Bill Text: IL HB4055 | 2023-2024 | 103rd General Assembly | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Amends the Prior Authorization Reform Act. Provides that notwithstanding any other provision of law, a health insurance issuer or a contracted utilization review organization may not require a prior authorization for drug therapies approved by the U.S. Food and Drug Administration for the treatment of hereditary bleeding disorders any more frequently than 6 months or the length of time the prescription for that dosage remains valid, whichever period is shorter. Effective January 1, 2026.

Spectrum: Moderate Partisan Bill (Republican 9-1)

Status: (Passed) 2024-07-19 - Public Act . . . . . . . . . 103-0659 [HB4055 Detail]

Download: Illinois-2023-HB4055-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4055 Introduced , by Rep. William E Hauter SYNOPSIS AS INTRODUCED:
215 ILCS 200/15
215 ILCS 200/20.5 new
Amends the Prior Authorization Reform Act. Changes the definition of "emergency services" to provide that for the purposes of the provisions, emergency services are not required to be provided in the emergency department of a hospital. Provides that notwithstanding any other provision of law, a health insurance issuer or a contracted utilization review organization may not require prior authorization or approval by the health plan for emergency services.
LRB103 31972 BMS 60758 b
A BILL FOR
HB4055 LRB103 31972 BMS 60758 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Prior Authorization Reform Act is amended
by changing Section 15 and by adding Section 20.5 as follows:
(215 ILCS 200/15)
Sec. 15. Definitions. As used in this Act:
"Adverse determination" has the meaning given to that term
in Section 10 of the Health Carrier External Review Act.
"Appeal" means a formal request, either orally or in
writing, to reconsider an adverse determination.
"Approval" means a determination by a health insurance
issuer or its contracted utilization review organization that
a health care service has been reviewed and, based on the
information provided, satisfies the health insurance issuer's
or its contracted utilization review organization's
requirements for medical necessity and appropriateness.
"Clinical review criteria" has the meaning given to that
term in Section 10 of the Health Carrier External Review Act.
"Department" means the Department of Insurance.
"Emergency medical condition" has the meaning given to
that term in Section 10 of the Managed Care Reform and Patient
Rights Act.

HB4055 - 2 - LRB103 31972 BMS 60758 b
"Emergency services" has the meaning given to that term in
federal health insurance reform requirements for the group and
individual health insurance markets, 45 CFR 147.138, except,
for the purposes of this Act, emergency services are not
required to be provided in the emergency department of a
hospital.
"Enrollee" has the meaning given to that term in Section
10 of the Managed Care Reform and Patient Rights Act.
"Health care professional" has the meaning given to that
term in Section 10 of the Managed Care Reform and Patient
Rights Act.
"Health care provider" has the meaning given to that term
in Section 10 of the Managed Care Reform and Patient Rights
Act, except that facilities licensed under the Nursing Home
Care Act and long-term care facilities as defined in Section
1-113 of the Nursing Home Care Act are excluded from this Act.
"Health care service" means any services or level of
services included in the furnishing to an individual of
medical care or the hospitalization incident to the furnishing
of such care, as well as the furnishing to any person of any
other services for the purpose of preventing, alleviating,
curing, or healing human illness or injury, including
behavioral health, mental health, home health, and
pharmaceutical services and products.
"Health insurance issuer" has the meaning given to that
term in Section 5 of the Illinois Health Insurance Portability

HB4055 - 3 - LRB103 31972 BMS 60758 b
and Accountability Act.
"Medically necessary" means a health care professional
exercising prudent clinical judgment would provide care to a
patient for the purpose of preventing, diagnosing, or treating
an illness, injury, disease, or its symptoms and that are: (i)
in accordance with generally accepted standards of medical
practice; (ii) clinically appropriate in terms of type,
frequency, extent, site, and duration and are considered
effective for the patient's illness, injury, or disease; and
(iii) not primarily for the convenience of the patient,
treating physician, other health care professional, caregiver,
family member, or other interested party, but focused on what
is best for the patient's health outcome.
"Physician" means a person licensed under the Medical
Practice Act of 1987 or licensed under the laws of another
state to practice medicine in all its branches.
"Prior authorization" means the process by which health
insurance issuers or their contracted utilization review
organizations determine the medical necessity and medical
appropriateness of otherwise covered health care services
before the rendering of such health care services. "Prior
authorization" includes any health insurance issuer's or its
contracted utilization review organization's requirement that
an enrollee, health care professional, or health care provider
notify the health insurance issuer or its contracted
utilization review organization before, at the time of, or

HB4055 - 4 - LRB103 31972 BMS 60758 b
concurrent to providing a health care service.
"Urgent health care service" means a health care service
with respect to which the application of the time periods for
making a non-expedited prior authorization that in the opinion
of a health care professional with knowledge of the enrollee's
medical condition:
(1) could seriously jeopardize the life or health of
the enrollee or the ability of the enrollee to regain
maximum function; or
(2) could subject the enrollee to severe pain that
cannot be adequately managed without the care or treatment
that is the subject of the utilization review.
"Urgent health care service" does not include emergency
services.
"Utilization review organization" has the meaning given to
that term in 50 Ill. Adm. Code 4520.30.
(Source: P.A. 102-409, eff. 1-1-22.)
(215 ILCS 200/20.5 new)
Sec. 20.5. Health insurance issuer's and contracted
utilization review organization's obligations with respect to
prior authorizations for emergency services. Notwithstanding
any other provision of law, a health insurance issuer or a
contracted utilization review organization may not require
prior authorization or approval by the health plan for
emergency services.