described in paragraph (2) of subsection (b-5). | ||||||
23 | (7) A provision that the beneficiary shall receive | ||||||
24 | emergency care coverage such that payment for this | ||||||
25 | coverage is not dependent upon whether the emergency | ||||||
26 | services are performed by a preferred or non-preferred |
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1 | provider and the coverage shall be at the same benefit | ||||||
2 | level as if the service or treatment had been rendered by a | ||||||
3 | preferred provider. For purposes of this paragraph (7), | ||||||
4 | "the same benefit level" means that the beneficiary is | ||||||
5 | provided the covered service at no greater cost to the | ||||||
6 | beneficiary than if the service had been provided by a | ||||||
7 | preferred provider. This provision shall be consistent | ||||||
8 | with Section 356z.3a of the Illinois Insurance Code. | ||||||
9 | (8) A limitation that complies with subsections (d) | ||||||
10 | and (e) of Section 55 of the Prior Authorization Reform | ||||||
11 | Act , if the plan provides that the beneficiary will incur | ||||||
12 | a penalty for failing to pre-certify inpatient hospital | ||||||
13 | treatment, the penalty may not exceed $1,000 per | ||||||
14 | occurrence in addition to the plan cost sharing | ||||||
15 | provisions . | ||||||
16 | (c) The network plan shall demonstrate to the Director a | ||||||
17 | minimum ratio of providers to plan beneficiaries as required | ||||||
18 | by the Department. | ||||||
19 | (1) The ratio of physicians or other providers to plan | ||||||
20 | beneficiaries shall be established annually by the | ||||||
21 | Department in consultation with the Department of Public | ||||||
22 | Health based upon the guidance from the federal Centers | ||||||
23 | for Medicare and Medicaid Services. The Department shall | ||||||
24 | not establish ratios for vision or dental providers who | ||||||
25 | provide services under dental-specific or vision-specific | ||||||
26 | benefits. The Department shall consider establishing |
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1 | ratios for the following physicians or other providers: | ||||||
2 | (A) Primary Care; | ||||||
3 | (B) Pediatrics; | ||||||
4 | (C) Cardiology; | ||||||
5 | (D) Gastroenterology; | ||||||
6 | (E) General Surgery; | ||||||
7 | (F) Neurology; | ||||||
8 | (G) OB/GYN; | ||||||
9 | (H) Oncology/Radiation; | ||||||
10 | (I) Ophthalmology; | ||||||
11 | (J) Urology; | ||||||
12 | (K) Behavioral Health; | ||||||
13 | (L) Allergy/Immunology; | ||||||
14 | (M) Chiropractic; | ||||||
15 | (N) Dermatology; | ||||||
16 | (O) Endocrinology; | ||||||
17 | (P) Ears, Nose, and Throat (ENT)/Otolaryngology; | ||||||
18 | (Q) Infectious Disease; | ||||||
19 | (R) Nephrology; | ||||||
20 | (S) Neurosurgery; | ||||||
21 | (T) Orthopedic Surgery; | ||||||
22 | (U) Physiatry/Rehabilitative; | ||||||
23 | (V) Plastic Surgery; | ||||||
24 | (W) Pulmonary; | ||||||
25 | (X) Rheumatology; | ||||||
26 | (Y) Anesthesiology; |
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1 | (Z) Pain Medicine; | ||||||
2 | (AA) Pediatric Specialty Services; | ||||||
3 | (BB) Outpatient Dialysis; and | ||||||
4 | (CC) HIV. | ||||||
5 | (2) The Director shall establish a process for the | ||||||
6 | review of the adequacy of these standards, along with an | ||||||
7 | assessment of additional specialties to be included in the | ||||||
8 | list under this subsection (c). | ||||||
9 | (d) The network plan shall demonstrate to the Director | ||||||
10 | maximum travel and distance standards for plan beneficiaries, | ||||||
11 | which shall be established annually by the Department in | ||||||
12 | consultation with the Department of Public Health based upon | ||||||
13 | the guidance from the federal Centers for Medicare and | ||||||
14 | Medicaid Services. These standards shall consist of the | ||||||
15 | maximum minutes or miles to be traveled by a plan beneficiary | ||||||
16 | for each county type, such as large counties, metro counties, | ||||||
17 | or rural counties as defined by Department rule. | ||||||
18 | The maximum travel time and distance standards must | ||||||
19 | include standards for each physician and other provider | ||||||
20 | category listed for which ratios have been established. | ||||||
21 | The Director shall establish a process for the review of | ||||||
22 | the adequacy of these standards along with an assessment of | ||||||
23 | additional specialties to be included in the list under this | ||||||
24 | subsection (d). | ||||||
25 | (d-5)(1) Every insurer shall ensure that beneficiaries | ||||||
26 | have timely and proximate access to treatment for mental, |
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1 | emotional, nervous, or substance use disorders or conditions | ||||||
2 | in accordance with the provisions of paragraph (4) of | ||||||
3 | subsection (a) of Section 370c of the Illinois Insurance Code. | ||||||
4 | Insurers shall use a comparable process, strategy, evidentiary | ||||||
5 | standard, and other factors in the development and application | ||||||
6 | of the network adequacy standards for timely and proximate | ||||||
7 | access to treatment for mental, emotional, nervous, or | ||||||
8 | substance use disorders or conditions and those for the access | ||||||
9 | to treatment for medical and surgical conditions. As such, the | ||||||
10 | network adequacy standards for timely and proximate access | ||||||
11 | shall equally be applied to treatment facilities and providers | ||||||
12 | for mental, emotional, nervous, or substance use disorders or | ||||||
13 | conditions and specialists providing medical or surgical | ||||||
14 | benefits pursuant to the parity requirements of Section 370c.1 | ||||||
15 | of the Illinois Insurance Code and the federal Paul Wellstone | ||||||
16 | and Pete Domenici Mental Health Parity and Addiction Equity | ||||||
17 | Act of 2008. Notwithstanding the foregoing, the network | ||||||
18 | adequacy standards for timely and proximate access to | ||||||
19 | treatment for mental, emotional, nervous, or substance use | ||||||
20 | disorders or conditions shall, at a minimum, satisfy the | ||||||
21 | following requirements: | ||||||
22 | (A) For beneficiaries residing in the metropolitan | ||||||
23 | counties of Cook, DuPage, Kane, Lake, McHenry, and Will, | ||||||
24 | network adequacy standards for timely and proximate access | ||||||
25 | to treatment for mental, emotional, nervous, or substance | ||||||
26 | use disorders or conditions means a beneficiary shall not |
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1 | have to travel longer than 30 minutes or 30 miles from the | ||||||
2 | beneficiary's residence to receive outpatient treatment | ||||||
3 | for mental, emotional, nervous, or substance use disorders | ||||||
4 | or conditions. Beneficiaries shall not be required to wait | ||||||
5 | longer than 10 business days between requesting an initial | ||||||
6 | appointment and being seen by the facility or provider of | ||||||
7 | mental, emotional, nervous, or substance use disorders or | ||||||
8 | conditions for outpatient treatment or to wait longer than | ||||||
9 | 20 business days between requesting a repeat or follow-up | ||||||
10 | appointment and being seen by the facility or provider of | ||||||
11 | mental, emotional, nervous, or substance use disorders or | ||||||
12 | conditions for outpatient treatment; however, subject to | ||||||
13 | the protections of paragraph (3) of this subsection, a | ||||||
14 | network plan shall not be held responsible if the | ||||||
15 | beneficiary or provider voluntarily chooses to schedule an | ||||||
16 | appointment outside of these required time frames. | ||||||
17 | (B) For beneficiaries residing in Illinois counties | ||||||
18 | other than those counties listed in subparagraph (A) of | ||||||
19 | this paragraph, network adequacy standards for timely and | ||||||
20 | proximate access to treatment for mental, emotional, | ||||||
21 | nervous, or substance use disorders or conditions means a | ||||||
22 | beneficiary shall not have to travel longer than 60 | ||||||
23 | minutes or 60 miles from the beneficiary's residence to | ||||||
24 | receive outpatient treatment for mental, emotional, | ||||||
25 | nervous, or substance use disorders or conditions. | ||||||
26 | Beneficiaries shall not be required to wait longer than 10 |
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1 | business days between requesting an initial appointment | ||||||
2 | and being seen by the facility or provider of mental, | ||||||
3 | emotional, nervous, or substance use disorders or | ||||||
4 | conditions for outpatient treatment or to wait longer than | ||||||
5 | 20 business days between requesting a repeat or follow-up | ||||||
6 | appointment and being seen by the facility or provider of | ||||||
7 | mental, emotional, nervous, or substance use disorders or | ||||||
8 | conditions for outpatient treatment; however, subject to | ||||||
9 | the protections of paragraph (3) of this subsection, a | ||||||
10 | network plan shall not be held responsible if the | ||||||
11 | beneficiary or provider voluntarily chooses to schedule an | ||||||
12 | appointment outside of these required time frames. | ||||||
13 | (2) For beneficiaries residing in all Illinois counties, | ||||||
14 | network adequacy standards for timely and proximate access to | ||||||
15 | treatment for mental, emotional, nervous, or substance use | ||||||
16 | disorders or conditions means a beneficiary shall not have to | ||||||
17 | travel longer than 60 minutes or 60 miles from the | ||||||
18 | beneficiary's residence to receive inpatient or residential | ||||||
19 | treatment for mental, emotional, nervous, or substance use | ||||||
20 | disorders or conditions. | ||||||
21 | (3) If there is no in-network facility or provider | ||||||
22 | available for a beneficiary to receive timely and proximate | ||||||
23 | access to treatment for mental, emotional, nervous, or | ||||||
24 | substance use disorders or conditions in accordance with the | ||||||
25 | network adequacy standards outlined in this subsection, the | ||||||
26 | insurer shall provide necessary exceptions to its network to |
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1 | ensure admission and treatment with a provider or at a | ||||||
2 | treatment facility in accordance with the network adequacy | ||||||
3 | standards in this subsection. | ||||||
4 | (e) Except for network plans solely offered as a group | ||||||
5 | health plan, these ratio and time and distance standards apply | ||||||
6 | to the lowest cost-sharing tier of any tiered network. | ||||||
7 | (f) The network plan may consider use of other health care | ||||||
8 | service delivery options, such as telemedicine or telehealth, | ||||||
9 | mobile clinics, and centers of excellence, or other ways of | ||||||
10 | delivering care to partially meet the requirements set under | ||||||
11 | this Section. | ||||||
12 | (g) Except for the requirements set forth in subsection | ||||||
13 | (d-5), insurers who are not able to comply with the provider | ||||||
14 | ratios and time and distance standards established by the | ||||||
15 | Department may request an exception to these requirements from | ||||||
16 | the Department. The Department may grant an exception in the | ||||||
17 | following circumstances: | ||||||
18 | (1) if no providers or facilities meet the specific | ||||||
19 | time and distance standard in a specific service area and | ||||||
20 | the insurer (i) discloses information on the distance and | ||||||
21 | travel time points that beneficiaries would have to travel | ||||||
22 | beyond the required criterion to reach the next closest | ||||||
23 | contracted provider outside of the service area and (ii) | ||||||
24 | provides contact information, including names, addresses, | ||||||
25 | and phone numbers for the next closest contracted provider | ||||||
26 | or facility; |
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1 | (2) if patterns of care in the service area do not | ||||||
2 | support the need for the requested number of provider or | ||||||
3 | facility type and the insurer provides data on local | ||||||
4 | patterns of care, such as claims data, referral patterns, | ||||||
5 | or local provider interviews, indicating where the | ||||||
6 | beneficiaries currently seek this type of care or where | ||||||
7 | the physicians currently refer beneficiaries, or both; or | ||||||
8 | (3) other circumstances deemed appropriate by the | ||||||
9 | Department consistent with the requirements of this Act. | ||||||
10 | (h) Insurers are required to report to the Director any | ||||||
11 | material change to an approved network plan within 15 days | ||||||
12 | after the change occurs and any change that would result in | ||||||
13 | failure to meet the requirements of this Act. Upon notice from | ||||||
14 | the insurer, the Director shall reevaluate the network plan's | ||||||
15 | compliance with the network adequacy and transparency | ||||||
16 | standards of this Act. | ||||||
17 | (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; | ||||||
18 | 102-1117, eff. 1-13-23.)
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19 | Section 20. The Health Maintenance Organization Act is | ||||||
20 | amended by changing Section 5-3 as follows:
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21 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | ||||||
22 | Sec. 5-3. Insurance Code provisions. | ||||||
23 | (a) Health Maintenance Organizations shall be subject to | ||||||
24 | the provisions of Sections 133, 134, 136, 137, 139, 140, |
| |||||||
| |||||||
1 | 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, | ||||||
2 | 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, | ||||||
3 | 155.49, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, | ||||||
4 | 356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | ||||||
5 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||
6 | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | ||||||
7 | 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, | ||||||
8 | 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | ||||||
9 | 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, | ||||||
10 | 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | ||||||
11 | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | ||||||
12 | 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | ||||||
13 | 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
14 | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||||||
15 | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | ||||||
16 | subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||||||
17 | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||||||
18 | Illinois Insurance Code. | ||||||
19 | (b) For purposes of the Illinois Insurance Code, except | ||||||
20 | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||||||
21 | Health Maintenance Organizations in the following categories | ||||||
22 | are deemed to be "domestic companies": | ||||||
23 | (1) a corporation authorized under the Dental Service | ||||||
24 | Plan Act or the Voluntary Health Services Plans Act; | ||||||
25 | (2) a corporation organized under the laws of this | ||||||
26 | State; or |
| |||||||
| |||||||
1 | (3) a corporation organized under the laws of another | ||||||
2 | state, 30% or more of the enrollees of which are residents | ||||||
3 | of this State, except a corporation subject to | ||||||
4 | substantially the same requirements in its state of | ||||||
5 | organization as is a "domestic company" under Article VIII | ||||||
6 | 1/2 of the Illinois Insurance Code. | ||||||
7 | (c) In considering the merger, consolidation, or other | ||||||
8 | acquisition of control of a Health Maintenance Organization | ||||||
9 | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||||||
10 | (1) the Director shall give primary consideration to | ||||||
11 | the continuation of benefits to enrollees and the | ||||||
12 | financial conditions of the acquired Health Maintenance | ||||||
13 | Organization after the merger, consolidation, or other | ||||||
14 | acquisition of control takes effect; | ||||||
15 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
16 | Section 131.8 of the Illinois Insurance Code shall not | ||||||
17 | apply and (ii) the Director, in making his determination | ||||||
18 | with respect to the merger, consolidation, or other | ||||||
19 | acquisition of control, need not take into account the | ||||||
20 | effect on competition of the merger, consolidation, or | ||||||
21 | other acquisition of control; | ||||||
22 | (3) the Director shall have the power to require the | ||||||
23 | following information: | ||||||
24 | (A) certification by an independent actuary of the | ||||||
25 | adequacy of the reserves of the Health Maintenance | ||||||
26 | Organization sought to be acquired; |
| |||||||
| |||||||
1 | (B) pro forma financial statements reflecting the | ||||||
2 | combined balance sheets of the acquiring company and | ||||||
3 | the Health Maintenance Organization sought to be | ||||||
4 | acquired as of the end of the preceding year and as of | ||||||
5 | a date 90 days prior to the acquisition, as well as pro | ||||||
6 | forma financial statements reflecting projected | ||||||
7 | combined operation for a period of 2 years; | ||||||
8 | (C) a pro forma business plan detailing an | ||||||
9 | acquiring party's plans with respect to the operation | ||||||
10 | of the Health Maintenance Organization sought to be | ||||||
11 | acquired for a period of not less than 3 years; and | ||||||
12 | (D) such other information as the Director shall | ||||||
13 | require. | ||||||
14 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
15 | Insurance Code and this Section 5-3 shall apply to the sale by | ||||||
16 | any health maintenance organization of greater than 10% of its | ||||||
17 | enrollee population (including , without limitation , the health | ||||||
18 | maintenance organization's right, title, and interest in and | ||||||
19 | to its health care certificates). | ||||||
20 | (e) In considering any management contract or service | ||||||
21 | agreement subject to Section 141.1 of the Illinois Insurance | ||||||
22 | Code, the Director (i) shall, in addition to the criteria | ||||||
23 | specified in Section 141.2 of the Illinois Insurance Code, | ||||||
24 | take into account the effect of the management contract or | ||||||
25 | service agreement on the continuation of benefits to enrollees | ||||||
26 | and the financial condition of the health maintenance |
| |||||||
| |||||||
1 | organization to be managed or serviced, and (ii) need not take | ||||||
2 | into account the effect of the management contract or service | ||||||
3 | agreement on competition. | ||||||
4 | (f) Except for small employer groups as defined in the | ||||||
5 | Small Employer Rating, Renewability and Portability Health | ||||||
6 | Insurance Act and except for medicare supplement policies as | ||||||
7 | defined in Section 363 of the Illinois Insurance Code, a | ||||||
8 | Health Maintenance Organization may by contract agree with a | ||||||
9 | group or other enrollment unit to effect refunds or charge | ||||||
10 | additional premiums under the following terms and conditions: | ||||||
11 | (i) the amount of, and other terms and conditions with | ||||||
12 | respect to, the refund or additional premium are set forth | ||||||
13 | in the group or enrollment unit contract agreed in advance | ||||||
14 | of the period for which a refund is to be paid or | ||||||
15 | additional premium is to be charged (which period shall | ||||||
16 | not be less than one year); and | ||||||
17 | (ii) the amount of the refund or additional premium | ||||||
18 | shall not exceed 20% of the Health Maintenance | ||||||
19 | Organization's profitable or unprofitable experience with | ||||||
20 | respect to the group or other enrollment unit for the | ||||||
21 | period (and, for purposes of a refund or additional | ||||||
22 | premium, the profitable or unprofitable experience shall | ||||||
23 | be calculated taking into account a pro rata share of the | ||||||
24 | Health Maintenance Organization's administrative and | ||||||
25 | marketing expenses, but shall not include any refund to be | ||||||
26 | made or additional premium to be paid pursuant to this |
| |||||||
| |||||||
1 | subsection (f)). The Health Maintenance Organization and | ||||||
2 | the group or enrollment unit may agree that the profitable | ||||||
3 | or unprofitable experience may be calculated taking into | ||||||
4 | account the refund period and the immediately preceding 2 | ||||||
5 | plan years. | ||||||
6 | The Health Maintenance Organization shall include a | ||||||
7 | statement in the evidence of coverage issued to each enrollee | ||||||
8 | describing the possibility of a refund or additional premium, | ||||||
9 | and upon request of any group or enrollment unit, provide to | ||||||
10 | the group or enrollment unit a description of the method used | ||||||
11 | to calculate (1) the Health Maintenance Organization's | ||||||
12 | profitable experience with respect to the group or enrollment | ||||||
13 | unit and the resulting refund to the group or enrollment unit | ||||||
14 | or (2) the Health Maintenance Organization's unprofitable | ||||||
15 | experience with respect to the group or enrollment unit and | ||||||
16 | the resulting additional premium to be paid by the group or | ||||||
17 | enrollment unit. | ||||||
18 | In no event shall the Illinois Health Maintenance | ||||||
19 | Organization Guaranty Association be liable to pay any | ||||||
20 | contractual obligation of an insolvent organization to pay any | ||||||
21 | refund authorized under this Section. | ||||||
22 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
23 | if any, is conditioned on the rules being adopted in | ||||||
24 | accordance with all provisions of the Illinois Administrative | ||||||
25 | Procedure Act and all rules and procedures of the Joint | ||||||
26 | Committee on Administrative Rules; any purported rule not so |
| |||||||
| |||||||
1 | adopted, for whatever reason, is unauthorized. | ||||||
2 | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||||||
3 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
4 | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||||||
5 | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||||||
6 | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||||||
7 | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||||||
8 | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||||||
9 | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||||||
10 | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
11 | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
| ||||||
12 | Section 25. The Limited Health Service Organization Act is | ||||||
13 | amended by changing Section 4003 as follows:
| ||||||
14 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) | ||||||
15 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
16 | health service organizations shall be subject to the | ||||||
17 | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | ||||||
18 | 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153, | ||||||
19 | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, | ||||||
20 | 355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, | ||||||
21 | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | ||||||
22 | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | ||||||
23 | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | ||||||
24 | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, |
| |||||||
| |||||||
1 | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, | ||||||
2 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. | ||||||
3 | Nothing in this Section shall require a limited health care | ||||||
4 | plan to cover any service that is not a limited health service. | ||||||
5 | For purposes of the Illinois Insurance Code, except for | ||||||
6 | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited | ||||||
7 | health service organizations in the following categories are | ||||||
8 | deemed to be domestic companies: | ||||||
9 | (1) a corporation under the laws of this State; or | ||||||
10 | (2) a corporation organized under the laws of another | ||||||
11 | state, 30% or more of the enrollees of which are residents | ||||||
12 | of this State, except a corporation subject to | ||||||
13 | substantially the same requirements in its state of | ||||||
14 | organization as is a domestic company under Article VIII | ||||||
15 | 1/2 of the Illinois Insurance Code. | ||||||
16 | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||||||
17 | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | ||||||
18 | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | ||||||
19 | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | ||||||
20 | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | ||||||
21 | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
22 | eff. 1-1-24; revised 8-29-23.)
| ||||||
23 | Section 30. The Managed Care Reform and Patient Rights Act | ||||||
24 | is amended by changing Sections 10, 45, and 85 as follows:
|
| |||||||
| |||||||
1 | (215 ILCS 134/10) | ||||||
2 | Sec. 10. Definitions. In this Act: | ||||||
3 | For a health care plan under Section 45 or for a | ||||||
4 | utilization review program under Section 85, "adverse | ||||||
5 | determination" has the meaning given to that term in Section | ||||||
6 | 10 of the Health Carrier External Review Act "Adverse | ||||||
7 | determination" means a determination by a health care plan | ||||||
8 | under Section 45 or by a utilization review program under | ||||||
9 | Section 85 that a health care service is not medically | ||||||
10 | necessary . | ||||||
11 | "Clinical peer" means a health care professional who is in | ||||||
12 | the same profession and the same or similar specialty as the | ||||||
13 | health care provider who typically manages the medical | ||||||
14 | condition, procedures, or treatment under review. | ||||||
15 | "Department" means the Department of Insurance. | ||||||
16 | "Emergency medical condition" means a medical condition | ||||||
17 | manifesting itself by acute symptoms of sufficient severity, | ||||||
18 | regardless of the final diagnosis given, such that a prudent | ||||||
19 | layperson, who possesses an average knowledge of health and | ||||||
20 | medicine, could reasonably expect the absence of immediate | ||||||
21 | medical attention to result in: | ||||||
22 | (1) placing the health of the individual (or, with | ||||||
23 | respect to a pregnant woman, the health of the woman or her | ||||||
24 | unborn child) in serious jeopardy; | ||||||
25 | (2) serious impairment to bodily functions; | ||||||
26 | (3) serious dysfunction of any bodily organ or part; |
| |||||||
| |||||||
1 | (4) inadequately controlled pain; or | ||||||
2 | (5) with respect to a pregnant woman who is having | ||||||
3 | contractions: | ||||||
4 | (A) inadequate time to complete a safe transfer to | ||||||
5 | another hospital before delivery; or | ||||||
6 | (B) a transfer to another hospital may pose a | ||||||
7 | threat to the health or safety of the woman or unborn | ||||||
8 | child. | ||||||
9 | "Emergency medical screening examination" means a medical | ||||||
10 | screening examination and evaluation by a physician licensed | ||||||
11 | to practice medicine in all its branches, or to the extent | ||||||
12 | permitted by applicable laws, by other appropriately licensed | ||||||
13 | personnel under the supervision of or in collaboration with a | ||||||
14 | physician licensed to practice medicine in all its branches to | ||||||
15 | determine whether the need for emergency services exists. | ||||||
16 | "Emergency services" means, with respect to an enrollee of | ||||||
17 | a health care plan, transportation services, including but not | ||||||
18 | limited to ambulance services, and covered inpatient and | ||||||
19 | outpatient hospital services furnished by a provider qualified | ||||||
20 | to furnish those services that are needed to evaluate or | ||||||
21 | stabilize an emergency medical condition. "Emergency services" | ||||||
22 | does not refer to post-stabilization medical services. | ||||||
23 | "Enrollee" means any person and his or her dependents | ||||||
24 | enrolled in or covered by a health care plan. | ||||||
25 | "Health care plan" means a plan, including, but not | ||||||
26 | limited to, a health maintenance organization, a managed care |
| |||||||
| |||||||
1 | community network as defined in the Illinois Public Aid Code, | ||||||
2 | or an accountable care entity as defined in the Illinois | ||||||
3 | Public Aid Code that receives capitated payments to cover | ||||||
4 | medical services from the Department of Healthcare and Family | ||||||
5 | Services, that establishes, operates, or maintains a network | ||||||
6 | of health care providers that has entered into an agreement | ||||||
7 | with the plan to provide health care services to enrollees to | ||||||
8 | whom the plan has the ultimate obligation to arrange for the | ||||||
9 | provision of or payment for services through organizational | ||||||
10 | arrangements for ongoing quality assurance, utilization review | ||||||
11 | programs, or dispute resolution. Nothing in this definition | ||||||
12 | shall be construed to mean that an independent practice | ||||||
13 | association or a physician hospital organization that | ||||||
14 | subcontracts with a health care plan is, for purposes of that | ||||||
15 | subcontract, a health care plan. | ||||||
16 | For purposes of this definition, "health care plan" shall | ||||||
17 | not include the following: | ||||||
18 | (1) indemnity health insurance policies including | ||||||
19 | those using a contracted provider network; | ||||||
20 | (2) health care plans that offer only dental or only | ||||||
21 | vision coverage; | ||||||
22 | (3) preferred provider administrators, as defined in | ||||||
23 | Section 370g(g) of the Illinois Insurance Code; | ||||||
24 | (4) employee or employer self-insured health benefit | ||||||
25 | plans under the federal Employee Retirement Income | ||||||
26 | Security Act of 1974; |
| |||||||
| |||||||
1 | (5) health care provided pursuant to the Workers' | ||||||
2 | Compensation Act or the Workers' Occupational Diseases | ||||||
3 | Act; and | ||||||
4 | (6) except with respect to subsections (a) and (b) of | ||||||
5 | Section 65 and subsection (a-5) of Section 70, | ||||||
6 | not-for-profit voluntary health services plans with health | ||||||
7 | maintenance organization authority in existence as of | ||||||
8 | January 1, 1999 that are affiliated with a union and that | ||||||
9 | only extend coverage to union members and their | ||||||
10 | dependents. | ||||||
11 | "Health care professional" means a physician, a registered | ||||||
12 | professional nurse, or other individual appropriately licensed | ||||||
13 | or registered to provide health care services. | ||||||
14 | "Health care provider" means any physician, hospital | ||||||
15 | facility, facility licensed under the Nursing Home Care Act, | ||||||
16 | long-term care facility as defined in Section 1-113 of the | ||||||
17 | Nursing Home Care Act, or other person that is licensed or | ||||||
18 | otherwise authorized to deliver health care services. Nothing | ||||||
19 | in this Act shall be construed to define Independent Practice | ||||||
20 | Associations or Physician-Hospital Organizations as health | ||||||
21 | care providers. | ||||||
22 | "Health care services" means any services included in the | ||||||
23 | furnishing to any individual of medical care, or the | ||||||
24 | hospitalization incident to the furnishing of such care, as | ||||||
25 | well as the furnishing to any person of any and all other | ||||||
26 | services for the purpose of preventing, alleviating, curing, |
| |||||||
| |||||||
1 | or healing human illness or injury including behavioral | ||||||
2 | health, mental health, home health, and pharmaceutical | ||||||
3 | services and products. | ||||||
4 | "Medical director" means a physician licensed in any state | ||||||
5 | to practice medicine in all its branches appointed by a health | ||||||
6 | care plan. | ||||||
7 | "Person" means a corporation, association, partnership, | ||||||
8 | limited liability company, sole proprietorship, or any other | ||||||
9 | legal entity. | ||||||
10 | "Physician" means a person licensed under the Medical | ||||||
11 | Practice Act of 1987. | ||||||
12 | "Post-stabilization medical services" means health care | ||||||
13 | services provided to an enrollee that are furnished in a | ||||||
14 | licensed hospital by a provider that is qualified to furnish | ||||||
15 | such services, and determined to be medically necessary and | ||||||
16 | directly related to the emergency medical condition following | ||||||
17 | stabilization. | ||||||
18 | "Stabilization" means, with respect to an emergency | ||||||
19 | medical condition, to provide such medical treatment of the | ||||||
20 | condition as may be necessary to assure, within reasonable | ||||||
21 | medical probability, that no material deterioration of the | ||||||
22 | condition is likely to result. | ||||||
23 | "Utilization review" means the evaluation , including any | ||||||
24 | evaluation based on an algorithmic automated process, of the | ||||||
25 | medical necessity, appropriateness, and efficiency of the use | ||||||
26 | of health care services, procedures, and facilities. |
| |||||||
| |||||||
1 | "Utilization review program" means a program established | ||||||
2 | by a person to perform utilization review. | ||||||
3 | (Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
| ||||||
4 | (215 ILCS 134/45) | ||||||
5 | Sec. 45. Health care services appeals, complaints, and | ||||||
6 | external independent reviews. | ||||||
7 | (a) A health care plan shall establish and maintain an | ||||||
8 | appeals procedure as outlined in this Act. Compliance with | ||||||
9 | this Act's appeals procedures shall satisfy a health care | ||||||
10 | plan's obligation to provide appeal procedures under any other | ||||||
11 | State law or rules. All appeals of a health care plan's | ||||||
12 | administrative determinations and complaints regarding its | ||||||
13 | administrative decisions shall be handled as required under | ||||||
14 | Section 50. | ||||||
15 | (b) When an appeal concerns a decision or action by a | ||||||
16 | health care plan, its employees, or its subcontractors that | ||||||
17 | relates to (i) health care services, including, but not | ||||||
18 | limited to, procedures or treatments, for an enrollee with an | ||||||
19 | ongoing course of treatment ordered by a health care provider, | ||||||
20 | the denial of which could significantly increase the risk to | ||||||
21 | an enrollee's health, or (ii) a treatment referral, service, | ||||||
22 | procedure, or other health care service, the denial of which | ||||||
23 | could significantly increase the risk to an enrollee's health, | ||||||
24 | the health care plan must allow for the filing of an appeal | ||||||
25 | either orally or in writing. Upon submission of the appeal, a |
| |||||||
| |||||||
1 | health care plan must notify the party filing the appeal, as | ||||||
2 | soon as possible, but in no event more than 24 hours after the | ||||||
3 | submission of the appeal, of all information that the plan | ||||||
4 | requires to evaluate the appeal. The health care plan shall | ||||||
5 | render a decision on the appeal within 24 hours after receipt | ||||||
6 | of the required information. The health care plan shall notify | ||||||
7 | the party filing the appeal and the enrollee, enrollee's | ||||||
8 | primary care physician, and any health care provider who | ||||||
9 | recommended the health care service involved in the appeal of | ||||||
10 | its decision orally followed-up by a written notice of the | ||||||
11 | determination. | ||||||
12 | (c) For all appeals related to health care services | ||||||
13 | including, but not limited to, procedures or treatments for an | ||||||
14 | enrollee and not covered by subsection (b) above, the health | ||||||
15 | care plan shall establish a procedure for the filing of such | ||||||
16 | appeals. Upon submission of an appeal under this subsection, a | ||||||
17 | health care plan must notify the party filing an appeal, | ||||||
18 | within 3 business days, of all information that the plan | ||||||
19 | requires to evaluate the appeal. The health care plan shall | ||||||
20 | render a decision on the appeal within 15 business days after | ||||||
21 | receipt of the required information. The health care plan | ||||||
22 | shall notify the party filing the appeal, the enrollee, the | ||||||
23 | enrollee's primary care physician, and any health care | ||||||
24 | provider who recommended the health care service involved in | ||||||
25 | the appeal orally of its decision followed-up by a written | ||||||
26 | notice of the determination. |
| |||||||
| |||||||
1 | (d) An appeal under subsection (b) or (c) may be filed by | ||||||
2 | the enrollee, the enrollee's designee or guardian, the | ||||||
3 | enrollee's primary care physician, or the enrollee's health | ||||||
4 | care provider. A health care plan shall designate a clinical | ||||||
5 | peer to review appeals, because these appeals pertain to | ||||||
6 | medical or clinical matters and such an appeal must be | ||||||
7 | reviewed by an appropriate health care professional. No one | ||||||
8 | reviewing an appeal may have had any involvement in the | ||||||
9 | initial determination that is the subject of the appeal. The | ||||||
10 | written notice of determination required under subsections (b) | ||||||
11 | and (c) shall include (i) clear and detailed reasons for the | ||||||
12 | determination, (ii) the medical or clinical criteria for the | ||||||
13 | determination, which shall be based upon sound clinical | ||||||
14 | evidence and reviewed on a periodic basis, and (iii) in the | ||||||
15 | case of an adverse determination, the procedures for | ||||||
16 | requesting an external independent review as provided by the | ||||||
17 | Illinois Health Carrier External Review Act. | ||||||
18 | (e) If an appeal filed under subsection (b) or (c) is | ||||||
19 | denied for a reason including, but not limited to, the | ||||||
20 | service, procedure, or treatment is not viewed as medically | ||||||
21 | necessary, denial of specific tests or procedures, denial of | ||||||
22 | referral to specialist physicians or denial of hospitalization | ||||||
23 | requests or length of stay requests, any involved party may | ||||||
24 | request an external independent review as provided by the | ||||||
25 | Illinois Health Carrier External Review Act. | ||||||
26 | (f) Until July 1, 2013, if an external independent review |
| |||||||
| |||||||
1 | decision made pursuant to the Illinois Health Carrier External | ||||||
2 | Review Act upholds a determination adverse to the covered | ||||||
3 | person, the covered person has the right to appeal the final | ||||||
4 | decision to the Department; if the external review decision is | ||||||
5 | found by the Director to have been arbitrary and capricious, | ||||||
6 | then the Director, with consultation from a licensed medical | ||||||
7 | professional, may overturn the external review decision and | ||||||
8 | require the health carrier to pay for the health care service | ||||||
9 | or treatment; such decision, if any, shall be made solely on | ||||||
10 | the legal or medical merits of the claim. If an external review | ||||||
11 | decision is overturned by the Director pursuant to this | ||||||
12 | Section and the health carrier so requests, then the Director | ||||||
13 | shall assign a new independent review organization to | ||||||
14 | reconsider the overturned decision. The new independent review | ||||||
15 | organization shall follow subsection (d) of Section 40 of the | ||||||
16 | Health Carrier External Review Act in rendering a decision. | ||||||
17 | (g) Future contractual or employment action by the health | ||||||
18 | care plan regarding the patient's physician or other health | ||||||
19 | care provider shall not be based solely on the physician's or | ||||||
20 | other health care provider's participation in health care | ||||||
21 | services appeals, complaints, or external independent reviews | ||||||
22 | under the Illinois Health Carrier External Review Act. | ||||||
23 | (h) Nothing in this Section shall be construed to require | ||||||
24 | a health care plan to pay for a health care service not covered | ||||||
25 | under the enrollee's certificate of coverage or policy. | ||||||
26 | (i) Even if a health care plan or other utilization review |
| |||||||
| |||||||
1 | program uses an algorithmic automated process in the course of | ||||||
2 | utilization review, the health care plan or other utilization | ||||||
3 | review program shall ensure that only a clinical peer makes | ||||||
4 | any adverse determination and that any appeal is processed as | ||||||
5 | required by this Section, including the restriction that only | ||||||
6 | a clinical peer may review an appeal. A health care plan or | ||||||
7 | other utilization review program using an automated process | ||||||
8 | shall have the accreditation and the policies and procedures | ||||||
9 | required by subsection (b-10) of Section 85 of this Act. | ||||||
10 | (Source: P.A. 96-857, eff. 7-1-10 .)
| ||||||
11 | (215 ILCS 134/85) | ||||||
12 | Sec. 85. Utilization review program registration. | ||||||
13 | (a) No person may conduct a utilization review program in | ||||||
14 | this State unless once every 2 years the person registers the | ||||||
15 | utilization review program with the Department and provides | ||||||
16 | proof of current accreditation for itself and its | ||||||
17 | subcontractors certifies compliance with the Health | ||||||
18 | Utilization Management Standards of the Utilization Review | ||||||
19 | Accreditation Commission or another accreditation entity | ||||||
20 | authorized under this Section Health Utilization Management | ||||||
21 | Standards of the American Accreditation Healthcare Commission | ||||||
22 | (URAC) sufficient to achieve American Accreditation Healthcare | ||||||
23 | Commission (URAC) accreditation or submits evidence of | ||||||
24 | accreditation by the American Accreditation Healthcare | ||||||
25 | Commission (URAC) for its Health Utilization Management |
| |||||||
| |||||||
1 | Standards. Nothing in this Act shall be construed to require a | ||||||
2 | health care plan or its subcontractors to become American | ||||||
3 | Accreditation Healthcare Commission (URAC) accredited . | ||||||
4 | (b) In addition, the Director of the Department, in | ||||||
5 | consultation with the Director of the Department of Public | ||||||
6 | Health, may certify alternative utilization review standards | ||||||
7 | of national accreditation organizations or entities in order | ||||||
8 | for plans to comply with this Section. Any alternative | ||||||
9 | utilization review standards shall meet or exceed those | ||||||
10 | standards required under subsection (a). | ||||||
11 | (b-5) The Department shall recognize the Accreditation | ||||||
12 | Association for Ambulatory Health Care among the list of | ||||||
13 | accreditors from which utilization organizations may receive | ||||||
14 | accreditation and qualify for reduced registration and renewal | ||||||
15 | fees. | ||||||
16 | (b-10) Utilization review programs that use algorithmic | ||||||
17 | automated processes in the course of utilization review shall | ||||||
18 | use objective, evidence-based criteria compliant with the | ||||||
19 | accreditation requirements of the Health Utilization | ||||||
20 | Management Standards of the Utilization Review Accreditation | ||||||
21 | Commission or the National Committee for Quality Assurance | ||||||
22 | (NCQA) and shall provide proof of such compliance to the | ||||||
23 | Department with the registration required under subsection | ||||||
24 | (a), including any renewal registrations. Nothing in this | ||||||
25 | subsection supersedes paragraph (2) of subsection (e). The | ||||||
26 | utilization review program shall include, with its |
| |||||||
| |||||||
1 | registration materials, attachments that contain policies and | ||||||
2 | procedures: | ||||||
3 | (1) to ensure that licensed physicians with relevant | ||||||
4 | board certifications establish all criteria that the | ||||||
5 | algorithmic automated process uses for utilization review; | ||||||
6 | and | ||||||
7 | (2) for a program integrity system that, both before | ||||||
8 | new or revised criteria are used for utilization review | ||||||
9 | and when implementation errors in the algorithmic | ||||||
10 | automated process are identified after new or revised | ||||||
11 | criteria go into effect, requires licensed physicians with | ||||||
12 | relevant board certifications to verify that the | ||||||
13 | algorithmic automated process and corrections to it yield | ||||||
14 | results consistent with the criteria for their certified | ||||||
15 | field. | ||||||
16 | (c) The provisions of this Section do not apply to: | ||||||
17 | (1) persons providing utilization review program | ||||||
18 | services only to the federal government; | ||||||
19 | (2) self-insured health plans under the federal | ||||||
20 | Employee Retirement Income Security Act of 1974, however, | ||||||
21 | this Section does apply to persons conducting a | ||||||
22 | utilization review program on behalf of these health | ||||||
23 | plans; | ||||||
24 | (3) hospitals and medical groups performing | ||||||
25 | utilization review activities for internal purposes unless | ||||||
26 | the utilization review program is conducted for another |
| |||||||
| |||||||
1 | person. | ||||||
2 | Nothing in this Act prohibits a health care plan or other | ||||||
3 | entity from contractually requiring an entity designated in | ||||||
4 | item (3) of this subsection to adhere to the utilization | ||||||
5 | review program requirements of this Act. | ||||||
6 | (d) This registration shall include submission of all of | ||||||
7 | the following information regarding utilization review program | ||||||
8 | activities: | ||||||
9 | (1) The name, address, and telephone number of the | ||||||
10 | utilization review programs. | ||||||
11 | (2) The organization and governing structure of the | ||||||
12 | utilization review programs. | ||||||
13 | (3) The number of lives for which utilization review | ||||||
14 | is conducted by each utilization review program. | ||||||
15 | (4) Hours of operation of each utilization review | ||||||
16 | program. | ||||||
17 | (5) Description of the grievance process for each | ||||||
18 | utilization review program. | ||||||
19 | (6) Number of covered lives for which utilization | ||||||
20 | review was conducted for the previous calendar year for | ||||||
21 | each utilization review program. | ||||||
22 | (7) Written policies and procedures for protecting | ||||||
23 | confidential information according to applicable State and | ||||||
24 | federal laws for each utilization review program. | ||||||
25 | (e) (1) A utilization review program shall have written | ||||||
26 | procedures for assuring that patient-specific information |
| |||||||
| |||||||
1 | obtained during the process of utilization review will be: | ||||||
2 | (A) kept confidential in accordance with applicable | ||||||
3 | State and federal laws; and | ||||||
4 | (B) shared only with the enrollee, the enrollee's | ||||||
5 | designee, the enrollee's health care provider, and those | ||||||
6 | who are authorized by law to receive the information. | ||||||
7 | Summary data shall not be considered confidential if it | ||||||
8 | does not provide information to allow identification of | ||||||
9 | individual patients or health care providers. | ||||||
10 | (2) Only a clinical peer health care professional may | ||||||
11 | make adverse determinations regarding the medical | ||||||
12 | necessity of health care services during the course of | ||||||
13 | utilization review. Either a health care professional or | ||||||
14 | an accredited algorithmic automated process, or both in | ||||||
15 | combination, may certify the medical necessity of a health | ||||||
16 | care service in accordance with accreditation standards. | ||||||
17 | Nothing in this subsection prohibits an accredited | ||||||
18 | algorithmic automated process from being used to refer a | ||||||
19 | case to a clinical peer for a potential adverse | ||||||
20 | determination. | ||||||
21 | (3) When making retrospective reviews, utilization | ||||||
22 | review programs shall base reviews solely on the medical | ||||||
23 | information available to the attending physician or | ||||||
24 | ordering provider at the time the health care services | ||||||
25 | were provided. This paragraph includes billing records and | ||||||
26 | diagnosis or procedure codes that substantively contain |
| |||||||
| |||||||
1 | the same medical information to an equal or lesser degree | ||||||
2 | of specificity as the records the attending physician or | ||||||
3 | ordering provider directly consulted at the time health | ||||||
4 | care services were provided. | ||||||
5 | (4) When making prospective, concurrent, and | ||||||
6 | retrospective determinations, utilization review programs | ||||||
7 | shall collect only information that is necessary to make | ||||||
8 | the determination and shall not routinely require health | ||||||
9 | care providers to numerically code diagnoses or procedures | ||||||
10 | to be considered for certification, unless required under | ||||||
11 | State or federal Medicare or Medicaid rules or | ||||||
12 | regulations, but may request such code if available, or | ||||||
13 | routinely request copies of medical records of all | ||||||
14 | enrollees reviewed. During prospective or concurrent | ||||||
15 | review, copies of medical records shall only be required | ||||||
16 | when necessary to verify that the health care services | ||||||
17 | subject to review are medically necessary. In these cases, | ||||||
18 | only the necessary or relevant sections of the medical | ||||||
19 | record shall be required. | ||||||
20 | (f) If the Department finds that a utilization review | ||||||
21 | program is not in compliance with this Section, the Department | ||||||
22 | shall issue a corrective action plan and allow a reasonable | ||||||
23 | amount of time for compliance with the plan. If the | ||||||
24 | utilization review program does not come into compliance, the | ||||||
25 | Department may issue a cease and desist order. Before issuing | ||||||
26 | a cease and desist order under this Section, the Department |
| |||||||
| |||||||
1 | shall provide the utilization review program with a written | ||||||
2 | notice of the reasons for the order and allow a reasonable | ||||||
3 | amount of time to supply additional information demonstrating | ||||||
4 | compliance with requirements of this Section and to request a | ||||||
5 | hearing. The hearing notice shall be sent by certified mail, | ||||||
6 | return receipt requested, and the hearing shall be conducted | ||||||
7 | in accordance with the Illinois Administrative Procedure Act. | ||||||
8 | (g) A utilization review program subject to a corrective | ||||||
9 | action may continue to conduct business until a final decision | ||||||
10 | has been issued by the Department. | ||||||
11 | (h) Any adverse determination made by a health care plan | ||||||
12 | or its subcontractors may be appealed in accordance with | ||||||
13 | subsection (f) of Section 45. | ||||||
14 | (i) The Director may by rule establish a registration fee | ||||||
15 | for each person conducting a utilization review program. All | ||||||
16 | fees paid to and collected by the Director under this Section | ||||||
17 | shall be deposited into the Insurance Producer Administration | ||||||
18 | Fund. | ||||||
19 | (Source: P.A. 99-111, eff. 1-1-16 .)
| ||||||
20 | Section 35. The Voluntary Health Services Plans Act is | ||||||
21 | amended by changing Section 10 as follows:
| ||||||
22 | (215 ILCS 165/10) (from Ch. 32, par. 604) | ||||||
23 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
24 | services plan corporations and all persons interested therein |
| |||||||
| |||||||
1 | or dealing therewith shall be subject to the provisions of | ||||||
2 | Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, | ||||||
3 | 143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, | ||||||
4 | 355b, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, | ||||||
5 | 356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, | ||||||
6 | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | ||||||
7 | 356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, | ||||||
8 | 356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, | ||||||
9 | 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | ||||||
10 | 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, | ||||||
11 | 356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401, | ||||||
12 | 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) | ||||||
13 | and (15) of Section 367 of the Illinois Insurance Code. | ||||||
14 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
15 | any, is conditioned on the rules being adopted in accordance | ||||||
16 | with all provisions of the Illinois Administrative Procedure | ||||||
17 | Act and all rules and procedures of the Joint Committee on | ||||||
18 | Administrative Rules; any purported rule not so adopted, for | ||||||
19 | whatever reason, is unauthorized. | ||||||
20 | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||||||
21 | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. | ||||||
22 | 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, | ||||||
23 | eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | ||||||
24 | 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. | ||||||
25 | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||||||
26 | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; |
| |||||||
| |||||||
1 | 103-551, eff. 8-11-23; revised 8-29-23.)
| ||||||
2 | Section 40. The Health Carrier External Review Act is | ||||||
3 | amended by changing Section 10 as follows:
| ||||||
4 | (215 ILCS 180/10) | ||||||
5 | Sec. 10. Definitions. For the purposes of this Act: | ||||||
6 | "Adverse determination" means: | ||||||
7 | (1) a determination by a health carrier or its | ||||||
8 | designee utilization review organization that, based upon | ||||||
9 | the health information provided, a request for a benefit , | ||||||
10 | including any quantity, frequency, duration, or other | ||||||
11 | measurement of a benefit, under the health carrier's | ||||||
12 | health benefit plan upon application of any utilization | ||||||
13 | review technique does not meet the health carrier's | ||||||
14 | requirements for medical necessity, appropriateness, | ||||||
15 | health care setting, level of care, or effectiveness or is | ||||||
16 | determined to be experimental or investigational and the | ||||||
17 | requested benefit is therefore denied, reduced, or | ||||||
18 | terminated or payment is not provided or made, in whole or | ||||||
19 | in part, for the benefit; | ||||||
20 | (2) the denial, reduction, or termination of or | ||||||
21 | failure to provide or make payment, in whole or in part, | ||||||
22 | for a benefit based on a determination by a health carrier | ||||||
23 | or its designee utilization review organization that a | ||||||
24 | preexisting condition was present before the effective |
| |||||||
| |||||||
1 | date of coverage; or | ||||||
2 | (3) a rescission of coverage determination, which does | ||||||
3 | not include a cancellation or discontinuance of coverage | ||||||
4 | that is attributable to a failure to timely pay required | ||||||
5 | premiums or contributions towards the cost of coverage. | ||||||
6 | "Adverse determination" includes unilateral | ||||||
7 | determinations that replace the requested health care service | ||||||
8 | with an approval of an alternative health care service, or | ||||||
9 | that condition approval of the requested service on first | ||||||
10 | trying an alternative health care service, either if the | ||||||
11 | request was made under a medical exceptions procedure, or if | ||||||
12 | all of the following are true: (1) the requested service was | ||||||
13 | not excluded by name, description, or service category under | ||||||
14 | the written terms of coverage, (2) the alternative health care | ||||||
15 | service poses no greater risk to the patient based on | ||||||
16 | generally accepted standards of care, and (3) the alternative | ||||||
17 | health care service is at least as likely to produce the same | ||||||
18 | or better effect on the covered person's health as the | ||||||
19 | requested service based on generally accepted standards of | ||||||
20 | care. "Adverse determination" includes determinations made | ||||||
21 | based on any source of health information pertaining to the | ||||||
22 | covered person that is used to deny, reduce, replace, | ||||||
23 | condition, or terminate the benefit or payment. "Adverse | ||||||
24 | determination" includes determinations made in response to a | ||||||
25 | request for authorization when the request was submitted by | ||||||
26 | the health care provider regardless of whether the provider |
| |||||||
| |||||||
1 | gave notice to or obtained the consent of the covered person or | ||||||
2 | authorized representative to file the request. "Adverse | ||||||
3 | determination" does not include substitutions performed under | ||||||
4 | Section 19.5 or 25 of the Pharmacy Practice Act. | ||||||
5 | "Authorized representative" means: | ||||||
6 | (1) a person to whom a covered person has given | ||||||
7 | express written consent to represent the covered person | ||||||
8 | for purposes of this Law; | ||||||
9 | (2) a person authorized by law to provide substituted | ||||||
10 | consent for a covered person; | ||||||
11 | (3) a family member of the covered person or the | ||||||
12 | covered person's treating health care professional when | ||||||
13 | the covered person is unable to provide consent; | ||||||
14 | (4) a health care provider when the covered person's | ||||||
15 | health benefit plan requires that a request for a benefit | ||||||
16 | under the plan be initiated by the health care provider; | ||||||
17 | or | ||||||
18 | (5) in the case of an urgent care request, a health | ||||||
19 | care provider with knowledge of the covered person's | ||||||
20 | medical condition. | ||||||
21 | "Best evidence" means evidence based on: | ||||||
22 | (1) randomized clinical trials; | ||||||
23 | (2) if randomized clinical trials are not available, | ||||||
24 | then cohort studies or case-control studies; | ||||||
25 | (3) if items (1) and (2) are not available, then | ||||||
26 | case-series; or |
| |||||||
| |||||||
1 | (4) if items (1), (2), and (3) are not available, then | ||||||
2 | expert opinion. | ||||||
3 | "Case-series" means an evaluation of a series of patients | ||||||
4 | with a particular outcome, without the use of a control group. | ||||||
5 | "Clinical review criteria" means the written screening | ||||||
6 | procedures, decision abstracts, clinical protocols, and | ||||||
7 | practice guidelines used by a health carrier to determine the | ||||||
8 | necessity and appropriateness of health care services. | ||||||
9 | "Cohort study" means a prospective evaluation of 2 groups | ||||||
10 | of patients with only one group of patients receiving specific | ||||||
11 | intervention. | ||||||
12 | "Concurrent review" means a review conducted during a | ||||||
13 | patient's stay or course of treatment in a facility, the | ||||||
14 | office of a health care professional, or other inpatient or | ||||||
15 | outpatient health care setting. | ||||||
16 | "Covered benefits" or "benefits" means those health care | ||||||
17 | services to which a covered person is entitled under the terms | ||||||
18 | of a health benefit plan. | ||||||
19 | "Covered person" means a policyholder, subscriber, | ||||||
20 | enrollee, or other individual participating in a health | ||||||
21 | benefit plan. | ||||||
22 | "Director" means the Director of the Department of | ||||||
23 | Insurance. | ||||||
24 | "Emergency medical condition" means a medical condition | ||||||
25 | manifesting itself by acute symptoms of sufficient severity, | ||||||
26 | including, but not limited to, severe pain, such that a |
| |||||||
| |||||||
1 | prudent layperson who possesses an average knowledge of health | ||||||
2 | and medicine could reasonably expect the absence of immediate | ||||||
3 | medical attention to result in: | ||||||
4 | (1) placing the health of the individual or, with | ||||||
5 | respect to a pregnant woman, the health of the woman or her | ||||||
6 | unborn child, in serious jeopardy; | ||||||
7 | (2) serious impairment to bodily functions; or | ||||||
8 | (3) serious dysfunction of any bodily organ or part. | ||||||
9 | "Emergency services" means health care items and services | ||||||
10 | furnished or required to evaluate and treat an emergency | ||||||
11 | medical condition. | ||||||
12 | "Evidence-based standard" means the conscientious, | ||||||
13 | explicit, and judicious use of the current best evidence based | ||||||
14 | on an overall systematic review of the research in making | ||||||
15 | decisions about the care of individual patients. | ||||||
16 | "Expert opinion" means a belief or an interpretation by | ||||||
17 | specialists with experience in a specific area about the | ||||||
18 | scientific evidence pertaining to a particular service, | ||||||
19 | intervention, or therapy. | ||||||
20 | "Facility" means an institution providing health care | ||||||
21 | services or a health care setting. | ||||||
22 | "Final adverse determination" means an adverse | ||||||
23 | determination involving a covered benefit that has been upheld | ||||||
24 | by a health carrier, or its designee utilization review | ||||||
25 | organization, at the completion of the health carrier's | ||||||
26 | internal grievance process procedures as set forth by the |
| |||||||
| |||||||
1 | Managed Care Reform and Patient Rights Act or as set forth for | ||||||
2 | any additional authorization or internal appeal process | ||||||
3 | provided by contract between the health carrier and the | ||||||
4 | provider. "Final adverse determination" includes | ||||||
5 | determinations made in an appeal of a denial of prior | ||||||
6 | authorization when the appeal was submitted by the health care | ||||||
7 | provider regardless of whether the provider gave notice to or | ||||||
8 | obtained the consent of the covered person or authorized | ||||||
9 | representative to file an internal appeal . | ||||||
10 | "Health benefit plan" means a policy, contract, | ||||||
11 | certificate, plan, or agreement offered or issued by a health | ||||||
12 | carrier to provide, deliver, arrange for, pay for, or | ||||||
13 | reimburse any of the costs of health care services. | ||||||
14 | "Health care provider" or "provider" means a physician, | ||||||
15 | hospital facility, or other health care practitioner licensed, | ||||||
16 | accredited, or certified to perform specified health care | ||||||
17 | services consistent with State law, responsible for | ||||||
18 | recommending health care services on behalf of a covered | ||||||
19 | person. | ||||||
20 | "Health care services" means services for the diagnosis, | ||||||
21 | prevention, treatment, cure, or relief of a health condition, | ||||||
22 | illness, injury, or disease. | ||||||
23 | "Health carrier" means an entity subject to the insurance | ||||||
24 | laws and regulations of this State, or subject to the | ||||||
25 | jurisdiction of the Director, that contracts or offers to | ||||||
26 | contract to provide, deliver, arrange for, pay for, or |
| |||||||
| |||||||
1 | reimburse any of the costs of health care services, including | ||||||
2 | a sickness and accident insurance company, a health | ||||||
3 | maintenance organization, or any other entity providing a plan | ||||||
4 | of health insurance, health benefits, or health care services. | ||||||
5 | "Health carrier" also means Limited Health Service | ||||||
6 | Organizations (LHSO) and Voluntary Health Service Plans. | ||||||
7 | "Health information" means information or data, whether | ||||||
8 | oral or recorded in any form or medium, and personal facts or | ||||||
9 | information about events or relationships that relate to: | ||||||
10 | (1) the past, present, or future physical, mental, or | ||||||
11 | behavioral health or condition of an individual or a | ||||||
12 | member of the individual's family; | ||||||
13 | (2) the provision of health care services to an | ||||||
14 | individual; or | ||||||
15 | (3) payment for the provision of health care services | ||||||
16 | to an individual. | ||||||
17 | "Independent review organization" means an entity that | ||||||
18 | conducts independent external reviews of adverse | ||||||
19 | determinations and final adverse determinations. | ||||||
20 | "Medical or scientific evidence" means evidence found in | ||||||
21 | the following sources: | ||||||
22 | (1) peer-reviewed scientific studies published in or | ||||||
23 | accepted for publication by medical journals that meet | ||||||
24 | nationally recognized requirements for scientific | ||||||
25 | manuscripts and that submit most of their published | ||||||
26 | articles for review by experts who are not part of the |
| |||||||
| |||||||
1 | editorial staff; | ||||||
2 | (2) peer-reviewed medical literature, including | ||||||
3 | literature relating to therapies reviewed and approved by | ||||||
4 | a qualified institutional review board, biomedical | ||||||
5 | compendia, and other medical literature that meet the | ||||||
6 | criteria of the National Institutes of Health's Library of | ||||||
7 | Medicine for indexing in Index Medicus (Medline) and | ||||||
8 | Elsevier Science Ltd. for indexing in Excerpta Medicus | ||||||
9 | (EMBASE); | ||||||
10 | (3) medical journals recognized by the Secretary of | ||||||
11 | Health and Human Services under Section 1861(t)(2) of the | ||||||
12 | federal Social Security Act; | ||||||
13 | (4) the following standard reference compendia: | ||||||
14 | (a) The American Hospital Formulary Service-Drug | ||||||
15 | Information; | ||||||
16 | (b) Drug Facts and Comparisons; | ||||||
17 | (c) The American Dental Association Accepted | ||||||
18 | Dental Therapeutics; and | ||||||
19 | (d) The United States Pharmacopoeia-Drug | ||||||
20 | Information; | ||||||
21 | (5) findings, studies, or research conducted by or | ||||||
22 | under the auspices of federal government agencies and | ||||||
23 | nationally recognized federal research institutes, | ||||||
24 | including: | ||||||
25 | (a) the federal Agency for Healthcare Research and | ||||||
26 | Quality; |
| |||||||
| |||||||
1 | (b) the National Institutes of Health; | ||||||
2 | (c) the National Cancer Institute; | ||||||
3 | (d) the National Academy of Sciences; | ||||||
4 | (e) the Centers for Medicare & Medicaid Services; | ||||||
5 | (f) the federal Food and Drug Administration; and | ||||||
6 | (g) any national board recognized by the National | ||||||
7 | Institutes of Health for the purpose of evaluating the | ||||||
8 | medical value of health care services; or | ||||||
9 | (6) any other medical or scientific evidence that is | ||||||
10 | comparable to the sources listed in items (1) through (5). | ||||||
11 | "Person" means an individual, a corporation, a | ||||||
12 | partnership, an association, a joint venture, a joint stock | ||||||
13 | company, a trust, an unincorporated organization, any similar | ||||||
14 | entity, or any combination of the foregoing. | ||||||
15 | "Prospective review" means a review conducted prior to an | ||||||
16 | admission or the provision of a health care service or a course | ||||||
17 | of treatment in accordance with a health carrier's requirement | ||||||
18 | that the health care service or course of treatment, in whole | ||||||
19 | or in part, be approved prior to its provision. | ||||||
20 | "Protected health information" means health information | ||||||
21 | (i) that identifies an individual who is the subject of the | ||||||
22 | information; or (ii) with respect to which there is a | ||||||
23 | reasonable basis to believe that the information could be used | ||||||
24 | to identify an individual. | ||||||
25 | "Randomized clinical trial" means a controlled prospective | ||||||
26 | study of patients that have been randomized into an |
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1 | experimental group and a control group at the beginning of the | ||||||
2 | study with only the experimental group of patients receiving a | ||||||
3 | specific intervention, which includes study of the groups for | ||||||
4 | variables and anticipated outcomes over time. | ||||||
5 | "Retrospective review" means any review of a request for a | ||||||
6 | benefit that is not a concurrent or prospective review | ||||||
7 | request. "Retrospective review" does not include the review of | ||||||
8 | a claim that is limited to veracity of documentation or | ||||||
9 | accuracy of coding. | ||||||
10 | "Utilization review" has the meaning provided by the | ||||||
11 | Managed Care Reform and Patient Rights Act. | ||||||
12 | "Utilization review organization" means a utilization | ||||||
13 | review program as defined in the Managed Care Reform and | ||||||
14 | Patient Rights Act. | ||||||
15 | (Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12; | ||||||
16 | 98-756, eff. 7-16-14.)
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17 | Section 45. The Prior Authorization Reform Act is amended | ||||||
18 | by changing Section 55 as follows:
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19 | (215 ILCS 200/55) | ||||||
20 | Sec. 55. Denial or penalty . | ||||||
21 | (a) The health insurance issuer or its contracted | ||||||
22 | utilization review organization may not revoke or further | ||||||
23 | limit, condition, or restrict a previously issued prior | ||||||
24 | authorization approval while it remains valid under this Act. |
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1 | (b) Notwithstanding any other provision of law, if a claim | ||||||
2 | is properly coded and submitted timely to a health insurance | ||||||
3 | issuer, the health insurance issuer shall make payment | ||||||
4 | according to the terms of coverage on claims for health care | ||||||
5 | services for which prior authorization was required and | ||||||
6 | approval received before the rendering of health care | ||||||
7 | services, unless one of the following occurs: | ||||||
8 | (1) it is timely determined that the enrollee's health | ||||||
9 | care professional or health care provider knowingly | ||||||
10 | provided health care services that required prior | ||||||
11 | authorization from the health insurance issuer or its | ||||||
12 | contracted utilization review organization without first | ||||||
13 | obtaining prior authorization for those health care | ||||||
14 | services; | ||||||
15 | (2) it is timely determined that the health care | ||||||
16 | services claimed were not performed; | ||||||
17 | (3) it is timely determined that the health care | ||||||
18 | services rendered were contrary to the instructions of the | ||||||
19 | health insurance issuer or its contracted utilization | ||||||
20 | review organization or delegated reviewer if contact was | ||||||
21 | made between those parties before the service being | ||||||
22 | rendered; | ||||||
23 | (4) it is timely determined that the enrollee | ||||||
24 | receiving such health care services was not an enrollee of | ||||||
25 | the health care plan; or | ||||||
26 | (5) the approval was based upon a material |
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1 | misrepresentation by the enrollee, health care | ||||||
2 | professional, or health care provider; as used in this | ||||||
3 | paragraph (5), "material" means a fact or situation that | ||||||
4 | is not merely technical in nature and results or could | ||||||
5 | result in a substantial change in the situation. | ||||||
6 | (c) Nothing in this Section shall preclude a utilization | ||||||
7 | review organization or a health insurance issuer from | ||||||
8 | performing post-service reviews of health care claims for | ||||||
9 | purposes of payment integrity or for the prevention of fraud, | ||||||
10 | waste, or abuse. | ||||||
11 | (d) If a health insurance issuer imposes a monetary | ||||||
12 | penalty on the enrollee for the enrollee's, health care | ||||||
13 | professional's, or health care provider's failure to obtain | ||||||
14 | any form of prior authorization for a health care service, the | ||||||
15 | penalty may not exceed the lesser of: | ||||||
16 | (1) the actual cost of the health care service; or | ||||||
17 | (2) $1,000 per occurrence in addition to the plan | ||||||
18 | cost-sharing provisions. | ||||||
19 | (e) A health insurance issuer may not require both the | ||||||
20 | enrollee and the health care professional or health care | ||||||
21 | provider to obtain any form of prior authorization for the | ||||||
22 | same instance of a health care service, nor otherwise require | ||||||
23 | more than one prior authorization for the same instance of a | ||||||
24 | health care service. | ||||||
25 | (Source: P.A. 102-409, eff. 1-1-22 .)
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