Bill Text: IL HB5395 | 2023-2024 | 103rd General Assembly | Chaptered

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Bill Title: Reinserts the provisions of the engrossed bill with changes that include the following. Requires the issuer of a network plan to submit a self-audit of its provider directory and a summary to the Department of Insurance, which the Department shall make publicly available. Makes changes to the information that must be provided in a network plan directory. Sets forth required actions if an issuer or the Department identifies a provider incorrectly listed in the provider directory. Removes provisions repealing the Short-Term, Limited-Duration Health Insurance Coverage Act and the related changes. Makes changes to provisions concerning confidentiality; transition of services; unreasonable and inadequate rates; the definitions of "excepted benefits" and "step therapy requirement"; off-formulary exception requests; algorithmic automated review processes; utilization review criteria; and adverse determinations. Makes other changes. Effective January 1, 2025, except that certain changes to the Managed Care Reform and Patient Rights Act take effect January 1, 2026.

Spectrum: Partisan Bill (Democrat 82-1)

Status: (Passed) 2024-07-10 - Public Act . . . . . . . . . 103-0650 [HB5395 Detail]

Download: Illinois-2023-HB5395-Chaptered.html

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Public Act 103-0650
HB5395 Enrolled LRB103 37071 RPS 67189 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Article 1.
Section 1-1. This Act may be referred to as the Health Care
Protection Act.
Article 2.
Section 2-5. The Illinois Administrative Procedure Act is
amended by adding Section 5-45.55 as follows:
(5 ILCS 100/5-45.55 new)
Sec. 5-45.55. Emergency rulemaking; Network Adequacy and
Transparency Act. To provide for the expeditious and timely
implementation of the Network Adequacy and Transparency Act,
emergency rules implementing federal standards for provider
ratios, travel time and distance, and appointment wait times
if such standards apply to health insurance coverage regulated
by the Department of Insurance and are more stringent than the
State standards extant at the time the final federal standards
are published may be adopted in accordance with Section 5-45
by the Department of Insurance. The adoption of emergency

rules authorized by Section 5-45 and this Section is deemed to
be necessary for the public interest, safety, and welfare.
Section 2-10. The Network Adequacy and Transparency Act is
amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and
by adding Sections 35, 36, 40, 50, and 55 as follows:
(215 ILCS 124/3)
Sec. 3. Applicability of Act. This Act applies to an
individual or group policy of accident and health insurance
coverage with a network plan amended, delivered, issued, or
renewed in this State on or after January 1, 2019. This Act
does not apply to an individual or group policy for excepted
benefits or short-term, limited-duration health insurance
coverage dental or vision insurance or a limited health
service organization with a network plan amended, delivered,
issued, or renewed in this State on or after January 1, 2019,
except to the extent that federal law establishes network
adequacy and transparency standards for stand-alone dental
plans, which the Department shall enforce for plans amended,
delivered, issued, or renewed on or after January 1, 2025.
(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
(215 ILCS 124/5)
Sec. 5. Definitions. In this Act:
"Authorized representative" means a person to whom a

beneficiary has given express written consent to represent the
beneficiary; a person authorized by law to provide substituted
consent for a beneficiary; or the beneficiary's treating
provider only when the beneficiary or his or her family member
is unable to provide consent.
"Beneficiary" means an individual, an enrollee, an
insured, a participant, or any other person entitled to
reimbursement for covered expenses of or the discounting of
provider fees for health care services under a program in
which the beneficiary has an incentive to utilize the services
of a provider that has entered into an agreement or
arrangement with an issuer insurer.
"Department" means the Department of Insurance.
"Essential community provider" has the meaning ascribed to
that term in 45 CFR 156.235.
"Excepted benefits" has the meaning ascribed to that term
in 42 U.S.C. 300gg-91(c) and implementing regulations.
"Excepted benefits" includes individual, group, or blanket
coverage.
"Exchange" has the meaning ascribed to that term in 45 CFR
155.20.
"Director" means the Director of Insurance.
"Family caregiver" means a relative, partner, friend, or
neighbor who has a significant relationship with the patient
and administers or assists the patient with activities of
daily living, instrumental activities of daily living, or

other medical or nursing tasks for the quality and welfare of
that patient.
"Group health plan" has the meaning ascribed to that term
in Section 5 of the Illinois Health Insurance Portability and
Accountability Act.
"Health insurance coverage" has the meaning ascribed to
that term in Section 5 of the Illinois Health Insurance
Portability and Accountability Act. "Health insurance
coverage" does not include any coverage or benefits under
Medicare or under the medical assistance program established
under Article V of the Illinois Public Aid Code.
"Issuer" means a "health insurance issuer" as defined in
Section 5 of the Illinois Health Insurance Portability and
Accountability Act.
"Insurer" means any entity that offers individual or group
accident and health insurance, including, but not limited to,
health maintenance organizations, preferred provider
organizations, exclusive provider organizations, and other
plan structures requiring network participation, excluding the
medical assistance program under the Illinois Public Aid Code,
the State employees group health insurance program, workers
compensation insurance, and pharmacy benefit managers.
"Material change" means a significant reduction in the
number of providers available in a network plan, including,
but not limited to, a reduction of 10% or more in a specific
type of providers within any county, the removal of a major

health system that causes a network to be significantly
different within any county from the network when the
beneficiary purchased the network plan, or any change that
would cause the network to no longer satisfy the requirements
of this Act or the Department's rules for network adequacy and
transparency.
"Network" means the group or groups of preferred providers
providing services to a network plan.
"Network plan" means an individual or group policy of
accident and health insurance coverage that either requires a
covered person to use or creates incentives, including
financial incentives, for a covered person to use providers
managed, owned, under contract with, or employed by the issuer
or by a third party contracted to arrange, contract for, or
administer such provider-related incentives for the issuer
insurer.
"Ongoing course of treatment" means (1) treatment for a
life-threatening condition, which is a disease or condition
for which likelihood of death is probable unless the course of
the disease or condition is interrupted; (2) treatment for a
serious acute condition, defined as a disease or condition
requiring complex ongoing care that the covered person is
currently receiving, such as chemotherapy, radiation therapy,
or post-operative visits, or a serious and complex condition
as defined under 42 U.S.C. 300gg-113(b)(2); (3) a course of
treatment for a health condition that a treating provider

attests that discontinuing care by that provider would worsen
the condition or interfere with anticipated outcomes; or (4)
the third trimester of pregnancy through the post-partum
period; (5) undergoing a course of institutional or inpatient
care from the provider within the meaning of 42 U.S.C.
300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective
surgery from the provider, including receipt of preoperative
or postoperative care from such provider with respect to such
a surgery; (7) being determined to be terminally ill, as
determined under 42 U.S.C. 1395x(dd)(3)(A), and receiving
treatment for such illness from such provider; or (8) any
other treatment of a condition or disease that requires
repeated health care services pursuant to a plan of treatment
by a provider because of the potential for changes in the
therapeutic regimen or because of the potential for a
recurrence of symptoms.
"Preferred provider" means any provider who has entered,
either directly or indirectly, into an agreement with an
employer or risk-bearing entity relating to health care
services that may be rendered to beneficiaries under a network
plan.
"Providers" means physicians licensed to practice medicine
in all its branches, other health care professionals,
hospitals, or other health care institutions or facilities
that provide health care services.
"Short-term, limited-duration insurance" means any type of

accident and health insurance offered or provided within this
State pursuant to a group or individual policy or individual
certificate by a company, regardless of the situs state of the
delivery of the policy, that has an expiration date specified
in the contract that is fewer than 365 days after the original
effective date. Regardless of the duration of coverage,
"short-term, limited-duration insurance" does not include
excepted benefits or any student health insurance coverage.
"Stand-alone dental plan" has the meaning ascribed to that
term in 45 CFR 156.400.
"Telehealth" has the meaning given to that term in Section
356z.22 of the Illinois Insurance Code.
"Telemedicine" has the meaning given to that term in
Section 49.5 of the Medical Practice Act of 1987.
"Tiered network" means a network that identifies and
groups some or all types of provider and facilities into
specific groups to which different provider reimbursement,
covered person cost-sharing or provider access requirements,
or any combination thereof, apply for the same services.
"Woman's principal health care provider" means a physician
licensed to practice medicine in all of its branches
specializing in obstetrics, gynecology, or family practice.
(Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)
(215 ILCS 124/10)
Sec. 10. Network adequacy.

(a) Before issuing, delivering, or renewing a network
plan, an issuer An insurer providing a network plan shall file
a description of all of the following with the Director:
(1) The written policies and procedures for adding
providers to meet patient needs based on increases in the
number of beneficiaries, changes in the
patient-to-provider ratio, changes in medical and health
care capabilities, and increased demand for services.
(2) The written policies and procedures for making
referrals within and outside the network.
(3) The written policies and procedures on how the
network plan will provide 24-hour, 7-day per week access
to network-affiliated primary care, emergency services,
and women's principal health care providers.
An issuer insurer shall not prohibit a preferred provider
from discussing any specific or all treatment options with
beneficiaries irrespective of the insurer's position on those
treatment options or from advocating on behalf of
beneficiaries within the utilization review, grievance, or
appeals processes established by the issuer insurer in
accordance with any rights or remedies available under
applicable State or federal law.
(b) Before issuing, delivering, or renewing a network
plan, an issuer Insurers must file for review a description of
the services to be offered through a network plan. The
description shall include all of the following:

(1) A geographic map of the area proposed to be served
by the plan by county service area and zip code, including
marked locations for preferred providers.
(2) As deemed necessary by the Department, the names,
addresses, phone numbers, and specialties of the providers
who have entered into preferred provider agreements under
the network plan.
(3) The number of beneficiaries anticipated to be
covered by the network plan.
(4) An Internet website and toll-free telephone number
for beneficiaries and prospective beneficiaries to access
current and accurate lists of preferred providers in each
plan, additional information about the plan, as well as
any other information required by Department rule.
(5) A description of how health care services to be
rendered under the network plan are reasonably accessible
and available to beneficiaries. The description shall
address all of the following:
(A) the type of health care services to be
provided by the network plan;
(B) the ratio of physicians and other providers to
beneficiaries, by specialty and including primary care
physicians and facility-based physicians when
applicable under the contract, necessary to meet the
health care needs and service demands of the currently
enrolled population;

(C) the travel and distance standards for plan
beneficiaries in county service areas; and
(D) a description of how the use of telemedicine,
telehealth, or mobile care services may be used to
partially meet the network adequacy standards, if
applicable.
(6) A provision ensuring that whenever a beneficiary
has made a good faith effort, as evidenced by accessing
the provider directory, calling the network plan, and
calling the provider, to utilize preferred providers for a
covered service and it is determined the insurer does not
have the appropriate preferred providers due to
insufficient number, type, unreasonable travel distance or
delay, or preferred providers refusing to provide a
covered service because it is contrary to the conscience
of the preferred providers, as protected by the Health
Care Right of Conscience Act, the issuer insurer shall
ensure, directly or indirectly, by terms contained in the
payer contract, that the beneficiary will be provided the
covered service at no greater cost to the beneficiary than
if the service had been provided by a preferred provider.
This paragraph (6) does not apply to: (A) a beneficiary
who willfully chooses to access a non-preferred provider
for health care services available through the panel of
preferred providers, or (B) a beneficiary enrolled in a
health maintenance organization. In these circumstances,

the contractual requirements for non-preferred provider
reimbursements shall apply unless Section 356z.3a of the
Illinois Insurance Code requires otherwise. In no event
shall a beneficiary who receives care at a participating
health care facility be required to search for
participating providers under the circumstances described
in subsection (b) or (b-5) of Section 356z.3a of the
Illinois Insurance Code except under the circumstances
described in paragraph (2) of subsection (b-5).
(7) A provision that the beneficiary shall receive
emergency care coverage such that payment for this
coverage is not dependent upon whether the emergency
services are performed by a preferred or non-preferred
provider and the coverage shall be at the same benefit
level as if the service or treatment had been rendered by a
preferred provider. For purposes of this paragraph (7),
"the same benefit level" means that the beneficiary is
provided the covered service at no greater cost to the
beneficiary than if the service had been provided by a
preferred provider. This provision shall be consistent
with Section 356z.3a of the Illinois Insurance Code.
(8) A limitation that, if the plan provides that the
beneficiary will incur a penalty for failing to
pre-certify inpatient hospital treatment, the penalty may
not exceed $1,000 per occurrence in addition to the plan
cost sharing provisions.

(9) For a network plan to be offered through the
Exchange in the individual or small group market, as well
as any off-Exchange mirror of such a network plan,
evidence that the network plan includes essential
community providers in accordance with rules established
by the Exchange that will operate in this State for the
applicable plan year.
(c) The issuer network plan shall demonstrate to the
Director a minimum ratio of providers to plan beneficiaries as
required by the Department for each network plan.
(1) The minimum ratio of physicians or other providers
to plan beneficiaries shall be established annually by the
Department in consultation with the Department of Public
Health based upon the guidance from the federal Centers
for Medicare and Medicaid Services. The Department shall
not establish ratios for vision or dental providers who
provide services under dental-specific or vision-specific
benefits, except to the extent provided under federal law
for stand-alone dental plans. The Department shall
consider establishing ratios for the following physicians
or other providers:
(A) Primary Care;
(B) Pediatrics;
(C) Cardiology;
(D) Gastroenterology;
(E) General Surgery;

(F) Neurology;
(G) OB/GYN;
(H) Oncology/Radiation;
(I) Ophthalmology;
(J) Urology;
(K) Behavioral Health;
(L) Allergy/Immunology;
(M) Chiropractic;
(N) Dermatology;
(O) Endocrinology;
(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
(Q) Infectious Disease;
(R) Nephrology;
(S) Neurosurgery;
(T) Orthopedic Surgery;
(U) Physiatry/Rehabilitative;
(V) Plastic Surgery;
(W) Pulmonary;
(X) Rheumatology;
(Y) Anesthesiology;
(Z) Pain Medicine;
(AA) Pediatric Specialty Services;
(BB) Outpatient Dialysis; and
(CC) HIV.
(2) The Director shall establish a process for the
review of the adequacy of these standards, along with an

assessment of additional specialties to be included in the
list under this subsection (c).
(3) Notwithstanding any other law or rule, the minimum
ratio for each provider type shall be no less than any such
ratio established for qualified health plans in
Federally-Facilitated Exchanges by federal law or by the
federal Centers for Medicare and Medicaid Services, even
if the network plan is issued in the large group market or
is otherwise not issued through an exchange. Federal
standards for stand-alone dental plans shall only apply to
such network plans. In the absence of an applicable
Department rule, the federal standards shall apply for the
time period specified in the federal law, regulation, or
guidance. If the Centers for Medicare and Medicaid
Services establish standards that are more stringent than
the standards in effect under any Department rule, the
Department may amend its rules to conform to the more
stringent federal standards.
(d) The network plan shall demonstrate to the Director
maximum travel and distance standards and appointment wait
time standards for plan beneficiaries, which shall be
established annually by the Department in consultation with
the Department of Public Health based upon the guidance from
the federal Centers for Medicare and Medicaid Services. These
standards shall consist of the maximum minutes or miles to be
traveled by a plan beneficiary for each county type, such as

large counties, metro counties, or rural counties as defined
by Department rule.
The maximum travel time and distance standards must
include standards for each physician and other provider
category listed for which ratios have been established.
The Director shall establish a process for the review of
the adequacy of these standards along with an assessment of
additional specialties to be included in the list under this
subsection (d).
Notwithstanding any other law or Department rule, the
maximum travel time and distance standards and appointment
wait time standards shall be no greater than any such
standards established for qualified health plans in
Federally-Facilitated Exchanges by federal law or by the
federal Centers for Medicare and Medicaid Services, even if
the network plan is issued in the large group market or is
otherwise not issued through an exchange. Federal standards
for stand-alone dental plans shall only apply to such network
plans. In the absence of an applicable Department rule, the
federal standards shall apply for the time period specified in
the federal law, regulation, or guidance. If the Centers for
Medicare and Medicaid Services establish standards that are
more stringent than the standards in effect under any
Department rule, the Department may amend its rules to conform
to the more stringent federal standards.
If the federal area designations for the maximum time or

distance or appointment wait time standards required are
changed by the most recent Letter to Issuers in the
Federally-facilitated Marketplaces, the Department shall post
on its website notice of such changes and may amend its rules
to conform to those designations if the Director deems
appropriate.
(d-5)(1) Every issuer insurer shall ensure that
beneficiaries have timely and proximate access to treatment
for mental, emotional, nervous, or substance use disorders or
conditions in accordance with the provisions of paragraph (4)
of subsection (a) of Section 370c of the Illinois Insurance
Code. Issuers Insurers shall use a comparable process,
strategy, evidentiary standard, and other factors in the
development and application of the network adequacy standards
for timely and proximate access to treatment for mental,
emotional, nervous, or substance use disorders or conditions
and those for the access to treatment for medical and surgical
conditions. As such, the network adequacy standards for timely
and proximate access shall equally be applied to treatment
facilities and providers for mental, emotional, nervous, or
substance use disorders or conditions and specialists
providing medical or surgical benefits pursuant to the parity
requirements of Section 370c.1 of the Illinois Insurance Code
and the federal Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008. Notwithstanding the
foregoing, the network adequacy standards for timely and

proximate access to treatment for mental, emotional, nervous,
or substance use disorders or conditions shall, at a minimum,
satisfy the following requirements:
(A) For beneficiaries residing in the metropolitan
counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
network adequacy standards for timely and proximate access
to treatment for mental, emotional, nervous, or substance
use disorders or conditions means a beneficiary shall not
have to travel longer than 30 minutes or 30 miles from the
beneficiary's residence to receive outpatient treatment
for mental, emotional, nervous, or substance use disorders
or conditions. Beneficiaries shall not be required to wait
longer than 10 business days between requesting an initial
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(B) For beneficiaries residing in Illinois counties
other than those counties listed in subparagraph (A) of

this paragraph, network adequacy standards for timely and
proximate access to treatment for mental, emotional,
nervous, or substance use disorders or conditions means a
beneficiary shall not have to travel longer than 60
minutes or 60 miles from the beneficiary's residence to
receive outpatient treatment for mental, emotional,
nervous, or substance use disorders or conditions.
Beneficiaries shall not be required to wait longer than 10
business days between requesting an initial appointment
and being seen by the facility or provider of mental,
emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(2) For beneficiaries residing in all Illinois counties,
network adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions means a beneficiary shall not have to
travel longer than 60 minutes or 60 miles from the
beneficiary's residence to receive inpatient or residential

treatment for mental, emotional, nervous, or substance use
disorders or conditions.
(3) If there is no in-network facility or provider
available for a beneficiary to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with the
network adequacy standards outlined in this subsection, the
issuer insurer shall provide necessary exceptions to its
network to ensure admission and treatment with a provider or
at a treatment facility in accordance with the network
adequacy standards in this subsection.
(4) If the federal Centers for Medicare and Medicaid
Services establishes or law requires more stringent standards
for qualified health plans in the Federally-Facilitated
Exchanges, the federal standards shall control for all network
plans for the time period specified in the federal law,
regulation, or guidance, even if the network plan is issued in
the large group market, is issued through a different type of
Exchange, or is otherwise not issued through an Exchange.
(e) Except for network plans solely offered as a group
health plan, these ratio and time and distance standards apply
to the lowest cost-sharing tier of any tiered network.
(f) The network plan may consider use of other health care
service delivery options, such as telemedicine or telehealth,
mobile clinics, and centers of excellence, or other ways of
delivering care to partially meet the requirements set under

this Section.
(g) Except for the requirements set forth in subsection
(d-5), issuers insurers who are not able to comply with the
provider ratios and time and distance or appointment wait time
standards established under this Act or federal law by the
Department may request an exception to these requirements from
the Department. The Department may grant an exception in the
following circumstances:
(1) if no providers or facilities meet the specific
time and distance standard in a specific service area and
the issuer insurer (i) discloses information on the
distance and travel time points that beneficiaries would
have to travel beyond the required criterion to reach the
next closest contracted provider outside of the service
area and (ii) provides contact information, including
names, addresses, and phone numbers for the next closest
contracted provider or facility;
(2) if patterns of care in the service area do not
support the need for the requested number of provider or
facility type and the issuer insurer provides data on
local patterns of care, such as claims data, referral
patterns, or local provider interviews, indicating where
the beneficiaries currently seek this type of care or
where the physicians currently refer beneficiaries, or
both; or
(3) other circumstances deemed appropriate by the

Department consistent with the requirements of this Act.
(h) Issuers Insurers are required to report to the
Director any material change to an approved network plan
within 15 business days after the change occurs and any change
that would result in failure to meet the requirements of this
Act. The issuer shall submit a revised version of the portions
of the network adequacy filing affected by the material
change, as determined by the Director by rule, and the issuer
shall attach versions with the changes indicated for each
document that was revised from the previous version of the
filing. Upon notice from the issuer insurer, the Director
shall reevaluate the network plan's compliance with the
network adequacy and transparency standards of this Act. For
every day past 15 business days that the issuer fails to submit
a revised network adequacy filing to the Director, the
Director may order a fine of $5,000 per day.
(i) If a network plan is inadequate under this Act with
respect to a provider type in a county, and if the network plan
does not have an approved exception for that provider type in
that county pursuant to subsection (g), an issuer shall cover
out-of-network claims for covered health care services
received from that provider type within that county at the
in-network benefit level and shall retroactively adjudicate
and reimburse beneficiaries to achieve that objective if their
claims were processed at the out-of-network level contrary to
this subsection. Nothing in this subsection shall be construed

to supersede Section 356z.3a of the Illinois Insurance Code.
(j) If the Director determines that a network is
inadequate in any county and no exception has been granted
under subsection (g) and the issuer does not have a process in
place to comply with subsection (d-5), the Director may
prohibit the network plan from being issued or renewed within
that county until the Director determines that the network is
adequate apart from processes and exceptions described in
subsections (d-5) and (g). Nothing in this subsection shall be
construed to terminate any beneficiary's health insurance
coverage under a network plan before the expiration of the
beneficiary's policy period if the Director makes a
determination under this subsection after the issuance or
renewal of the beneficiary's policy or certificate because of
a material change. Policies or certificates issued or renewed
in violation of this subsection may subject the issuer to a
civil penalty of $5,000 per policy.
(k) For the Department to enforce any new or modified
federal standard before the Department adopts the standard by
rule, the Department must, no later than May 15 before the
start of the plan year, give public notice to the affected
health insurance issuers through a bulletin.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
102-1117, eff. 1-13-23.)
(215 ILCS 124/15)

Sec. 15. Notice of nonrenewal or termination.
(a) A network plan must give at least 60 days' notice of
nonrenewal or termination of a provider to the provider and to
the beneficiaries served by the provider. The notice shall
include a name and address to which a beneficiary or provider
may direct comments and concerns regarding the nonrenewal or
termination and the telephone number maintained by the
Department for consumer complaints. Immediate written notice
may be provided without 60 days' notice when a provider's
license has been disciplined by a State licensing board or
when the network plan reasonably believes direct imminent
physical harm to patients under the provider's providers care
may occur. The notice to the beneficiary shall provide the
individual with an opportunity to notify the issuer of the
individual's need for transitional care.
(b) Primary care providers must notify active affected
patients of nonrenewal or termination of the provider from the
network plan, except in the case of incapacitation.
(Source: P.A. 100-502, eff. 9-15-17.)
(215 ILCS 124/20)
Sec. 20. Transition of services.
(a) A network plan shall provide for continuity of care
for its beneficiaries as follows:
(1) If a beneficiary's physician or hospital provider
leaves the network plan's network of providers for reasons

other than termination of a contract in situations
involving imminent harm to a patient or a final
disciplinary action by a State licensing board and the
provider remains within the network plan's service area,
if benefits provided under such network plan with respect
to such provider or facility are terminated because of a
change in the terms of the participation of such provider
or facility in such plan, or if a contract between a group
health plan and a health insurance issuer offering a
network plan in connection with the group health plan is
terminated and results in a loss of benefits provided
under such plan with respect to such provider, then the
network plan shall permit the beneficiary to continue an
ongoing course of treatment with that provider during a
transitional period for the following duration:
(A) 90 days from the date of the notice to the
beneficiary of the provider's disaffiliation from the
network plan if the beneficiary has an ongoing course
of treatment; or
(B) if the beneficiary has entered the third
trimester of pregnancy at the time of the provider's
disaffiliation, a period that includes the provision
of post-partum care directly related to the delivery.
(2) Notwithstanding the provisions of paragraph (1) of
this subsection (a), such care shall be authorized by the
network plan during the transitional period in accordance

with the following:
(A) the provider receives continued reimbursement
from the network plan at the rates and terms and
conditions applicable under the terminated contract
prior to the start of the transitional period;
(B) the provider adheres to the network plan's
quality assurance requirements, including provision to
the network plan of necessary medical information
related to such care; and
(C) the provider otherwise adheres to the network
plan's policies and procedures, including, but not
limited to, procedures regarding referrals and
obtaining preauthorizations for treatment.
(3) The provisions of this Section governing health
care provided during the transition period do not apply if
the beneficiary has successfully transitioned to another
provider participating in the network plan, if the
beneficiary has already met or exceeded the benefit
limitations of the plan, or if the care provided is not
medically necessary.
(b) A network plan shall provide for continuity of care
for new beneficiaries as follows:
(1) If a new beneficiary whose provider is not a
member of the network plan's provider network, but is
within the network plan's service area, enrolls in the
network plan, the network plan shall permit the

beneficiary to continue an ongoing course of treatment
with the beneficiary's current physician during a
transitional period:
(A) of 90 days from the effective date of
enrollment if the beneficiary has an ongoing course of
treatment; or
(B) if the beneficiary has entered the third
trimester of pregnancy at the effective date of
enrollment, that includes the provision of post-partum
care directly related to the delivery.
(2) If a beneficiary, or a beneficiary's authorized
representative, elects in writing to continue to receive
care from such provider pursuant to paragraph (1) of this
subsection (b), such care shall be authorized by the
network plan for the transitional period in accordance
with the following:
(A) the provider receives reimbursement from the
network plan at rates established by the network plan;
(B) the provider adheres to the network plan's
quality assurance requirements, including provision to
the network plan of necessary medical information
related to such care; and
(C) the provider otherwise adheres to the network
plan's policies and procedures, including, but not
limited to, procedures regarding referrals and
obtaining preauthorization for treatment.

(3) The provisions of this Section governing health
care provided during the transition period do not apply if
the beneficiary has successfully transitioned to another
provider participating in the network plan, if the
beneficiary has already met or exceeded the benefit
limitations of the plan, or if the care provided is not
medically necessary.
(c) In no event shall this Section be construed to require
a network plan to provide coverage for benefits not otherwise
covered or to diminish or impair preexisting condition
limitations contained in the beneficiary's contract.
(d) A provider shall comply with the requirements of 42
U.S.C. 300gg-138.
(Source: P.A. 100-502, eff. 9-15-17.)
(215 ILCS 124/25)
Sec. 25. Network transparency.
(a) A network plan shall post electronically an
up-to-date, accurate, and complete provider directory for each
of its network plans, with the information and search
functions, as described in this Section.
(1) In making the directory available electronically,
the network plans shall ensure that the general public is
able to view all of the current providers for a plan
through a clearly identifiable link or tab and without
creating or accessing an account or entering a policy or

contract number.
(2) An issuer's failure to update a network plan's
directory shall subject the issuer to a civil penalty of
$5,000 per month. The network plan shall update the online
provider directory at least monthly. Providers shall
notify the network plan electronically or in writing
within 10 business days of any changes to their
information as listed in the provider directory, including
the information required in subsections (b), (c), and (d)
subparagraph (K) of paragraph (1) of subsection (b). With
regard to subparagraph (I) of paragraph (1) of subsection
(b), the provider must give notice to the issuer within 20
business days of deciding to cease accepting new patients
covered by the plan if the new patient limitation is
expected to last 40 business days or longer. The network
plan shall update its online provider directory in a
manner consistent with the information provided by the
provider within 2 10 business days after being notified of
the change by the provider. Nothing in this paragraph (2)
shall void any contractual relationship between the
provider and the plan.
(3) At least once every 90 days, the issuer shall
self-audit each network plan's The network plan shall
audit periodically at least 25% of its provider
directories for accuracy, make any corrections necessary,
and retain documentation of the audit. The issuer shall

submit the self-audit and a summary to the Department, and
the Department shall make the summary of each self-audit
publicly available. The Department shall specify the
requirements of the summary, which shall be statistical in
nature except for a high-level narrative evaluating the
impact of internal and external factors on the accuracy of
the directory and the timeliness of updates. The network
plan shall submit the audit to the Director upon request.
As part of these self-audits audits, the network plan
shall contact any provider in its network that has not
submitted a claim to the plan or otherwise communicated
his or her intent to continue participation in the plan's
network. The self-audits shall comply with 42 U.S.C.
300gg-115(a)(2), except that "provider directory
information" shall include all information required to be
included in a provider directory pursuant to this Act.
(4) A network plan shall provide a print copy of a
current provider directory or a print copy of the
requested directory information upon request of a
beneficiary or a prospective beneficiary. Except when an
issuer's print copies use the same provider information as
the electronic provider directory on each print copy's
date of printing, print Print copies must be updated at
least every 90 days quarterly and an errata that reflects
changes in the provider network must be included in each
update updated quarterly.

(5) For each network plan, a network plan shall
include, in plain language in both the electronic and
print directory, the following general information:
(A) in plain language, a description of the
criteria the plan has used to build its provider
network;
(B) if applicable, in plain language, a
description of the criteria the issuer insurer or
network plan has used to create tiered networks;
(C) if applicable, in plain language, how the
network plan designates the different provider tiers
or levels in the network and identifies for each
specific provider, hospital, or other type of facility
in the network which tier each is placed, for example,
by name, symbols, or grouping, in order for a
beneficiary-covered person or a prospective
beneficiary-covered person to be able to identify the
provider tier; and
(D) if applicable, a notation that authorization
or referral may be required to access some providers; .
(E) a telephone number and email address for a
customer service representative to whom directory
inaccuracies may be reported; and
(F) a detailed description of the process to
dispute charges for out-of-network providers,
hospitals, or facilities that were incorrectly listed

as in-network prior to the provision of care and a
telephone number and email address to dispute such
charges.
(6) A network plan shall make it clear for both its
electronic and print directories what provider directory
applies to which network plan, such as including the
specific name of the network plan as marketed and issued
in this State. The network plan shall include in both its
electronic and print directories a customer service email
address and telephone number or electronic link that
beneficiaries or the general public may use to notify the
network plan of inaccurate provider directory information
and contact information for the Department's Office of
Consumer Health Insurance.
(7) A provider directory, whether in electronic or
print format, shall accommodate the communication needs of
individuals with disabilities, and include a link to or
information regarding available assistance for persons
with limited English proficiency.
(b) For each network plan, a network plan shall make
available through an electronic provider directory the
following information in a searchable format:
(1) for health care professionals:
(A) name;
(B) gender;
(C) participating office locations;

(D) patient population served (such as pediatric,
adult, elderly, or women) and specialty or
subspecialty, if applicable;
(E) medical group affiliations, if applicable;
(F) facility affiliations, if applicable;
(G) participating facility affiliations, if
applicable;
(H) languages spoken other than English, if
applicable;
(I) whether accepting new patients;
(J) board certifications, if applicable; and
(K) use of telehealth or telemedicine, including,
but not limited to:
(i) whether the provider offers the use of
telehealth or telemedicine to deliver services to
patients for whom it would be clinically
appropriate;
(ii) what modalities are used and what types
of services may be provided via telehealth or
telemedicine; and
(iii) whether the provider has the ability and
willingness to include in a telehealth or
telemedicine encounter a family caregiver who is
in a separate location than the patient if the
patient wishes and provides his or her consent;
(L) whether the health care professional accepts

appointment requests from patients; and
(M) the anticipated date the provider will leave
the network, if applicable, which shall be included no
more than 10 days after the issuer confirms that the
provider is scheduled to leave the network;
(2) for hospitals:
(A) hospital name;
(B) hospital type (such as acute, rehabilitation,
children's, or cancer);
(C) participating hospital location; and
(D) hospital accreditation status; and
(E) the anticipated date the hospital will leave
the network, if applicable, which shall be included no
more than 10 days after the issuer confirms the
hospital is scheduled to leave the network; and
(3) for facilities, other than hospitals, by type:
(A) facility name;
(B) facility type;
(C) types of services performed; and
(D) participating facility location or locations;
and .
(E) the anticipated date the facility will leave
the network, if applicable, which shall be included no
more than 10 days after the issuer confirms the
facility is scheduled to leave the network.
(c) For the electronic provider directories, for each

network plan, a network plan shall make available all of the
following information in addition to the searchable
information required in this Section:
(1) for health care professionals:
(A) contact information, including both a
telephone number and digital contact information if
the provider has supplied digital contact information;
and
(B) languages spoken other than English by
clinical staff, if applicable;
(2) for hospitals, telephone number and digital
contact information; and
(3) for facilities other than hospitals, telephone
number.
(d) The issuer insurer or network plan shall make
available in print, upon request, the following provider
directory information for the applicable network plan:
(1) for health care professionals:
(A) name;
(B) contact information, including a telephone
number and digital contact information if the provider
has supplied digital contact information;
(C) participating office location or locations;
(D) patient population (such as pediatric, adult,
elderly, or women) and specialty or subspecialty, if
applicable;

(E) languages spoken other than English, if
applicable;
(F) whether accepting new patients; and
(G) use of telehealth or telemedicine, including,
but not limited to:
(i) whether the provider offers the use of
telehealth or telemedicine to deliver services to
patients for whom it would be clinically
appropriate;
(ii) what modalities are used and what types
of services may be provided via telehealth or
telemedicine; and
(iii) whether the provider has the ability and
willingness to include in a telehealth or
telemedicine encounter a family caregiver who is
in a separate location than the patient if the
patient wishes and provides his or her consent;
and
(H) whether the health care professional accepts
appointment requests from patients.
(2) for hospitals:
(A) hospital name;
(B) hospital type (such as acute, rehabilitation,
children's, or cancer); and
(C) participating hospital location, and telephone
number, and digital contact information; and

(3) for facilities, other than hospitals, by type:
(A) facility name;
(B) facility type;
(C) patient population (such as pediatric, adult,
elderly, or women) served, if applicable, and types of
services performed; and
(D) participating facility location or locations,
and telephone numbers, and digital contact information
for each location.
(e) The network plan shall include a disclosure in the
print format provider directory that the information included
in the directory is accurate as of the date of printing and
that beneficiaries or prospective beneficiaries should consult
the issuer's insurer's electronic provider directory on its
website and contact the provider. The network plan shall also
include a telephone number and email address in the print
format provider directory for a customer service
representative where the beneficiary can obtain current
provider directory information or report provider directory
inaccuracies. The printed provider directory shall include a
detailed description of the process to dispute charges for
out-of-network providers, hospitals, or facilities that were
incorrectly listed as in-network prior to the provision of
care and a telephone number and email address to dispute those
charges.
(f) The Director may conduct periodic audits of the

accuracy of provider directories. A network plan shall not be
subject to any fines or penalties for information required in
this Section that a provider submits that is inaccurate or
incomplete.
(g) To the extent not otherwise provided in this Act, an
issuer shall comply with the requirements of 42 U.S.C.
300gg-115, except that "provider directory information" shall
include all information required to be included in a provider
directory pursuant to this Section.
(h) If the issuer or the Department identifies a provider
incorrectly listed in the provider directory, the issuer shall
check each of the issuer's network plan provider directories
for the provider within 2 business days to ascertain whether
the provider is a preferred provider in that network plan and,
if the provider is incorrectly listed in the provider
directory, remove the provider from the provider directory
without delay.
(i) If the Director determines that an issuer violated
this Section, the Director may assess a fine up to $5,000 per
violation, except for inaccurate information given by a
provider to the issuer. If an issuer, or any entity or person
acting on the issuer's behalf, knew or reasonably should have
known that a provider was incorrectly included in a provider
directory, the Director may assess a fine of up to $25,000 per
violation against the issuer.
(j) This Section applies to network plans not otherwise

exempt under Section 3, including stand-alone dental plans.
(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
(215 ILCS 124/30)
Sec. 30. Administration and enforcement.
(a) Issuers Insurers, as defined in this Act, have a
continuing obligation to comply with the requirements of this
Act. Other than the duties specifically created in this Act,
nothing in this Act is intended to preclude, prevent, or
require the adoption, modification, or termination of any
utilization management, quality management, or claims
processing methodologies of an issuer insurer.
(b) Nothing in this Act precludes, prevents, or requires
the adoption, modification, or termination of any network plan
term, benefit, coverage or eligibility provision, or payment
methodology.
(c) The Director shall enforce the provisions of this Act
pursuant to the enforcement powers granted to it by law.
(d) The Department shall adopt rules to enforce compliance
with this Act to the extent necessary.
(e) In accordance with Section 5-45 of the Illinois
Administrative Procedure Act, the Department may adopt
emergency rules to implement federal standards for provider
ratios, travel time and distance, and appointment wait times
if such standards apply to health insurance coverage regulated
by the Department and are more stringent than the State

standards extant at the time the final federal standards are
published.
(Source: P.A. 100-502, eff. 9-15-17.)
(215 ILCS 124/35 new)
Sec. 35. Provider requirements. Providers shall comply
with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations
promulgated thereunder, as well as Section 20, paragraph (2)
of subsection (a) of Section 25, subsections (h) and (j) of
Section 25, and Section 36 of this Act, except that "provider
directory information" includes all information required to be
included in a provider directory pursuant to Section 25 of
this Act.
(215 ILCS 124/36 new)
Sec. 36. Complaint of incorrect charges.
(a) A beneficiary who, taking into account the
reimbursement, if any, by the issuer, incurs a cost in excess
of the in-network cost-sharing for a covered service from a
provider, facility, or hospital that was listed as in-network
in the plan's provider directory prior to or at the time of the
provision of services may file a complaint with the
Department. The Department shall investigate the complaint and
determine if the provider was incorrectly included in the
plan's provider directory when the beneficiary made the
appointment or received the service.

(b) Upon the Department's confirmation of the allegations
in the complaint that the beneficiary incurred a cost in
excess of the in-network cost-sharing for covered services
provided by an incorrectly included provider when the
appointment was made or service was provided, the issuer shall
reimburse the beneficiary for all costs incurred in excess of
the in-network cost-sharing. However, if the issuer has paid
the claim to the provider directly, the issuer shall notify
the beneficiary and the provider of the beneficiary's right to
reimbursement from the provider for any payments in excess of
the in-network cost-sharing amount pursuant to 42 U.S.C.
300gg-139(b), and the issuer's notice shall specify the
in-network cost-sharing amount for the covered services. The
amounts paid by the beneficiary within the in-network
cost-sharing amount shall apply towards the in-network
deductible and out-of-pocket maximum, if any.
(215 ILCS 124/40 new)
Sec. 40. Confidentiality.
(a) All records in the custody or possession of the
Department are presumed to be open to public inspection or
copying unless exempt from disclosure by Section 7 or 7.5 of
the Freedom of Information Act. Except as otherwise provided
in this Section or other applicable law, the filings required
under this Act shall be open to public inspection or copying.
(b) The following information shall not be deemed

confidential:
(1) actual or projected ratios of providers to
beneficiaries;
(2) actual or projected time and distance between
network providers and beneficiaries or actual or projected
waiting times for a beneficiary to see a network provider;
(3) geographic maps of network providers;
(4) requests for exceptions under subsection (g) of
Section 10, except with respect to any discussion of
ongoing or planned contractual negotiations with providers
that the issuer requests to be treated as confidential;
(5) provider directories and provider lists;
(6) self-audit summaries required under paragraph (3)
of subsection (a) of Section 25 of this Act; and
(7) issuer or Department statements of determination
as to whether a network plan has satisfied this Act's
requirements regarding the information described in this
subsection.
(c) An issuer's work papers and reports on the results of a
self-audit of its provider directories, including any
communications between the issuer and the Department, shall
remain confidential unless expressly waived by the issuer or
unless deemed public information under federal law.
(d) The filings required under Section 10 of this Act
shall be confidential while they remain under the Department's
review but shall become open to public inspection and copying

upon completion of the review, except as provided in this
Section or under other applicable law.
(e) Nothing in this Section shall supersede the statutory
requirement that work papers obtained during a market conduct
examination be deemed confidential.
(215 ILCS 124/50 new)
Sec. 50. Funds for enforcement. Moneys from fines and
penalties collected from issuers for violations of this Act
shall be deposited into the Insurance Producer Administration
Fund for appropriation by the General Assembly to the
Department to be used for providing financial support of the
Department's enforcement of this Act.
(215 ILCS 124/55 new)
Sec. 55. Uniform electronic provider directory information
notification forms.
(a) On or before January 1, 2026, the Department shall
develop and publish a uniform electronic provider directory
information form that issuers shall make available to
onboarding, current, and former preferred providers to notify
the issuer of the provider's currently accurate provider
directory information under Section 25 of this Act and 42
U.S.C. 300gg-139. The form shall address information needed
from newly onboarding preferred providers, updates to
previously supplied provider directory information, reporting

an inaccurate directory entry of previously supplied
information, contract terminations, and differences in
information for specific network plans offered by an issuer,
such as whether the provider is a preferred provider for the
network plan or is accepting new patients under that plan. The
Department shall allow issuers to implement this form through
either a PDF or a web portal that requests the same
information.
(b) Notwithstanding any other provision of law to the
contrary, beginning 6 months after the Department publishes
the uniform electronic provider directory information form and
no later than July 1, 2026, every provider must use the uniform
electronic provider directory information form to notify
issuers of their provider directory information as required
under Section 25 of this Act and 42 U.S.C. 300gg-139. Issuers
shall accept this form as sufficient to update their provider
directories. Issuers shall not accept paper or fax submissions
of provider directory information from providers.
(c) The Uniform Electronic Provider Directory Information
Form Task Force is created. The purpose of this task force is
to provide input and advice to the Department of Insurance in
the development of a uniform electronic provider directory
information form. The task force shall include at least the
following individuals:
(1) the Director of Insurance or a designee, as chair;
(2) the Marketplace Director or a designee;

(3) the Director of the Division of Professional
Regulation or a designee;
(4) the Director of Public Health or a designee;
(5) the Secretary of Innovation and Technology or a
designee;
(6) the Director of Healthcare and Family Services or
a designee;
(7) the following individuals appointed by the
Director:
(A) one representative of a statewide association
representing physicians;
(B) one representative of a statewide association
representing nurses;
(C) one representative of a statewide organization
representing a majority of Illinois hospitals;
(D) one representative of a statewide organization
representing Illinois pharmacies;
(E) one representative of a statewide organization
representing mental health care providers;
(F) one representative of a statewide organization
representing substance use disorder health care
providers;
(G) 2 representatives of health insurance issuers
doing business in this State or issuer trade
associations, at least one of which represents a
State-domiciled mutual health insurance company, with

a demonstrated expertise in the business of health
insurance or health benefits administration; and
(H) 2 representatives of a health insurance
consumer advocacy group.
(d) The Department shall convene the task force described
in this Section no later than April 1, 2025.
(e) The Department, in development of the uniform
electronic provider directory information form, and the task
force, in offering input, shall take into consideration the
following:
(1) readability and user experience;
(2) interoperability;
(3) existing regulations established by the federal
Centers for Medicare and Medicaid Services, the Department
of Insurance, the Department of Healthcare and Family
Service, the Department of Financial and Professional
Regulation, and the Department of Public Health;
(4) potential opportunities to avoid duplication of
data collection efforts, including, but not limited to,
opportunities related to:
(A) integrating any provider reporting required
under Section 25 of this Act and 42 U.S.C. 300gg-139
with the provider reporting required under the Health
Care Professional Credentials Data Collection Act;
(B) furnishing information to any national
provider directory established by the federal Centers

for Medicare and Medicaid Services or another federal
agency with jurisdiction over health care providers;
and
(C) furnishing information in compliance with the
Patients' Right to Know Act;
(5) compatibility with the Illinois Health Benefits
Exchange;
(6) provider licensing requirements and forms; and
(7) information needed to classify a provider under
any specialty type for which a network adequacy standard
may be established under this Act when a specialty board
certification or State license does not currently exist.
Section 2-15. The Managed Care Reform and Patient Rights
Act is amended by changing Sections 20 and 25 as follows:
(215 ILCS 134/20)
Sec. 20. Notice of nonrenewal or termination. A health
care plan must give at least 60 days notice of nonrenewal or
termination of a health care provider to the health care
provider and to the enrollees served by the health care
provider. The notice shall include a name and address to which
an enrollee or health care provider may direct comments and
concerns regarding the nonrenewal or termination. Immediate
written notice may be provided without 60 days notice when a
health care provider's license has been disciplined by a State

licensing board. The notice to the enrollee shall provide the
individual with an opportunity to notify the health care plan
of the individual's need for transitional care.
(Source: P.A. 91-617, eff. 1-1-00.)
(215 ILCS 134/25)
Sec. 25. Transition of services.
(a) A health care plan shall provide for continuity of
care for its enrollees as follows:
(1) If an enrollee's health care provider physician
leaves the health care plan's network of health care
providers for reasons other than termination of a contract
in situations involving imminent harm to a patient or a
final disciplinary action by a State licensing board and
the provider physician remains within the health care
plan's service area, or if benefits provided under such
health care plan with respect to such provider are
terminated because of a change in the terms of the
participation of such provider in such plan, or if a
contract between a group health plan, as defined in
Section 5 of the Illinois Health Insurance Portability and
Accountability Act, and a health care plan offered in
connection with the group health plan is terminated and
results in a loss of benefits provided under such plan
with respect to such provider, the health care plan shall
permit the enrollee to continue an ongoing course of

treatment with that provider physician during a
transitional period:
(A) of 90 days from the date of the notice of
provider's physician's termination from the health
care plan to the enrollee of the provider's
physician's disaffiliation from the health care plan
if the enrollee has an ongoing course of treatment; or
(B) if the enrollee has entered the third
trimester of pregnancy at the time of the provider's
physician's disaffiliation, that includes the
provision of post-partum care directly related to the
delivery.
(2) Notwithstanding the provisions in item (1) of this
subsection, such care shall be authorized by the health
care plan during the transitional period only if the
provider physician agrees:
(A) to continue to accept reimbursement from the
health care plan at the rates applicable prior to the
start of the transitional period;
(B) to adhere to the health care plan's quality
assurance requirements and to provide to the health
care plan necessary medical information related to
such care; and
(C) to otherwise adhere to the health care plan's
policies and procedures, including but not limited to
procedures regarding referrals and obtaining

preauthorizations for treatment.
(3) During an enrollee's plan year, a health care plan
shall not remove a drug from its formulary or negatively
change its preferred or cost-tier sharing unless, at least
60 days before making the formulary change, the health
care plan:
(A) provides general notification of the change in
its formulary to current and prospective enrollees;
(B) directly notifies enrollees currently
receiving coverage for the drug, including information
on the specific drugs involved and the steps they may
take to request coverage determinations and
exceptions, including a statement that a certification
of medical necessity by the enrollee's prescribing
provider will result in continuation of coverage at
the existing level; and
(C) directly notifies in writing by first class
mail and through an electronic transmission, if
available, the prescribing provider of all health care
plan enrollees currently prescribed the drug affected
by the proposed change; the notice shall include a
one-page form by which the prescribing provider can
notify the health care plan in writing or
electronically by first class mail that coverage of
the drug for the enrollee is medically necessary.
The notification in paragraph (C) may direct the

prescribing provider to an electronic portal through which
the prescribing provider may electronically file a
certification to the health care plan that coverage of the
drug for the enrollee is medically necessary. The
prescribing provider may make a secure electronic
signature beside the words "certification of medical
necessity", and this certification shall authorize
continuation of coverage for the drug.
If the prescribing provider certifies to the health
care plan either in writing or electronically that the
drug is medically necessary for the enrollee as provided
in paragraph (C), a health care plan shall authorize
coverage for the drug prescribed based solely on the
prescribing provider's assertion that coverage is
medically necessary, and the health care plan is
prohibited from making modifications to the coverage
related to the covered drug, including, but not limited
to:
(i) increasing the out-of-pocket costs for the
covered drug;
(ii) moving the covered drug to a more restrictive
tier; or
(iii) denying an enrollee coverage of the drug for
which the enrollee has been previously approved for
coverage by the health care plan.
Nothing in this item (3) prevents a health care plan

from removing a drug from its formulary or denying an
enrollee coverage if the United States Food and Drug
Administration has issued a statement about the drug that
calls into question the clinical safety of the drug, the
drug manufacturer has notified the United States Food and
Drug Administration of a manufacturing discontinuance or
potential discontinuance of the drug as required by
Section 506C of the Federal Food, Drug, and Cosmetic Act,
as codified in 21 U.S.C. 356c, or the drug manufacturer
has removed the drug from the market.
Nothing in this item (3) prohibits a health care plan,
by contract, written policy or procedure, or any other
agreement or course of conduct, from requiring a
pharmacist to effect substitutions of prescription drugs
consistent with Section 19.5 of the Pharmacy Practice Act,
under which a pharmacist may substitute an interchangeable
biologic for a prescribed biologic product, and Section 25
of the Pharmacy Practice Act, under which a pharmacist may
select a generic drug determined to be therapeutically
equivalent by the United States Food and Drug
Administration and in accordance with the Illinois Food,
Drug and Cosmetic Act.
This item (3) applies to a policy or contract that is
amended, delivered, issued, or renewed on or after January
1, 2019. This item (3) does not apply to a health plan as
defined in the State Employees Group Insurance Act of 1971

or medical assistance under Article V of the Illinois
Public Aid Code.
(b) A health care plan shall provide for continuity of
care for new enrollees as follows:
(1) If a new enrollee whose physician is not a member
of the health care plan's provider network, but is within
the health care plan's service area, enrolls in the health
care plan, the health care plan shall permit the enrollee
to continue an ongoing course of treatment with the
enrollee's current physician during a transitional period:
(A) of 90 days from the effective date of
enrollment if the enrollee has an ongoing course of
treatment; or
(B) if the enrollee has entered the third
trimester of pregnancy at the effective date of
enrollment, that includes the provision of post-partum
care directly related to the delivery.
(2) If an enrollee elects to continue to receive care
from such physician pursuant to item (1) of this
subsection, such care shall be authorized by the health
care plan for the transitional period only if the
physician agrees:
(A) to accept reimbursement from the health care
plan at rates established by the health care plan;
such rates shall be the level of reimbursement
applicable to similar physicians within the health

care plan for such services;
(B) to adhere to the health care plan's quality
assurance requirements and to provide to the health
care plan necessary medical information related to
such care; and
(C) to otherwise adhere to the health care plan's
policies and procedures including, but not limited to
procedures regarding referrals and obtaining
preauthorization for treatment.
(c) In no event shall this Section be construed to require
a health care plan to provide coverage for benefits not
otherwise covered or to diminish or impair preexisting
condition limitations contained in the enrollee's contract. In
no event shall this Section be construed to prohibit the
addition of prescription drugs to a health care plan's list of
covered drugs during the coverage year.
(d) In this Section, "ongoing course of treatment" has the
meaning ascribed to that term in Section 5 of the Network
Adequacy and Transparency Act.
(Source: P.A. 100-1052, eff. 8-24-18.)
Article 3.
Section 3-5. The Illinois Insurance Code is amended by
changing Section 355 as follows:

(215 ILCS 5/355) (from Ch. 73, par. 967)
Sec. 355. Accident and health policies; provisions.
(a) As used in this Section:
"Inadequate rate" means a rate:
(1) that is insufficient to sustain projected losses
and expenses to which the rate applies; and
(2) the continued use of which endangers the solvency
of an insurer using that rate.
"Large employer" has the meaning provided in the Illinois
Health Insurance Portability and Accountability Act.
"Plain language" has the meaning provided in the federal
Plain Writing Act of 2010 and subsequent guidance documents,
including the Federal Plain Language Guidelines.
"Unreasonable rate increase" means a rate increase that
the Director determines to be excessive, unjustified, or
unfairly discriminatory in accordance with 45 CFR 154.205.
(b) No policy of insurance against loss or damage from the
sickness, or from the bodily injury or death of the insured by
accident shall be issued or delivered to any person in this
State until a copy of the form thereof and of the
classification of risks and the premium rates pertaining
thereto have been filed with the Director; nor shall it be so
issued or delivered until the Director shall have approved
such policy pursuant to the provisions of Section 143. If the
Director disapproves the policy form, he or she shall make a
written decision stating the respects in which such form does

not comply with the requirements of law and shall deliver a
copy thereof to the company and it shall be unlawful
thereafter for any such company to issue any policy in such
form. On and after January 1, 2025, any form filing submitted
for large employer group accident and health insurance shall
be automatically deemed approved within 90 days of the
submission date unless the Director extends by not more than
an additional 30 days the period within which the form shall be
approved or disapproved by giving written notice to the
insurer of such extension before the expiration of the 90
days. Any form in receipt of such an extension shall be
automatically deemed approved within 120 days of the
submission date. The Director may toll the filing due to a
conflict in legal interpretation of federal or State law as
long as the tolling is applied uniformly to all applicable
forms, written notification is provided to the insurer prior
to the tolling, the duration of the tolling is provided within
the notice to the insurer, and justification for the tolling
is posted to the Department's website. The Director may
disapprove the filing if the insurer fails to respond to an
objection or request for additional information within the
timeframe identified for response. As used in this subsection,
"large employer" has the meaning given in Section 5 of the
federal Health Insurance Portability and Accountability Act.
(c) For plan year 2026 and thereafter, premium rates for
all individual and small group accident and health insurance

policies must be filed with the Department for approval.
Unreasonable rate increases or inadequate rates shall be
modified or disapproved. For any plan year during which the
Illinois Health Benefits Exchange operates as a full
State-based exchange, the Department shall provide insurers at
least 30 days' notice of the deadline to submit rate filings.
(c-5) Unless prohibited under federal law, for plan year
2026 and thereafter, each insurer proposing to offer a
qualified health plan issued in the individual market through
the Illinois Health Benefits Exchange must incorporate the
following approach in its rate filing under this Section:
(1) The rate filing must apply a cost-sharing
reduction defunding adjustment factor within a range that:
(A) is uniform across all insurers;
(B) is consistent with the total adjustment
expected to be needed to cover actual cost-sharing
reduction costs across all silver plans on the
Illinois Health Benefits Exchange statewide, provided
that such costs are calculated assuming utilization by
the State's full individual-market risk pool; and
(C) assumes that the only on-Exchange silver plans
that will be purchased are the 87% and 94%
cost-sharing reduction variations.
(2) The rate filing must apply an induced demand
factor based on the following formula: (Plan Actuarial
Value)2 - (Plan Actuarial Value) + 1.24.

In the annual notice to insurers described in subsection
(c), the Department must include the specific numerical range
calculated for the applicable plan year under paragraph (1) of
this subsection (c-5) and the formula in paragraph (2) of this
subsection (c-5).
(d) For plan year 2025 and thereafter, the Department
shall post all insurers' rate filings and summaries on the
Department's website 5 business days after the rate filing
deadline set by the Department in annual guidance. The rate
filings and summaries posted to the Department's website shall
exclude information that is proprietary or trade secret
information protected under paragraph (g) of subsection (1) of
Section 7 of the Freedom of Information Act or confidential or
privileged under any applicable insurance law or rule. All
summaries shall include a brief justification of any rate
increase or decrease requested, including the number of
individual members, the medical loss ratio, medical trend,
administrative costs, and any other information required by
rule. The plain writing summary shall include notification of
the public comment period established in subsection (e).
(e) The Department shall open a 30-day public comment
period on the rate filings beginning on the date that all of
the rate filings are posted on the Department's website. The
Department shall post all of the comments received to the
Department's website within 5 business days after the comment
period ends.

(f) After the close of the public comment period described
in subsection (e), the Department, beginning for plan year
2026, shall issue a decision to approve, disapprove, or modify
a rate filing within 60 days. Any rate filing or any rates
within a filing on which the Director does not issue a decision
within 60 days shall automatically be deemed approved. The
Director's decision shall take into account the actuarial
justifications and public comments. The Department shall
notify the insurer of the decision, make the decision
available to the public by posting it on the Department's
website, and include an explanation of the findings, actuarial
justifications, and rationale that are the basis for the
decision. Any company whose rate has been modified or
disapproved shall be allowed to request a hearing within 10
days after the action taken. The action of the Director in
disapproving a rate shall be subject to judicial review under
the Administrative Review Law.
(g) If, following the issuance of a decision but before
the effective date of the premium rates approved by the
decision, an event occurs that materially affects the
Director's decision to approve, deny, or modify the rates, the
Director may consider supplemental facts or data reasonably
related to the event.
(h) The Department shall adopt rules implementing the
procedures described in subsections (d) through (g) by March
31, 2024.

(i) Subsection (a) and subsections (c) through (h) of this
Section do not apply to grandfathered health plans as defined
in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C.
300gg-91; student health insurance coverage as defined in 45
CFR 147.145; the large group market as defined in Section 5 of
the Illinois Health Insurance Portability and Accountability
Act; or short-term, limited-duration health insurance coverage
as defined in Section 5 of the Short-Term, Limited-Duration
Health Insurance Coverage Act. For a filing of premium rates
or classifications of risk for any of these types of coverage,
the Director's initial review period shall not exceed 60 days
to issue informal objections to the company that request
additional clarification, explanation, substantiating
documentation, or correction of concerns identified in the
filing before the company implements the premium rates,
classifications, or related rate-setting methodologies
described in the filing, except that the Director may extend
by not more than an additional 30 days the period of initial
review by giving written notice to the company of such
extension before the expiration of the initial 60-day period.
Nothing in this subsection shall confer authority upon the
Director to approve, modify, or disapprove rates where that
authority is not provided by other law. Nothing in this
subsection shall prohibit the Director from conducting any
investigation, examination, hearing, or other formal
administrative or enforcement proceeding with respect to a

company's rate filing or implementation thereof under
applicable law at any time, including after the period of
initial review.
(Source: P.A. 103-106, eff. 1-1-24.)
Section 3-10. The Illinois Health Benefits Exchange Law is
amended by changing Section 5-5 as follows:
(215 ILCS 122/5-5)
Sec. 5-5. State health benefits exchange. It is declared
that this State, beginning October 1, 2013, in accordance with
Section 1311 of the federal Patient Protection and Affordable
Care Act, shall establish a State health benefits exchange to
be known as the Illinois Health Benefits Exchange in order to
help individuals and small employers with no more than 50
employees shop for, select, and enroll in qualified,
affordable private health plans that fit their needs at
competitive prices. The Exchange shall separate coverage pools
for individuals and small employers and shall supplement and
not supplant any existing private health insurance market for
individuals and small employers. The Department of Insurance
shall operate the Illinois Health Benefits Exchange as a
State-based exchange using the federal platform by plan year
2025 and as a State-based exchange by plan year 2026. The
Director of Insurance may require that all plans in the
individual and small group markets, other than grandfathered

health plans, be made available for comparison on the Illinois
Health Benefits Exchange, but may not require that all plans
in the individual and small group markets be purchased
exclusively on the Illinois Health Benefits Exchange. Through
the adoption of rules, the Director of Insurance may require
that plans offered on the exchange conform with standardized
plan designs that provide for standardized cost sharing for
covered health services. Except when it is inconsistent with
State law, the Department of Insurance shall enforce the
coverage requirements under the federal Patient Protection and
Affordable Care Act, including the coverage of all United
States Preventive Services Task Force Grade A and B preventive
services without cost sharing notwithstanding any federal
overturning or repeal of 42 U.S.C. 300gg-13(a)(1), that apply
to the individual and small group markets. Beginning for plan
year 2026, if a health insurance issuer offers a product as
defined under 45 CFR 144.103 at the gold or silver level
through the Illinois Health Benefits Exchange, the issuer must
offer that product at both the gold and silver levels. The
Director of Insurance may elect to add a small business health
options program to the Illinois Health Benefits Exchange to
help small employers enroll their employees in qualified
health plans in the small group market. The General Assembly
shall appropriate funds to establish the Illinois Health
Benefits Exchange.
(Source: P.A. 103-103, eff. 6-27-23.)

Article 4.
Section 4-5. The Illinois Insurance Code is amended by
changing Section 355 as follows:
(215 ILCS 5/355) (from Ch. 73, par. 967)
Sec. 355. Accident and health policies; provisions.
(a) As used in this Section:
"Inadequate rate" means a rate:
(1) that is insufficient to sustain projected losses
and expenses to which the rate applies; and
(2) the continued use of which endangers the solvency
of an insurer using that rate.
"Large employer" has the meaning provided in the Illinois
Health Insurance Portability and Accountability Act.
"Plain language" has the meaning provided in the federal
Plain Writing Act of 2010 and subsequent guidance documents,
including the Federal Plain Language Guidelines.
"Unreasonable rate increase" means a rate increase that
the Director determines to be excessive, unjustified, or
unfairly discriminatory in accordance with 45 CFR 154.205.
(b) No policy of insurance against loss or damage from the
sickness, or from the bodily injury or death of the insured by
accident shall be issued or delivered to any person in this
State until a copy of the form thereof and of the

classification of risks and the premium rates pertaining
thereto have been filed with the Director; nor shall it be so
issued or delivered until the Director shall have approved
such policy pursuant to the provisions of Section 143. If the
Director disapproves the policy form, he or she shall make a
written decision stating the respects in which such form does
not comply with the requirements of law and shall deliver a
copy thereof to the company and it shall be unlawful
thereafter for any such company to issue any policy in such
form. On and after January 1, 2025, any form filing submitted
for large employer group accident and health insurance shall
be automatically deemed approved within 90 days of the
submission date unless the Director extends by not more than
an additional 30 days the period within which the form shall be
approved or disapproved by giving written notice to the
insurer of such extension before the expiration of the 90
days. Any form in receipt of such an extension shall be
automatically deemed approved within 120 days of the
submission date. The Director may toll the filing due to a
conflict in legal interpretation of federal or State law as
long as the tolling is applied uniformly to all applicable
forms, written notification is provided to the insurer prior
to the tolling, the duration of the tolling is provided within
the notice to the insurer, and justification for the tolling
is posted to the Department's website. The Director may
disapprove the filing if the insurer fails to respond to an

objection or request for additional information within the
timeframe identified for response. As used in this subsection,
"large employer" has the meaning given in Section 5 of the
federal Health Insurance Portability and Accountability Act.
(c) For plan year 2026 and thereafter, premium rates for
all individual and small group accident and health insurance
policies must be filed with the Department for approval.
Unreasonable rate increases or inadequate rates shall be
modified or disapproved. For any plan year during which the
Illinois Health Benefits Exchange operates as a full
State-based exchange, the Department shall provide insurers at
least 30 days' notice of the deadline to submit rate filings.
(d) For plan year 2025 and thereafter, the Department
shall post all insurers' rate filings and summaries on the
Department's website 5 business days after the rate filing
deadline set by the Department in annual guidance. The rate
filings and summaries posted to the Department's website shall
exclude information that is proprietary or trade secret
information protected under paragraph (g) of subsection (1) of
Section 7 of the Freedom of Information Act or confidential or
privileged under any applicable insurance law or rule. All
summaries shall include a brief justification of any rate
increase or decrease requested, including the number of
individual members, the medical loss ratio, medical trend,
administrative costs, and any other information required by
rule. The plain writing summary shall include notification of

the public comment period established in subsection (e).
(e) The Department shall open a 30-day public comment
period on the rate filings beginning on the date that all of
the rate filings are posted on the Department's website. The
Department shall post all of the comments received to the
Department's website within 5 business days after the comment
period ends.
(f) After the close of the public comment period described
in subsection (e), the Department, beginning for plan year
2026, shall issue a decision to approve, disapprove, or modify
a rate filing within 60 days. Any rate filing or any rates
within a filing on which the Director does not issue a decision
within 60 days shall automatically be deemed approved. The
Director's decision shall take into account the actuarial
justifications and public comments. The Department shall
notify the insurer of the decision, make the decision
available to the public by posting it on the Department's
website, and include an explanation of the findings, actuarial
justifications, and rationale that are the basis for the
decision. Any company whose rate has been modified or
disapproved shall be allowed to request a hearing within 10
days after the action taken. The action of the Director in
disapproving a rate shall be subject to judicial review under
the Administrative Review Law.
(g) If, following the issuance of a decision but before
the effective date of the premium rates approved by the

decision, an event occurs that materially affects the
Director's decision to approve, deny, or modify the rates, the
Director may consider supplemental facts or data reasonably
related to the event.
(h) The Department shall adopt rules implementing the
procedures described in subsections (d) through (g) by March
31, 2024.
(i) Subsection (a), and subsections (c) through (h), and
subsection (j) of this Section do not apply to grandfathered
health plans as defined in 45 CFR 147.140; excepted benefits
as defined in 42 U.S.C. 300gg-91; or student health insurance
coverage as defined in 45 CFR 147.145; the large group market
as defined in Section 5 of the Illinois Health Insurance
Portability and Accountability Act; or short-term,
limited-duration health insurance coverage as defined in
Section 5 of the Short-Term, Limited-Duration Health Insurance
Coverage Act. For a filing of premium rates or classifications
of risk for any of these types of coverage, the Director's
initial review period shall not exceed 60 days to issue
informal objections to the company that request additional
clarification, explanation, substantiating documentation, or
correction of concerns identified in the filing before the
company implements the premium rates, classifications, or
related rate-setting methodologies described in the filing,
except that the Director may extend by not more than an
additional 30 days the period of initial review by giving

written notice to the company of such extension before the
expiration of the initial 60-day period. Nothing in this
subsection shall confer authority upon the Director to
approve, modify, or disapprove rates where that authority is
not provided by other law. Nothing in this subsection shall
prohibit the Director from conducting any investigation,
examination, hearing, or other formal administrative or
enforcement proceeding with respect to a company's rate filing
or implementation thereof under applicable law at any time,
including after the period of initial review.
(j) Subsection (a) and subsections (c) through (h) do not
apply to group policies issued in the large group market as
defined in Section 5 of the Illinois Health Insurance
Portability and Accountability Act. For large group policies
issued, delivered, amended, or renewed on or after January 1,
2026 that are not described in subsection (i), the premium
rates and risk classifications, including any rate manuals and
rules used to arrive at the rates, must be filed with the
Department annually for approval at least 120 days before the
rates are intended to take effect.
(1) A rate filing shall be modified or disapproved if
the premiums are unreasonable in relation to the benefits
because the rates were not calculated in accordance with
sound actuarial principles.
(2) Within 60 days of receipt of the rate filing, the
Director shall issue a decision to approve, disapprove, or

modify the filing along with the reasons and actuarial
justification for the decision. Any rate filing or rates
within a filing on which the Director does not issue a
decision within 60 days shall be automatically deemed
approved.
(3) Any company whose rate or rate filing has been
modified or disapproved shall be allowed to request a
hearing within 10 days after the action taken. The action
of the Director in disapproving a rate or rate filing
shall be subject to judicial review under the
Administrative Review Law.
(4) Nothing in this subsection requires a company to
file a large group policy's final premium rates for prior
approval if the company negotiates the final rates or rate
adjustments with the plan sponsor or its administrator in
accordance with the rate manual and rules of the currently
approved rate filing for the policy.
In this subsection, "administrator" and "plan sponsor"
have the meaning given to those terms in 29 U.S.C. 1002(16).
(Source: P.A. 103-106, eff. 1-1-24.)
Section 4-10. The Health Maintenance Organization Act is
amended by changing Section 4-12 as follows:
(215 ILCS 125/4-12) (from Ch. 111 1/2, par. 1409.5)
Sec. 4-12. Changes in rate methodology and benefits,

material modifications. A health maintenance organization
shall file with the Director, prior to use, a notice of any
change in rate methodology, or benefits and of any material
modification of any matter or document furnished pursuant to
Section 2-1, together with such supporting documents as are
necessary to fully explain the change or modification.
(a) Contract modifications described in subsections
(c)(5), (c)(6) and (c)(7) of Section 2-1 shall include all
form agreements between the organization and enrollees,
providers, administrators of services and insurers of health
maintenance organizations.
(b) Material transactions or series of transactions other
than those described in subsection (a) of this Section, the
total annual value of which exceeds the greater of $100,000 or
5% of net earned subscription revenue for the most current
12-month period as determined from filed financial statements.
(c) Any agreement between the organization and an insurer
shall be subject to the provisions of the laws of this State
regarding reinsurance as provided in Article XI of the
Illinois Insurance Code. All reinsurance agreements must be
filed. Approval of the Director is required for all agreements
except the following: individual stop loss, aggregate excess,
hospitalization benefits or out-of-area of the participating
providers unless 20% or more of the organization's total risk
is reinsured, in which case all reinsurance agreements require
approval.

(d) In addition to any applicable provisions of this Act,
premium rate filings shall be subject to subsections (a) and
(c) through (j) (i) of Section 355 of the Illinois Insurance
Code.
(Source: P.A. 103-106, eff. 1-1-24.)
Section 4-15. The Limited Health Service Organization Act
is amended by changing Section 3006 as follows:
(215 ILCS 130/3006) (from Ch. 73, par. 1503-6)
Sec. 3006. Changes in rate methodology and benefits;
material modifications; addition of limited health services.
(a) A limited health service organization shall file with
the Director prior to use, a notice of any change in rate
methodology, charges, or benefits and of any material
modification of any matter or document furnished pursuant to
Section 2001, together with such supporting documents as are
necessary to fully explain the change or modification.
(1) Contract modifications described in paragraphs (5)
and (6) of subsection (c) of Section 2001 shall include
all agreements between the organization and enrollees,
providers, administrators of services, and insurers of
limited health services; also other material transactions
or series of transactions, the total annual value of which
exceeds the greater of $100,000 or 5% of net earned
subscription revenue for the most current 12-month 12

month period as determined from filed financial
statements.
(2) Contract modification for reinsurance. Any
agreement between the organization and an insurer shall be
subject to the provisions of Article XI of the Illinois
Insurance Code, as now or hereafter amended. All
reinsurance agreements must be filed with the Director.
Approval of the Director in required agreements must be
filed. Approval of the director is required for all
agreements except individual stop loss, aggregate excess,
hospitalization benefits, or out-of-area of the
participating providers, unless 20% or more of the
organization's total risk is reinsured, in which case all
reinsurance agreements shall require approval.
(b) If a limited health service organization desires to
add one or more additional limited health services, it shall
file a notice with the Director and, at the same time, submit
the information required by Section 2001 if different from
that filed with the prepaid limited health service
organization's application. Issuance of such an amended
certificate of authority shall be subject to the conditions of
Section 2002 of this Act.
(c) In addition to any applicable provisions of this Act,
premium rate filings shall be subject to subsection (i) and,
for pharmaceutical policies, subsection (j) of Section 355 of
the Illinois Insurance Code.

(Source: P.A. 103-106, eff. 1-1-24; revised 1-2-24.)
Article 6.
Section 6-5. The Illinois Insurance Code is amended by
changing Sections 155.36, 155.37, 356z.40, and 370c as
follows:
(215 ILCS 5/155.36)
Sec. 155.36. Managed Care Reform and Patient Rights Act.
Insurance companies that transact the kinds of insurance
authorized under Class 1(b) or Class 2(a) of Section 4 of this
Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65,
70, and 85, and 87, subsection (d) of Section 30, and the
definitions definition of the term "emergency medical
condition" and any other term in Section 10 of the Managed Care
Reform and Patient Rights Act that is used in the other
Sections listed in this Section.
(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
(215 ILCS 5/155.37)
Sec. 155.37. Drug formulary; notice.
(a) Insurance companies that transact the kinds of
insurance authorized under Class 1(b) or Class 2(a) of Section
4 of this Code and provide coverage for prescription drugs
through the use of a drug formulary must notify insureds of any

change in the formulary. A company may comply with this
Section by posting changes in the formulary on its website.
(b) No later than October 1, 2025, insurance companies
that use a drug formulary shall post the formulary on their
websites in a manner that is searchable and accessible to the
general public without requiring an individual to create any
account. This formulary shall adhere to a template developed
by the Department by March 31, 2025, which shall take into
consideration existing requirements for reporting of
information established by the federal Centers for Medicare
and Medicaid Services as well as display of cost-sharing
information. This template and all formularies also shall do
all the following:
(1) include information on cost-sharing tiers and
utilization controls, such as prior authorization, for
each covered drug;
(2) indicate any drugs on the formulary that are
preferred over other drugs on the formulary;
(3) include information to educate insureds about the
differences between drugs administered or provided under a
policy's medical benefit and drugs covered under a drug
benefit and how to obtain coverage information about drugs
that are not covered under the drug benefit;
(4) include information to educate insureds that
policies that provide drug benefits are required to have a
method for enrollees to obtain drugs not listed in the

formulary if they are deemed medically necessary by a
clinician under Section 45.1 of the Managed Care Reform
and Patient Rights Act;
(5) include information on which medications are
covered, including both generic and brand name; and
(6) include information on what tier of the plan's
drug formulary each medication is in.
(c) No formulary may establish a step therapy requirement
as prohibited by Section 87 of the Managed Care Reform and
Patient Rights Act.
(Source: P.A. 92-440, eff. 8-17-01; 92-651, eff. 7-11-02.)
(215 ILCS 5/356z.40)
Sec. 356z.40. Pregnancy and postpartum coverage.
(a) An individual or group policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed on or after the effective date of this amendatory Act
of the 102nd General Assembly shall provide coverage for
pregnancy and newborn care in accordance with 42 U.S.C.
18022(b) regarding essential health benefits.
(b) Benefits under this Section shall be as follows:
(1) An individual who has been identified as
experiencing a high-risk pregnancy by the individual's
treating provider shall have access to clinically
appropriate case management programs. As used in this
subsection, "case management" means a mechanism to

coordinate and assure continuity of services, including,
but not limited to, health services, social services, and
educational services necessary for the individual. "Case
management" involves individualized assessment of needs,
planning of services, referral, monitoring, and advocacy
to assist an individual in gaining access to appropriate
services and closure when services are no longer required.
"Case management" is an active and collaborative process
involving a single qualified case manager, the individual,
the individual's family, the providers, and the community.
This includes close coordination and involvement with all
service providers in the management plan for that
individual or family, including assuring that the
individual receives the services. As used in this
subsection, "high-risk pregnancy" means a pregnancy in
which the pregnant or postpartum individual or baby is at
an increased risk for poor health or complications during
pregnancy or childbirth, including, but not limited to,
hypertension disorders, gestational diabetes, and
hemorrhage.
(2) An individual shall have access to medically
necessary treatment of a mental, emotional, nervous, or
substance use disorder or condition consistent with the
requirements set forth in this Section and in Sections
370c and 370c.1 of this Code.
(3) The benefits provided for inpatient and outpatient

services for the treatment of a mental, emotional,
nervous, or substance use disorder or condition related to
pregnancy or postpartum complications shall be provided if
determined to be medically necessary, consistent with the
requirements of Sections 370c and 370c.1 of this Code. The
facility or provider shall notify the insurer of both the
admission and the initial treatment plan within 48 hours
after admission or initiation of treatment. Subject to the
requirements of Sections 370c and 370c.1 of this Code,
nothing Nothing in this paragraph shall prevent an insurer
from applying concurrent and post-service utilization
review of health care services, including review of
medical necessity, case management, experimental and
investigational treatments, managed care provisions, and
other terms and conditions of the insurance policy.
(4) The benefits for the first 48 hours of initiation
of services for an inpatient admission, detoxification or
withdrawal management program, or partial hospitalization
admission for the treatment of a mental, emotional,
nervous, or substance use disorder or condition related to
pregnancy or postpartum complications shall be provided
without post-service or concurrent review of medical
necessity, as the medical necessity for the first 48 hours
of such services shall be determined solely by the covered
pregnant or postpartum individual's provider. Subject to
Section 370c and 370c.1 of this Code, nothing Nothing in

this paragraph shall prevent an insurer from applying
concurrent and post-service utilization review, including
the review of medical necessity, case management,
experimental and investigational treatments, managed care
provisions, and other terms and conditions of the
insurance policy, of any inpatient admission,
detoxification or withdrawal management program admission,
or partial hospitalization admission services for the
treatment of a mental, emotional, nervous, or substance
use disorder or condition related to pregnancy or
postpartum complications received 48 hours after the
initiation of such services. If an insurer determines that
the services are no longer medically necessary, then the
covered person shall have the right to external review
pursuant to the requirements of the Health Carrier
External Review Act.
(5) If an insurer determines that continued inpatient
care, detoxification or withdrawal management, partial
hospitalization, intensive outpatient treatment, or
outpatient treatment in a facility is no longer medically
necessary, the insurer shall, within 24 hours, provide
written notice to the covered pregnant or postpartum
individual and the covered pregnant or postpartum
individual's provider of its decision and the right to
file an expedited internal appeal of the determination.
The insurer shall review and make a determination with

respect to the internal appeal within 24 hours and
communicate such determination to the covered pregnant or
postpartum individual and the covered pregnant or
postpartum individual's provider. If the determination is
to uphold the denial, the covered pregnant or postpartum
individual and the covered pregnant or postpartum
individual's provider have the right to file an expedited
external appeal. An independent utilization review
organization shall make a determination within 72 hours.
If the insurer's determination is upheld and it is
determined that continued inpatient care, detoxification
or withdrawal management, partial hospitalization,
intensive outpatient treatment, or outpatient treatment is
not medically necessary, the insurer shall remain
responsible for providing benefits for the inpatient care,
detoxification or withdrawal management, partial
hospitalization, intensive outpatient treatment, or
outpatient treatment through the day following the date
the determination is made, and the covered pregnant or
postpartum individual shall only be responsible for any
applicable copayment, deductible, and coinsurance for the
stay through that date as applicable under the policy. The
covered pregnant or postpartum individual shall not be
discharged or released from the inpatient facility,
detoxification or withdrawal management, partial
hospitalization, intensive outpatient treatment, or

outpatient treatment until all internal appeals and
independent utilization review organization appeals are
exhausted. A decision to reverse an adverse determination
shall comply with the Health Carrier External Review Act.
(6) Except as otherwise stated in this subsection (b),
the benefits and cost-sharing shall be provided to the
same extent as for any other medical condition covered
under the policy.
(7) The benefits required by paragraphs (2) and (6) of
this subsection (b) are to be provided to all covered
pregnant or postpartum individuals with a diagnosis of a
mental, emotional, nervous, or substance use disorder or
condition. The presence of additional related or unrelated
diagnoses shall not be a basis to reduce or deny the
benefits required by this subsection (b).
(Source: P.A. 102-665, eff. 10-8-21.)
(215 ILCS 5/370c) (from Ch. 73, par. 982c)
Sec. 370c. Mental and emotional disorders.
(a)(1) On and after January 1, 2022 (the effective date of
Public Act 102-579), every insurer that amends, delivers,
issues, or renews group accident and health policies providing
coverage for hospital or medical treatment or services for
illness on an expense-incurred basis shall provide coverage
for the medically necessary treatment of mental, emotional,
nervous, or substance use disorders or conditions consistent

with the parity requirements of Section 370c.1 of this Code.
(2) Each insured that is covered for mental, emotional,
nervous, or substance use disorders or conditions shall be
free to select the physician licensed to practice medicine in
all its branches, licensed clinical psychologist, licensed
clinical social worker, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Substance
Use Disorder Act of his or her choice to treat such disorders,
and the insurer shall pay the covered charges of such
physician licensed to practice medicine in all its branches,
licensed clinical psychologist, licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act up
to the limits of coverage, provided (i) the disorder or
condition treated is covered by the policy, and (ii) the
physician, licensed psychologist, licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act is
authorized to provide said services under the statutes of this
State and in accordance with accepted principles of his or her

profession.
(3) Insofar as this Section applies solely to licensed
clinical social workers, licensed clinical professional
counselors, licensed marriage and family therapists, licensed
speech-language pathologists, and other licensed or certified
professionals at programs licensed pursuant to the Substance
Use Disorder Act, those persons who may provide services to
individuals shall do so after the licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act
has informed the patient of the desirability of the patient
conferring with the patient's primary care physician.
(4) "Mental, emotional, nervous, or substance use disorder
or condition" means a condition or disorder that involves a
mental health condition or substance use disorder that falls
under any of the diagnostic categories listed in the mental
and behavioral disorders chapter of the current edition of the
World Health Organization's International Classification of
Disease or that is listed in the most recent version of the
American Psychiatric Association's Diagnostic and Statistical
Manual of Mental Disorders. "Mental, emotional, nervous, or
substance use disorder or condition" includes any mental
health condition that occurs during pregnancy or during the
postpartum period and includes, but is not limited to,

postpartum depression.
(5) Medically necessary treatment and medical necessity
determinations shall be interpreted and made in a manner that
is consistent with and pursuant to subsections (h) through
(t).
(b)(1) (Blank).
(2) (Blank).
(2.5) (Blank).
(3) Unless otherwise prohibited by federal law and
consistent with the parity requirements of Section 370c.1 of
this Code, the reimbursing insurer that amends, delivers,
issues, or renews a group or individual policy of accident and
health insurance, a qualified health plan offered through the
health insurance marketplace, or a provider of treatment of
mental, emotional, nervous, or substance use disorders or
conditions shall furnish medical records or other necessary
data that substantiate that initial or continued treatment is
at all times medically necessary. An insurer shall provide a
mechanism for the timely review by a provider holding the same
license and practicing in the same specialty as the patient's
provider, who is unaffiliated with the insurer, jointly
selected by the patient (or the patient's next of kin or legal
representative if the patient is unable to act for himself or
herself), the patient's provider, and the insurer in the event
of a dispute between the insurer and patient's provider
regarding the medical necessity of a treatment proposed by a

patient's provider. If the reviewing provider determines the
treatment to be medically necessary, the insurer shall provide
reimbursement for the treatment. Future contractual or
employment actions by the insurer regarding the patient's
provider may not be based on the provider's participation in
this procedure. Nothing prevents the insured from agreeing in
writing to continue treatment at his or her expense. When
making a determination of the medical necessity for a
treatment modality for mental, emotional, nervous, or
substance use disorders or conditions, an insurer must make
the determination in a manner that is consistent with the
manner used to make that determination with respect to other
diseases or illnesses covered under the policy, including an
appeals process. Medical necessity determinations for
substance use disorders shall be made in accordance with
appropriate patient placement criteria established by the
American Society of Addiction Medicine. No additional criteria
may be used to make medical necessity determinations for
substance use disorders.
(4) A group health benefit plan amended, delivered,
issued, or renewed on or after January 1, 2019 (the effective
date of Public Act 100-1024) or an individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024):

(A) shall provide coverage based upon medical
necessity for the treatment of a mental, emotional,
nervous, or substance use disorder or condition consistent
with the parity requirements of Section 370c.1 of this
Code; provided, however, that in each calendar year
coverage shall not be less than the following:
(i) 45 days of inpatient treatment; and
(ii) beginning on June 26, 2006 (the effective
date of Public Act 94-921), 60 visits for outpatient
treatment including group and individual outpatient
treatment; and
(iii) for plans or policies delivered, issued for
delivery, renewed, or modified after January 1, 2007
(the effective date of Public Act 94-906), 20
additional outpatient visits for speech therapy for
treatment of pervasive developmental disorders that
will be in addition to speech therapy provided
pursuant to item (ii) of this subparagraph (A); and
(B) may not include a lifetime limit on the number of
days of inpatient treatment or the number of outpatient
visits covered under the plan.
(C) (Blank).
(5) An issuer of a group health benefit plan or an
individual policy of accident and health insurance or a
qualified health plan offered through the health insurance
marketplace may not count toward the number of outpatient

visits required to be covered under this Section an outpatient
visit for the purpose of medication management and shall cover
the outpatient visits under the same terms and conditions as
it covers outpatient visits for the treatment of physical
illness.
(5.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after September 9, 2015
(the effective date of Public Act 99-480) shall offer coverage
for medically necessary acute treatment services and medically
necessary clinical stabilization services. The treating
provider shall base all treatment recommendations and the
health benefit plan shall base all medical necessity
determinations for substance use disorders in accordance with
the most current edition of the Treatment Criteria for
Addictive, Substance-Related, and Co-Occurring Conditions
established by the American Society of Addiction Medicine. The
treating provider shall base all treatment recommendations and
the health benefit plan shall base all medical necessity
determinations for medication-assisted treatment in accordance
with the most current Treatment Criteria for Addictive,
Substance-Related, and Co-Occurring Conditions established by
the American Society of Addiction Medicine.
As used in this subsection:
"Acute treatment services" means 24-hour medically
supervised addiction treatment that provides evaluation and
withdrawal management and may include biopsychosocial

assessment, individual and group counseling, psychoeducational
groups, and discharge planning.
"Clinical stabilization services" means 24-hour treatment,
usually following acute treatment services for substance
abuse, which may include intensive education and counseling
regarding the nature of addiction and its consequences,
relapse prevention, outreach to families and significant
others, and aftercare planning for individuals beginning to
engage in recovery from addiction.
(6) An issuer of a group health benefit plan may provide or
offer coverage required under this Section through a managed
care plan.
(6.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024):
(A) shall not impose prior authorization requirements,
other than those established under the Treatment Criteria
for Addictive, Substance-Related, and Co-Occurring
Conditions established by the American Society of
Addiction Medicine, on a prescription medication approved
by the United States Food and Drug Administration that is
prescribed or administered for the treatment of substance
use disorders;
(B) shall not impose any step therapy requirements,
other than those established under the Treatment Criteria
for Addictive, Substance-Related, and Co-Occurring

Conditions established by the American Society of
Addiction Medicine, before authorizing coverage for a
prescription medication approved by the United States Food
and Drug Administration that is prescribed or administered
for the treatment of substance use disorders;
(C) shall place all prescription medications approved
by the United States Food and Drug Administration
prescribed or administered for the treatment of substance
use disorders on, for brand medications, the lowest tier
of the drug formulary developed and maintained by the
individual or group health benefit plan that covers brand
medications and, for generic medications, the lowest tier
of the drug formulary developed and maintained by the
individual or group health benefit plan that covers
generic medications; and
(D) shall not exclude coverage for a prescription
medication approved by the United States Food and Drug
Administration for the treatment of substance use
disorders and any associated counseling or wraparound
services on the grounds that such medications and services
were court ordered.
(7) (Blank).
(8) (Blank).
(9) With respect to all mental, emotional, nervous, or
substance use disorders or conditions, coverage for inpatient
treatment shall include coverage for treatment in a

residential treatment center certified or licensed by the
Department of Public Health or the Department of Human
Services.
(c) This Section shall not be interpreted to require
coverage for speech therapy or other habilitative services for
those individuals covered under Section 356z.15 of this Code.
(d) With respect to a group or individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace, the
Department and, with respect to medical assistance, the
Department of Healthcare and Family Services shall each
enforce the requirements of this Section and Sections 356z.23
and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008, 42
U.S.C. 18031(j), and any amendments to, and federal guidance
or regulations issued under, those Acts, including, but not
limited to, final regulations issued under the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 and final regulations applying the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 to Medicaid managed care organizations, the
Children's Health Insurance Program, and alternative benefit
plans. Specifically, the Department and the Department of
Healthcare and Family Services shall take action:
(1) proactively ensuring compliance by individual and
group policies, including by requiring that insurers

submit comparative analyses, as set forth in paragraph (6)
of subsection (k) of Section 370c.1, demonstrating how
they design and apply nonquantitative treatment
limitations, both as written and in operation, for mental,
emotional, nervous, or substance use disorder or condition
benefits as compared to how they design and apply
nonquantitative treatment limitations, as written and in
operation, for medical and surgical benefits;
(2) evaluating all consumer or provider complaints
regarding mental, emotional, nervous, or substance use
disorder or condition coverage for possible parity
violations;
(3) performing parity compliance market conduct
examinations or, in the case of the Department of
Healthcare and Family Services, parity compliance audits
of individual and group plans and policies, including, but
not limited to, reviews of:
(A) nonquantitative treatment limitations,
including, but not limited to, prior authorization
requirements, concurrent review, retrospective review,
step therapy, network admission standards,
reimbursement rates, and geographic restrictions;
(B) denials of authorization, payment, and
coverage; and
(C) other specific criteria as may be determined
by the Department.

The findings and the conclusions of the parity compliance
market conduct examinations and audits shall be made public.
The Director may adopt rules to effectuate any provisions
of the Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act of 2008 that relate to the business of
insurance.
(e) Availability of plan information.
(1) The criteria for medical necessity determinations
made under a group health plan, an individual policy of
accident and health insurance, or a qualified health plan
offered through the health insurance marketplace with
respect to mental health or substance use disorder
benefits (or health insurance coverage offered in
connection with the plan with respect to such benefits)
must be made available by the plan administrator (or the
health insurance issuer offering such coverage) to any
current or potential participant, beneficiary, or
contracting provider upon request.
(2) The reason for any denial under a group health
benefit plan, an individual policy of accident and health
insurance, or a qualified health plan offered through the
health insurance marketplace (or health insurance coverage
offered in connection with such plan or policy) of
reimbursement or payment for services with respect to
mental, emotional, nervous, or substance use disorders or
conditions benefits in the case of any participant or

beneficiary must be made available within a reasonable
time and in a reasonable manner and in readily
understandable language by the plan administrator (or the
health insurance issuer offering such coverage) to the
participant or beneficiary upon request.
(f) As used in this Section, "group policy of accident and
health insurance" and "group health benefit plan" includes (1)
State-regulated employer-sponsored group health insurance
plans written in Illinois or which purport to provide coverage
for a resident of this State; and (2) State employee health
plans.
(g) (1) As used in this subsection:
"Benefits", with respect to insurers, means the benefits
provided for treatment services for inpatient and outpatient
treatment of substance use disorders or conditions at American
Society of Addiction Medicine levels of treatment 2.1
(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
(Clinically Managed Low-Intensity Residential), 3.3
(Clinically Managed Population-Specific High-Intensity
Residential), 3.5 (Clinically Managed High-Intensity
Residential), and 3.7 (Medically Monitored Intensive
Inpatient) and OMT (Opioid Maintenance Therapy) services.
"Benefits", with respect to managed care organizations,
means the benefits provided for treatment services for
inpatient and outpatient treatment of substance use disorders
or conditions at American Society of Addiction Medicine levels

of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
Hospitalization), 3.5 (Clinically Managed High-Intensity
Residential), and 3.7 (Medically Monitored Intensive
Inpatient) and OMT (Opioid Maintenance Therapy) services.
"Substance use disorder treatment provider or facility"
means a licensed physician, licensed psychologist, licensed
psychiatrist, licensed advanced practice registered nurse, or
licensed, certified, or otherwise State-approved facility or
provider of substance use disorder treatment.
(2) A group health insurance policy, an individual health
benefit plan, or qualified health plan that is offered through
the health insurance marketplace, small employer group health
plan, and large employer group health plan that is amended,
delivered, issued, executed, or renewed in this State, or
approved for issuance or renewal in this State, on or after
January 1, 2019 (the effective date of Public Act 100-1023)
shall comply with the requirements of this Section and Section
370c.1. The services for the treatment and the ongoing
assessment of the patient's progress in treatment shall follow
the requirements of 77 Ill. Adm. Code 2060.
(3) Prior authorization shall not be utilized for the
benefits under this subsection. The substance use disorder
treatment provider or facility shall notify the insurer of the
initiation of treatment. For an insurer that is not a managed
care organization, the substance use disorder treatment
provider or facility notification shall occur for the

initiation of treatment of the covered person within 2
business days. For managed care organizations, the substance
use disorder treatment provider or facility notification shall
occur in accordance with the protocol set forth in the
provider agreement for initiation of treatment within 24
hours. If the managed care organization is not capable of
accepting the notification in accordance with the contractual
protocol during the 24-hour period following admission, the
substance use disorder treatment provider or facility shall
have one additional business day to provide the notification
to the appropriate managed care organization. Treatment plans
shall be developed in accordance with the requirements and
timeframes established in 77 Ill. Adm. Code 2060. If the
substance use disorder treatment provider or facility fails to
notify the insurer of the initiation of treatment in
accordance with these provisions, the insurer may follow its
normal prior authorization processes.
(4) For an insurer that is not a managed care
organization, if an insurer determines that benefits are no
longer medically necessary, the insurer shall notify the
covered person, the covered person's authorized
representative, if any, and the covered person's health care
provider in writing of the covered person's right to request
an external review pursuant to the Health Carrier External
Review Act. The notification shall occur within 24 hours
following the adverse determination.

Pursuant to the requirements of the Health Carrier
External Review Act, the covered person or the covered
person's authorized representative may request an expedited
external review. An expedited external review may not occur if
the substance use disorder treatment provider or facility
determines that continued treatment is no longer medically
necessary.
If an expedited external review request meets the criteria
of the Health Carrier External Review Act, an independent
review organization shall make a final determination of
medical necessity within 72 hours. If an independent review
organization upholds an adverse determination, an insurer
shall remain responsible to provide coverage of benefits
through the day following the determination of the independent
review organization. A decision to reverse an adverse
determination shall comply with the Health Carrier External
Review Act.
(5) The substance use disorder treatment provider or
facility shall provide the insurer with 7 business days'
advance notice of the planned discharge of the patient from
the substance use disorder treatment provider or facility and
notice on the day that the patient is discharged from the
substance use disorder treatment provider or facility.
(6) The benefits required by this subsection shall be
provided to all covered persons with a diagnosis of substance
use disorder or conditions. The presence of additional related

or unrelated diagnoses shall not be a basis to reduce or deny
the benefits required by this subsection.
(7) Nothing in this subsection shall be construed to
require an insurer to provide coverage for any of the benefits
in this subsection.
(h) As used in this Section:
"Generally accepted standards of mental, emotional,
nervous, or substance use disorder or condition care" means
standards of care and clinical practice that are generally
recognized by health care providers practicing in relevant
clinical specialties such as psychiatry, psychology, clinical
sociology, social work, addiction medicine and counseling, and
behavioral health treatment. Valid, evidence-based sources
reflecting generally accepted standards of mental, emotional,
nervous, or substance use disorder or condition care include
peer-reviewed scientific studies and medical literature,
recommendations of nonprofit health care provider professional
associations and specialty societies, including, but not
limited to, patient placement criteria and clinical practice
guidelines, recommendations of federal government agencies,
and drug labeling approved by the United States Food and Drug
Administration.
"Medically necessary treatment of mental, emotional,
nervous, or substance use disorders or conditions" means a
service or product addressing the specific needs of that
patient, for the purpose of screening, preventing, diagnosing,

managing, or treating an illness, injury, or condition or its
symptoms and comorbidities, including minimizing the
progression of an illness, injury, or condition or its
symptoms and comorbidities in a manner that is all of the
following:
(1) in accordance with the generally accepted
standards of mental, emotional, nervous, or substance use
disorder or condition care;
(2) clinically appropriate in terms of type,
frequency, extent, site, and duration; and
(3) not primarily for the economic benefit of the
insurer, purchaser, or for the convenience of the patient,
treating physician, or other health care provider.
"Utilization review" means either of the following:
(1) prospectively, retrospectively, or concurrently
reviewing and approving, modifying, delaying, or denying,
based in whole or in part on medical necessity, requests
by health care providers, insureds, or their authorized
representatives for coverage of health care services
before, retrospectively, or concurrently with the
provision of health care services to insureds.
(2) evaluating the medical necessity, appropriateness,
level of care, service intensity, efficacy, or efficiency
of health care services, benefits, procedures, or
settings, under any circumstances, to determine whether a
health care service or benefit subject to a medical

necessity coverage requirement in an insurance policy is
covered as medically necessary for an insured.
"Utilization review criteria" means patient placement
criteria or any criteria, standards, protocols, or guidelines
used by an insurer to conduct utilization review.
(i)(1) Every insurer that amends, delivers, issues, or
renews a group or individual policy of accident and health
insurance or a qualified health plan offered through the
health insurance marketplace in this State and Medicaid
managed care organizations providing coverage for hospital or
medical treatment on or after January 1, 2023 shall, pursuant
to subsections (h) through (s), provide coverage for medically
necessary treatment of mental, emotional, nervous, or
substance use disorders or conditions.
(2) An insurer shall not set a specific limit on the
duration of benefits or coverage of medically necessary
treatment of mental, emotional, nervous, or substance use
disorders or conditions or limit coverage only to alleviation
of the insured's current symptoms.
(3) All utilization review conducted medical necessity
determinations made by the insurer concerning diagnosis,
prevention, and treatment service intensity, level of care
placement, continued stay, and transfer or discharge of
insureds diagnosed with mental, emotional, nervous, or
substance use disorders or conditions shall be conducted in
accordance with the requirements of subsections (k) through

(w) (u).
(4) An insurer that authorizes a specific type of
treatment by a provider pursuant to this Section shall not
rescind or modify the authorization after that provider
renders the health care service in good faith and pursuant to
this authorization for any reason, including, but not limited
to, the insurer's subsequent cancellation or modification of
the insured's or policyholder's contract, or the insured's or
policyholder's eligibility. Nothing in this Section shall
require the insurer to cover a treatment when the
authorization was granted based on a material
misrepresentation by the insured, the policyholder, or the
provider. Nothing in this Section shall require Medicaid
managed care organizations to pay for services if the
individual was not eligible for Medicaid at the time the
service was rendered. Nothing in this Section shall require an
insurer to pay for services if the individual was not the
insurer's enrollee at the time services were rendered. As used
in this paragraph, "material" means a fact or situation that
is not merely technical in nature and results in or could
result in a substantial change in the situation.
(j) An insurer shall not limit benefits or coverage for
medically necessary services on the basis that those services
should be or could be covered by a public entitlement program,
including, but not limited to, special education or an
individualized education program, Medicaid, Medicare,

Supplemental Security Income, or Social Security Disability
Insurance, and shall not include or enforce a contract term
that excludes otherwise covered benefits on the basis that
those services should be or could be covered by a public
entitlement program. Nothing in this subsection shall be
construed to require an insurer to cover benefits that have
been authorized and provided for a covered person by a public
entitlement program. Medicaid managed care organizations are
not subject to this subsection.
(k) An insurer shall base any medical necessity
determination or the utilization review criteria that the
insurer, and any entity acting on the insurer's behalf,
applies to determine the medical necessity of health care
services and benefits for the diagnosis, prevention, and
treatment of mental, emotional, nervous, or substance use
disorders or conditions on current generally accepted
standards of mental, emotional, nervous, or substance use
disorder or condition care. All denials and appeals shall be
reviewed by a professional with experience or expertise
comparable to the provider requesting the authorization.
(l) In conducting utilization review of all covered health
care services for the diagnosis, prevention, and treatment of
For medical necessity determinations relating to level of care
placement, continued stay, and transfer or discharge of
insureds diagnosed with mental, emotional, and nervous
disorders or conditions, an insurer shall apply the patient

placement criteria and guidelines set forth in the most recent
version of the treatment criteria developed by an unaffiliated
nonprofit professional association for the relevant clinical
specialty or, for Medicaid managed care organizations, patient
placement criteria and guidelines determined by the Department
of Healthcare and Family Services that are consistent with
generally accepted standards of mental, emotional, nervous or
substance use disorder or condition care. Pursuant to
subsection (b), in conducting utilization review of all
covered services and benefits for the diagnosis, prevention,
and treatment of substance use disorders an insurer shall use
the most recent edition of the patient placement criteria
established by the American Society of Addiction Medicine.
(m) In conducting utilization review For medical necessity
determinations relating to level of care placement, continued
stay, and transfer, or discharge, or any other patient care
decisions that are within the scope of the sources specified
in subsection (l), an insurer shall not apply different,
additional, conflicting, or more restrictive utilization
review criteria than the criteria set forth in those sources.
For all level of care placement decisions, the insurer shall
authorize placement at the level of care consistent with the
assessment of the insured using the relevant patient placement
criteria as specified in subsection (l). If that level of
placement is not available, the insurer shall authorize the
next higher level of care. In the event of disagreement, the

insurer shall provide full detail of its assessment using the
relevant criteria as specified in subsection (l) to the
provider of the service and the patient.
Nothing in this subsection or subsection (l) prohibits an
insurer from applying utilization review criteria that were
developed in accordance with subsection (k) to health care
services and benefits for mental, emotional, and nervous
disorders or conditions that are not related to medical
necessity determinations for level of care placement,
continued stay, and transfer or discharge. If an insurer
purchases or licenses utilization review criteria pursuant to
this subsection, the insurer shall verify and document before
use that the criteria were developed in accordance with
subsection (k).
(n) In conducting utilization review that is outside the
scope of the criteria as specified in subsection (l) or
relates to the advancements in technology or in the types or
levels of care that are not addressed in the most recent
versions of the sources specified in subsection (l), an
insurer shall conduct utilization review in accordance with
subsection (k).
(o) This Section does not in any way limit the rights of a
patient under the Medical Patient Rights Act.
(p) This Section does not in any way limit early and
periodic screening, diagnostic, and treatment benefits as
defined under 42 U.S.C. 1396d(r).

(q) To ensure the proper use of the criteria described in
subsection (l), every insurer shall do all of the following:
(1) Educate the insurer's staff, including any third
parties contracted with the insurer to review claims,
conduct utilization reviews, or make medical necessity
determinations about the utilization review criteria.
(2) Make the educational program available to other
stakeholders, including the insurer's participating or
contracted providers and potential participants,
beneficiaries, or covered lives. The education program
must be provided at least once a year, in-person or
digitally, or recordings of the education program must be
made available to the aforementioned stakeholders.
(3) Provide, at no cost, the utilization review
criteria and any training material or resources to
providers and insured patients upon request. For
utilization review criteria not concerning level of care
placement, continued stay, and transfer, or discharge, or
other patient care decisions used by the insurer pursuant
to subsection (m), the insurer may place the criteria on a
secure, password-protected website so long as the access
requirements of the website do not unreasonably restrict
access to insureds or their providers. No restrictions
shall be placed upon the insured's or treating provider's
access right to utilization review criteria obtained under
this paragraph at any point in time, including before an

initial request for authorization.
(4) Track, identify, and analyze how the utilization
review criteria are used to certify care, deny care, and
support the appeals process.
(5) Conduct interrater reliability testing to ensure
consistency in utilization review decision making that
covers how medical necessity decisions are made; this
assessment shall cover all aspects of utilization review
as defined in subsection (h).
(6) Run interrater reliability reports about how the
clinical guidelines are used in conjunction with the
utilization review process and parity compliance
activities.
(7) Achieve interrater reliability pass rates of at
least 90% and, if this threshold is not met, immediately
provide for the remediation of poor interrater reliability
and interrater reliability testing for all new staff
before they can conduct utilization review without
supervision.
(8) Maintain documentation of interrater reliability
testing and the remediation actions taken for those with
pass rates lower than 90% and submit to the Department of
Insurance or, in the case of Medicaid managed care
organizations, the Department of Healthcare and Family
Services the testing results and a summary of remedial
actions as part of parity compliance reporting set forth

in subsection (k) of Section 370c.1.
(r) This Section applies to all health care services and
benefits for the diagnosis, prevention, and treatment of
mental, emotional, nervous, or substance use disorders or
conditions covered by an insurance policy, including
prescription drugs.
(s) This Section applies to an insurer that amends,
delivers, issues, or renews a group or individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace in this State
providing coverage for hospital or medical treatment and
conducts utilization review as defined in this Section,
including Medicaid managed care organizations, and any entity
or contracting provider that performs utilization review or
utilization management functions on an insurer's behalf.
(t) If the Director determines that an insurer has
violated this Section, the Director may, after appropriate
notice and opportunity for hearing, by order, assess a civil
penalty between $1,000 and $5,000 for each violation. Moneys
collected from penalties shall be deposited into the Parity
Advancement Fund established in subsection (i) of Section
370c.1.
(u) An insurer shall not adopt, impose, or enforce terms
in its policies or provider agreements, in writing or in
operation, that undermine, alter, or conflict with the
requirements of this Section.

(v) The provisions of this Section are severable. If any
provision of this Section or its application is held invalid,
that invalidity shall not affect other provisions or
applications that can be given effect without the invalid
provision or application.
(w) Beginning January 1, 2026, coverage for inpatient
mental health treatment at participating hospitals shall
comply with the following requirements:
(1) Subject to paragraphs (2) and (3) of this
subsection, no policy shall require prior authorization
for admission for such treatment at any participating
hospital.
(2) Coverage provided under this subsection also shall
not be subject to concurrent review for the first 72
hours, provided that the hospital must notify the insurer
of both the admission and the initial treatment plan
within 48 hours of admission. A discharge plan must be
fully developed and continuity services prepared to meet
the patient's needs and the patient's community preference
upon release. Nothing in this paragraph supersedes a
health maintenance organization's referral requirement for
services from nonparticipating providers upon a patient's
discharge from a hospital.
(3) Treatment provided under this subsection may be
reviewed retrospectively. If coverage is denied
retrospectively, neither the insurer nor the participating

hospital shall bill, and the insured shall not be liable,
for any treatment under this subsection through the date
the adverse determination is issued, other than any
copayment, coinsurance, or deductible for the stay through
that date as applicable under the policy. Coverage shall
not be retrospectively denied for the first 72 hours of
treatment at a participating hospital except:
(A) upon reasonable determination that the
inpatient mental health treatment was not provided;
(B) upon determination that the patient receiving
the treatment was not an insured, enrollee, or
beneficiary under the policy;
(C) upon material misrepresentation by the patient
or health care provider. In this item (C), "material"
means a fact or situation that is not merely technical
in nature and results or could result in a substantial
change in the situation; or
(D) upon determination that a service was excluded
under the terms of coverage. In that case, the
limitation to billing for a copayment, coinsurance, or
deductible shall not apply.
(4) Nothing in this subsection shall be construed to
require a policy to cover any health care service excluded
under the terms of coverage.
(x) Notwithstanding any provision of this Section, nothing
shall require the medical assistance program under Article V

of the Illinois Public Aid Code to violate any applicable
federal laws, regulations, or grant requirements or any State
or federal consent decrees. Nothing in subsection (w) shall
prevent the Department of Healthcare and Family Services from
requiring a health care provider to use specified level of
care, admission, continued stay, or discharge criteria,
including, but not limited to, those under Section 5-5.23 of
the Illinois Public Aid Code, as long as the Department of
Healthcare and Family Services does not require a health care
provider to seek prior authorization or concurrent review from
the Department of Healthcare and Family Services, a Medicaid
managed care organization, or a utilization review
organization under the circumstances expressly prohibited by
subsection (w). Nothing in this Section prohibits a health
plan, including a Medicaid managed care organization, from
conducting reviews for fraud, waste, or abuse and reporting
suspected fraud, waste, or abuse according to State and
federal requirements.
(y) Children's Mental Health. Nothing in this Section
shall suspend the screening and assessment requirements for
mental health services for children participating in the
State's medical assistance program as required in Section
5-5.23 of the Illinois Public Aid Code.
(Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22;
102-813, eff. 5-13-22; 103-426, eff. 8-4-23.)

Section 6-10. The Managed Care Reform and Patient Rights
Act is amended by changing Sections 10, 45.1, and 85 and by
adding Section 87 as follows:
(215 ILCS 134/10)
Sec. 10. Definitions. In this Act:
"Adverse determination" means a determination by a health
care plan under Section 45 or by a utilization review program
under Section 85 that a health care service is not medically
necessary.
"Clinical peer" means a health care professional who is in
the same profession and the same or similar specialty as the
health care provider who typically manages the medical
condition, procedures, or treatment under review.
"Department" means the Department of Insurance.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
regardless of the final diagnosis given, such that a prudent
layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate
medical attention to result in:
(1) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy;
(2) serious impairment to bodily functions;
(3) serious dysfunction of any bodily organ or part;

(4) inadequately controlled pain; or
(5) with respect to a pregnant woman who is having
contractions:
(A) inadequate time to complete a safe transfer to
another hospital before delivery; or
(B) a transfer to another hospital may pose a
threat to the health or safety of the woman or unborn
child.
"Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed
to practice medicine in all its branches, or to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
"Emergency services" means, with respect to an enrollee of
a health care plan, transportation services, including but not
limited to ambulance services, and covered inpatient and
outpatient hospital services furnished by a provider qualified
to furnish those services that are needed to evaluate or
stabilize an emergency medical condition. "Emergency services"
does not refer to post-stabilization medical services.
"Enrollee" means any person and his or her dependents
enrolled in or covered by a health care plan.
"Generally accepted standards of care" means standards of
care and clinical practice that are generally recognized by

health care providers practicing in relevant clinical
specialties for the illness, injury, or condition or its
symptoms and comorbidities. Valid, evidence-based sources
reflecting generally accepted standards of care include
peer-reviewed scientific studies and medical literature,
recommendations of nonprofit health care provider professional
associations and specialty societies, including, but not
limited to, patient placement criteria and clinical practice
guidelines, recommendations of federal government agencies,
and drug labeling approved by the United States Food and Drug
Administration.
"Health care plan" means a plan, including, but not
limited to, a health maintenance organization, a managed care
community network as defined in the Illinois Public Aid Code,
or an accountable care entity as defined in the Illinois
Public Aid Code that receives capitated payments to cover
medical services from the Department of Healthcare and Family
Services, that establishes, operates, or maintains a network
of health care providers that has entered into an agreement
with the plan to provide health care services to enrollees to
whom the plan has the ultimate obligation to arrange for the
provision of or payment for services through organizational
arrangements for ongoing quality assurance, utilization review
programs, or dispute resolution. Nothing in this definition
shall be construed to mean that an independent practice
association or a physician hospital organization that

subcontracts with a health care plan is, for purposes of that
subcontract, a health care plan.
For purposes of this definition, "health care plan" shall
not include the following:
(1) indemnity health insurance policies including
those using a contracted provider network;
(2) health care plans that offer only dental or only
vision coverage;
(3) preferred provider administrators, as defined in
Section 370g(g) of the Illinois Insurance Code;
(4) employee or employer self-insured health benefit
plans under the federal Employee Retirement Income
Security Act of 1974;
(5) health care provided pursuant to the Workers'
Compensation Act or the Workers' Occupational Diseases
Act; and
(6) except with respect to subsections (a) and (b) of
Section 65 and subsection (a-5) of Section 70,
not-for-profit voluntary health services plans with health
maintenance organization authority in existence as of
January 1, 1999 that are affiliated with a union and that
only extend coverage to union members and their
dependents.
"Health care professional" means a physician, a registered
professional nurse, or other individual appropriately licensed
or registered to provide health care services.

"Health care provider" means any physician, hospital
facility, facility licensed under the Nursing Home Care Act,
long-term care facility as defined in Section 1-113 of the
Nursing Home Care Act, or other person that is licensed or
otherwise authorized to deliver health care services. Nothing
in this Act shall be construed to define Independent Practice
Associations or Physician-Hospital Organizations as health
care providers.
"Health care services" means any services included in the
furnishing to any individual of medical care, or the
hospitalization incident to the furnishing of such care, as
well as the furnishing to any person of any and all 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.
"Medical director" means a physician licensed in any state
to practice medicine in all its branches appointed by a health
care plan.
"Medically necessary" means that a service or product
addresses the specific needs of a patient for the purpose of
screening, preventing, diagnosing, managing, or treating an
illness, injury, or condition or its symptoms and
comorbidities, including minimizing the progression of an
illness, injury, or condition or its symptoms and
comorbidities, in a manner that is all of the following:

(1) in accordance with generally accepted standards of
care;
(2) clinically appropriate in terms of type,
frequency, extent, site, and duration; and
(3) not primarily for the economic benefit of the
health care plan, purchaser, or utilization review
organization, or for the convenience of the patient,
treating physician, or other health care provider.
"Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
"Physician" means a person licensed under the Medical
Practice Act of 1987.
"Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
licensed hospital by a provider that is qualified to furnish
such services, and determined to be medically necessary and
directly related to the emergency medical condition following
stabilization.
"Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to assure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
"Step therapy requirement" means a utilization review or
formulary requirement that specifies, as a condition of

coverage under a health care plan, the order in which certain
health care services must be used to treat or manage an
enrollee's health condition.
"Step therapy requirement" does not include:
(1) utilization review to identify when a treatment or
health care service is contraindicated or clinically
appropriate or to limit quantity or dosage for an enrollee
based on utilization review criteria consistent with
generally accepted standards of care developed in
accordance with Section 87 of this Act;
(2) the removal of a drug from a formulary or changing
the drug's preferred or cost-sharing tier to higher cost
sharing;
(3) use of the medical exceptions process under
Section 45.1 of this Act; any decision during a medical
exceptions process based on cost is step therapy and
prohibited;
(4) a requirement to obtain prior authorization for
the requested treatment; or
(5) for health care plans operated or overseen by the
Department of Healthcare and Family Services, including
Medicaid managed care plans, any utilization controls
mandated by 42 CFR 456.703 or a preferred drug list as
described in Section 5-30.14 of the Illinois Public Aid
Code.
"Utilization review" means the evaluation of the medical

necessity, appropriateness, and efficiency of the use of
health care services, procedures, and facilities.
"Utilization review" includes either of the following:
(1) prospectively, retrospectively, or concurrently
reviewing and approving, modifying, delaying, or denying,
based, in whole or in part, on medical necessity, requests
by health care providers, enrollees, or their authorized
representatives for coverage of health care services
before, retrospectively, or concurrently with the
provision of health care services to enrollees; or
(2) evaluating the medical necessity, appropriateness,
level of care, service intensity, efficacy, or efficiency
of health care services, benefits, procedures, or
settings, under any circumstances, to determine whether a
health care service or benefit subject to a medical
necessity coverage requirement in a health care plan is
covered as medically necessary for an enrollee.
"Utilization review criteria" means criteria, standards,
protocols, or guidelines used by a utilization review program
to conduct utilization review to ensure that a patient's care
is aligned with generally accepted standards of care and
consistent with State law.
"Utilization review program" means a program established
by a person to perform utilization review.
(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)

(215 ILCS 134/45.1)
Sec. 45.1. Medical exceptions procedures required.
(a) Notwithstanding any other provision of law, on or
after January 1, 2018 (the effective date of Public Act
99-761), every insurer licensed in this State to sell a policy
of group or individual accident and health insurance or a
health benefits plan shall establish and maintain a medical
exceptions process that allows covered persons or their
authorized representatives to request any clinically
appropriate prescription drug when (1) the drug is not covered
based on the health benefit plan's formulary; (2) the health
benefit plan is discontinuing coverage of the drug on the
plan's formulary for reasons other than safety or other than
because the prescription drug has been withdrawn from the
market by the drug's manufacturer; (3) (blank) the
prescription drug alternatives required to be used in
accordance with a step therapy requirement (A) has been
ineffective in the treatment of the enrollee's disease or
medical condition or, based on both sound clinical evidence
and medical and scientific evidence, the known relevant
physical or mental characteristics of the enrollee, and the
known characteristics of the drug regimen, is likely to be
ineffective or adversely affect the drug's effectiveness or
patient compliance or (B) has caused or, based on sound
medical evidence, is likely to cause an adverse reaction or
harm to the enrollee; or (4) the number of doses available

under a dose restriction for the prescription drug (A) has
been ineffective in the treatment of the enrollee's disease or
medical condition or (B) based on both sound clinical evidence
and medical and scientific evidence, the known relevant
physical and mental characteristics of the enrollee, and known
characteristics of the drug regimen, is likely to be
ineffective or adversely affect the drug's effective or
patient compliance.
(b) The health carrier's established medical exceptions
procedures must require, at a minimum, the following:
(1) Any request for approval of coverage made verbally
or in writing (regardless of whether made using a paper or
electronic form or some other writing) at any time shall
be reviewed by appropriate health care professionals.
(2) The health carrier must, within 72 hours after
receipt of a request made under subsection (a) of this
Section, either approve or deny the request. In the case
of a denial, the health carrier shall provide the covered
person or the covered person's authorized representative
and the covered person's prescribing provider with the
reason for the denial, an alternative covered medication,
if applicable, and information regarding the procedure for
submitting an appeal to the denial. A health carrier shall
not use the authorization of alternative covered
medications under this Section in a manner that
effectively creates a step therapy requirement.

(3) In the case of an expedited coverage
determination, the health carrier must either approve or
deny the request within 24 hours after receipt of the
request. In the case of a denial, the health carrier shall
provide the covered person or the covered person's
authorized representative and the covered person's
prescribing provider with the reason for the denial, an
alternative covered medication, if applicable, and
information regarding the procedure for submitting an
appeal to the denial.
(c) An off-formulary A step therapy requirement exception
request shall not be denied be approved if:
(1) the formulary required prescription drug is
contraindicated;
(2) the patient has tried the formulary required
prescription drug while under the patient's current or
previous health insurance or health benefit plan and the
prescribing provider submits evidence of failure or
intolerance; or
(3) the patient is stable on a prescription drug
selected by his or her health care provider for the
medical condition under consideration while on a current
or previous health insurance or health benefit plan.
(d) Upon the granting of an exception request, the
insurer, health plan, utilization review organization, or
other entity shall authorize the coverage for the drug

prescribed by the enrollee's treating health care provider, to
the extent the prescribed drug is a covered drug under the
policy or contract up to the quantity covered.
(e) Any approval of a medical exception request made
pursuant to this Section shall be honored for 12 months
following the date of the approval or until renewal of the
plan.
(f) Notwithstanding any other provision of this Section,
nothing in this Section shall be interpreted or implemented in
a manner not consistent with the federal Patient Protection
and Affordable Care Act (Public Law 111-148), as amended by
the federal Health Care and Education Reconciliation Act of
2010 (Public Law 111-152), and any amendments thereto, or
regulations or guidance issued under those Acts.
(g) Nothing in this Section shall require or authorize the
State agency responsible for the administration of the medical
assistance program established under the Illinois Public Aid
Code to approve, supply, or cover prescription drugs pursuant
to the procedure established in this Section.
(Source: P.A. 103-154, eff. 6-30-23.)
(215 ILCS 134/85)
Sec. 85. Utilization review program registration.
(a) No person may conduct a utilization review program in
this State unless once every 2 years the person registers the
utilization review program with the Department and certifies

compliance with the Health Utilization Management Standards of
the American Accreditation Healthcare Commission (URAC)
sufficient to achieve American Accreditation Healthcare
Commission (URAC) accreditation or submits evidence of
accreditation by the American Accreditation Healthcare
Commission (URAC) for its Health Utilization Management
Standards. Nothing in this Act shall be construed to require a
health care plan or its subcontractors to become American
Accreditation Healthcare Commission (URAC) accredited.
(b) In addition, the Director of the Department, in
consultation with the Director of the Department of Public
Health, may certify alternative utilization review standards
of national accreditation organizations or entities in order
for plans to comply with this Section. Any alternative
utilization review standards shall meet or exceed those
standards required under subsection (a).
(b-5) The Department shall recognize the Accreditation
Association for Ambulatory Health Care among the list of
accreditors from which utilization organizations may receive
accreditation and qualify for reduced registration and renewal
fees.
(c) The provisions of this Section do not apply to:
(1) persons providing utilization review program
services only to the federal government;
(2) self-insured health plans under the federal
Employee Retirement Income Security Act of 1974, however,

this Section does apply to persons conducting a
utilization review program on behalf of these health
plans;
(3) hospitals and medical groups performing
utilization review activities for internal purposes unless
the utilization review program is conducted for another
person.
Nothing in this Act prohibits a health care plan or other
entity from contractually requiring an entity designated in
item (3) of this subsection to adhere to the utilization
review program requirements of this Act.
(d) This registration shall include submission of all of
the following information regarding utilization review program
activities:
(1) The name, address, and telephone number of the
utilization review programs.
(2) The organization and governing structure of the
utilization review programs.
(3) The number of lives for which utilization review
is conducted by each utilization review program.
(4) Hours of operation of each utilization review
program.
(5) Description of the grievance process for each
utilization review program.
(6) Number of covered lives for which utilization
review was conducted for the previous calendar year for

each utilization review program.
(7) Written policies and procedures for protecting
confidential information according to applicable State and
federal laws for each utilization review program.
(e) (1) A utilization review program shall have written
procedures for assuring that patient-specific information
obtained during the process of utilization review will be:
(A) kept confidential in accordance with applicable
State and federal laws; and
(B) shared only with the enrollee, the enrollee's
designee, the enrollee's health care provider, and those
who are authorized by law to receive the information.
Summary data shall not be considered confidential if it
does not provide information to allow identification of
individual patients or health care providers.
(2) Only a clinical peer health care professional may
make adverse determinations regarding the medical
necessity of health care services during the course of
utilization review. Either a health care professional or
an accredited algorithmic automated process, or both in
combination, may certify the medical necessity of a health
care service in accordance with accreditation standards.
Nothing in this subsection prohibits an accredited
algorithmic automated process from being used to refer a
case to a clinical peer for a potential adverse
determination.

(3) When making retrospective reviews, utilization
review programs shall base reviews solely on the medical
information available to the attending physician or
ordering provider at the time the health care services
were provided.
(4) When making prospective, concurrent, and
retrospective determinations, utilization review programs
shall collect only information that is necessary to make
the determination and shall not routinely require health
care providers to numerically code diagnoses or procedures
to be considered for certification, unless required under
State or federal Medicare or Medicaid rules or
regulations, but may request such code if available, or
routinely request copies of medical records of all
enrollees reviewed. During prospective or concurrent
review, copies of medical records shall only be required
when necessary to verify that the health care services
subject to review are medically necessary. In these cases,
only the necessary or relevant sections of the medical
record shall be required.
(f) If the Department finds that a utilization review
program is not in compliance with this Section, the Department
shall issue a corrective action plan and allow a reasonable
amount of time for compliance with the plan. If the
utilization review program does not come into compliance, the
Department may issue a cease and desist order. Before issuing

a cease and desist order under this Section, the Department
shall provide the utilization review program with a written
notice of the reasons for the order and allow a reasonable
amount of time to supply additional information demonstrating
compliance with requirements of this Section and to request a
hearing. The hearing notice shall be sent by certified mail,
return receipt requested, and the hearing shall be conducted
in accordance with the Illinois Administrative Procedure Act.
(g) A utilization review program subject to a corrective
action may continue to conduct business until a final decision
has been issued by the Department.
(h) Any adverse determination made by a health care plan
or its subcontractors may be appealed in accordance with
subsection (f) of Section 45.
(i) The Director may by rule establish a registration fee
for each person conducting a utilization review program. All
fees paid to and collected by the Director under this Section
shall be deposited into the Insurance Producer Administration
Fund.
(Source: P.A. 99-111, eff. 1-1-16.)
(215 ILCS 134/87 new)
Sec. 87. General standards for use of utilization review
criteria.
(a) Beginning January 1, 2026, all utilization review
programs shall make medical necessity determinations in

accordance with the requirements of this Section. No policy,
contract, certificate, formulary, or evidence of coverage
issued to any enrollee may contain terms or conditions to the
contrary.
(b) All utilization review programs shall determine
medical necessity by using the most recent treatment criteria
developed by:
(1) an unaffiliated, nonprofit professional
association for the relevant clinical specialty;
(2) a third-party entity that develops treatment
criteria that: (i) are updated annually; (ii) are not paid
for clinical care decision outcomes; (iii) do not offer
different treatment criteria for the same health care
service unless otherwise required by State or federal law;
and (iv) are consistent with current generally accepted
standards of care; or
(3) the Department of Healthcare and Family Services
if the criteria are consistent with current generally
accepted standards of care.
(c) For all level of care placement decisions, the
utilization review program shall authorize placement at the
level of care at or above the level ordered by the provider
using the relevant treatment criteria as specified in
subsection (b). If there is a disagreement between the health
care plan and the provider or patient, the health care plan or
utilization review program shall provide its complete

assessment to the provider and the patient.
(d) If a utilization review program purchases or licenses
utilization review criteria pursuant to this Section, the
utilization review program shall, before using the criteria,
verify and document that the criteria were developed in
accordance with subsection (b).
(e) All health care plans and utilization review programs
must:
(1) make an educational program on the chosen
treatment criteria available to all staff and contracted
entities performing utilization review;
(2) provide, at no cost, the treatment criteria and
any related training material to providers and enrollees
upon request; enrollees and treating providers shall be
able to access treatment criteria at any point in time,
including before an initial request for authorization;
(3) track, identify, and analyze how the treatment
criteria are used to certify care, deny care, and support
the appeals process;
(4) conduct interrater reliability testing to ensure
consistency in utilization review decision-making; this
testing shall cover all aspects of utilization review
criteria as defined in Section 10;
(5) achieve interrater reliability pass rates of at
least 90% and, if this threshold is not met, initiate
remediation of poor interrater reliability within 3

business days after the finding and conduct interrater
reliability testing for all new staff before they can
conduct utilization review supervision; and
(6) maintain documentation of interrater reliability
testing and any remediation and submit to the Department
of Insurance, or, in the case of Medicaid managed care
organizations, the Department of Healthcare and Family
Services, the testing results de-identified of patient or
employee personal information and a summary of remedial
actions.
(f) Beginning January 1, 2026, no utilization review
program or any policy, contract, certificate, evidence of
coverage, or formulary shall impose step therapy requirements.
Nothing in this subsection prohibits a health care plan, by
contract, written policy, procedure, or any other agreement or
course of conduct, from requiring a pharmacist to effect
substitutions of prescription drugs consistent with Section
19.5 of the Pharmacy Practice Act, under which a pharmacist
may substitute an interchangeable biologic for a prescribed
biologic product, and Section 25 of the Pharmacy Practice Act,
under which a pharmacist may select a generic drug determined
to be therapeutically equivalent by the United States Food and
Drug Administration and in accordance with the Illinois Food,
Drug and Cosmetic Act. For health care plans operated or
overseen by the Department of Healthcare and Family Services,
including Medicaid managed care plans, the prohibition in this

subsection does not apply to step therapy requirements for
drugs that do not appear on the most recent Preferred Drug List
published by the Department of Healthcare and Family Services.
(g) Except for subsection (f), this Section does not apply
to utilization review concerning diagnosis, prevention, and
treatment of mental, emotional, nervous, or substance use
disorders or conditions, which shall be governed by Section
370c of the Illinois Insurance Code.
(h) Nothing in this Section supersedes or waives
requirements provided under any other State or federal law or
federal regulation that any coverage subject to this Section
comply with specific utilization review criteria for a
specific illness, level of care placement, injury, or
condition or its symptoms and comorbidities.
Section 6-15. The Health Carrier External Review Act is
amended by changing Section 10 as follows:
(215 ILCS 180/10)
Sec. 10. Definitions. For the purposes of this Act:
"Adverse determination" means:
(1) a determination by a health carrier or its
designee utilization review organization that, based upon
the information provided, a request for a benefit under
the health carrier's health benefit plan upon application
of any utilization review technique does not meet the

health carrier's requirements for medical necessity,
appropriateness, health care setting, level of care, or
effectiveness or is determined to be experimental or
investigational and the requested benefit is therefore
denied, reduced, or terminated or payment is not provided
or made, in whole or in part, for the benefit;
(2) the denial, reduction, or termination of or
failure to provide or make payment, in whole or in part,
for a benefit based on a determination by a health carrier
or its designee utilization review organization that a
preexisting condition was present before the effective
date of coverage; or
(3) a rescission of coverage determination, which does
not include a cancellation or discontinuance of coverage
that is attributable to a failure to timely pay required
premiums or contributions towards the cost of coverage.
"Authorized representative" means:
(1) a person to whom a covered person has given
express written consent to represent the covered person
for purposes of this Law;
(2) a person authorized by law to provide substituted
consent for a covered person;
(3) a family member of the covered person or the
covered person's treating health care professional when
the covered person is unable to provide consent;
(4) a health care provider when the covered person's

health benefit plan requires that a request for a benefit
under the plan be initiated by the health care provider;
or
(5) in the case of an urgent care request, a health
care provider with knowledge of the covered person's
medical condition.
"Best evidence" means evidence based on:
(1) randomized clinical trials;
(2) if randomized clinical trials are not available,
then cohort studies or case-control studies;
(3) if items (1) and (2) are not available, then
case-series; or
(4) if items (1), (2), and (3) are not available, then
expert opinion.
"Case-series" means an evaluation of a series of patients
with a particular outcome, without the use of a control group.
"Clinical review criteria" means the written screening
procedures, decision abstracts, clinical protocols, and
practice guidelines used by a health carrier to determine the
necessity and appropriateness of health care services.
"Clinical review criteria" includes all utilization review
criteria as defined in Section 10 of the Managed Care Reform
and Patient Rights Act.
"Cohort study" means a prospective evaluation of 2 groups
of patients with only one group of patients receiving specific
intervention.

"Concurrent review" means a review conducted during a
patient's stay or course of treatment in a facility, the
office of a health care professional, or other inpatient or
outpatient health care setting.
"Covered benefits" or "benefits" means those health care
services to which a covered person is entitled under the terms
of a health benefit plan.
"Covered person" means a policyholder, subscriber,
enrollee, or other individual participating in a health
benefit plan.
"Director" means the Director of the Department of
Insurance.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
including, but not limited to, severe pain, such that a
prudent layperson who possesses an average knowledge of health
and medicine could reasonably expect the absence of immediate
medical attention to result in:
(1) placing the health of the individual or, with
respect to a pregnant woman, the health of the woman or her
unborn child, in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
"Emergency services" means health care items and services
furnished or required to evaluate and treat an emergency
medical condition.

"Evidence-based standard" means the conscientious,
explicit, and judicious use of the current best evidence based
on an overall systematic review of the research in making
decisions about the care of individual patients.
"Expert opinion" means a belief or an interpretation by
specialists with experience in a specific area about the
scientific evidence pertaining to a particular service,
intervention, or therapy.
"Facility" means an institution providing health care
services or a health care setting.
"Final adverse determination" means an adverse
determination involving a covered benefit that has been upheld
by a health carrier, or its designee utilization review
organization, at the completion of the health carrier's
internal grievance process procedures as set forth by the
Managed Care Reform and Patient Rights Act.
"Health benefit plan" means a policy, contract,
certificate, plan, or agreement offered or issued by a health
carrier to provide, deliver, arrange for, pay for, or
reimburse any of the costs of health care services.
"Health care provider" or "provider" means a physician,
hospital facility, or other health care practitioner licensed,
accredited, or certified to perform specified health care
services consistent with State law, responsible for
recommending health care services on behalf of a covered
person.

"Health care services" means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition,
illness, injury, or disease.
"Health carrier" means an entity subject to the insurance
laws and regulations of this State, or subject to the
jurisdiction of the Director, that contracts or offers to
contract to provide, deliver, arrange for, pay for, or
reimburse any of the costs of health care services, including
a sickness and accident insurance company, a health
maintenance organization, or any other entity providing a plan
of health insurance, health benefits, or health care services.
"Health carrier" also means Limited Health Service
Organizations (LHSO) and Voluntary Health Service Plans.
"Health information" means information or data, whether
oral or recorded in any form or medium, and personal facts or
information about events or relationships that relate to:
(1) the past, present, or future physical, mental, or
behavioral health or condition of an individual or a
member of the individual's family;
(2) the provision of health care services to an
individual; or
(3) payment for the provision of health care services
to an individual.
"Independent review organization" means an entity that
conducts independent external reviews of adverse
determinations and final adverse determinations.

"Medical or scientific evidence" means evidence found in
the following sources:
(1) peer-reviewed scientific studies published in or
accepted for publication by medical journals that meet
nationally recognized requirements for scientific
manuscripts and that submit most of their published
articles for review by experts who are not part of the
editorial staff;
(2) peer-reviewed medical literature, including
literature relating to therapies reviewed and approved by
a qualified institutional review board, biomedical
compendia, and other medical literature that meet the
criteria of the National Institutes of Health's Library of
Medicine for indexing in Index Medicus (Medline) and
Elsevier Science Ltd. for indexing in Excerpta Medicus
(EMBASE);
(3) medical journals recognized by the Secretary of
Health and Human Services under Section 1861(t)(2) of the
federal Social Security Act;
(4) the following standard reference compendia:
(a) The American Hospital Formulary Service-Drug
Information;
(b) Drug Facts and Comparisons;
(c) The American Dental Association Accepted
Dental Therapeutics; and
(d) The United States Pharmacopoeia-Drug

Information;
(5) findings, studies, or research conducted by or
under the auspices of federal government agencies and
nationally recognized federal research institutes,
including:
(a) the federal Agency for Healthcare Research and
Quality;
(b) the National Institutes of Health;
(c) the National Cancer Institute;
(d) the National Academy of Sciences;
(e) the Centers for Medicare & Medicaid Services;
(f) the federal Food and Drug Administration; and
(g) any national board recognized by the National
Institutes of Health for the purpose of evaluating the
medical value of health care services; or
(6) any other medical or scientific evidence that is
comparable to the sources listed in items (1) through (5).
"Person" means an individual, a corporation, a
partnership, an association, a joint venture, a joint stock
company, a trust, an unincorporated organization, any similar
entity, or any combination of the foregoing.
"Prospective review" means a review conducted prior to an
admission or the provision of a health care service or a course
of treatment in accordance with a health carrier's requirement
that the health care service or course of treatment, in whole
or in part, be approved prior to its provision.

"Protected health information" means health information
(i) that identifies an individual who is the subject of the
information; or (ii) with respect to which there is a
reasonable basis to believe that the information could be used
to identify an individual.
"Randomized clinical trial" means a controlled prospective
study of patients that have been randomized into an
experimental group and a control group at the beginning of the
study with only the experimental group of patients receiving a
specific intervention, which includes study of the groups for
variables and anticipated outcomes over time.
"Retrospective review" means any review of a request for a
benefit that is not a concurrent or prospective review
request. "Retrospective review" does not include the review of
a claim that is limited to veracity of documentation or
accuracy of coding.
"Utilization review" has the meaning provided by the
Managed Care Reform and Patient Rights Act.
"Utilization review organization" means a utilization
review program as defined in the Managed Care Reform and
Patient Rights Act.
(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12;
98-756, eff. 7-16-14.)
Section 6-20. The Prior Authorization Reform Act is
amended by changing Sections 15 and 20 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.
"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.
"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
and Accountability Act.
"Medically necessary" has the meaning given to that term
in Section 10 of the Managed Care Reform and Patient Rights
Act. 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
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)
Sec. 20. Disclosure and review of prior authorization
requirements.
(a) A health insurance issuer shall maintain a complete
list of services for which prior authorization is required,
including for all services where prior authorization is
performed by an entity under contract with the health
insurance issuer. The health insurance issuer shall publish
this list on its public website without requiring a member of
the general public to create any account or enter any
credentials to access it. The list described in this
subsection is not required to contain the clinical review
criteria applicable to these services.
(b) A health insurance issuer shall make any current prior
authorization requirements and restrictions, including the
written clinical review criteria, readily accessible and

conspicuously posted on its website to enrollees, health care
professionals, and health care providers. Content published by
a third party and licensed for use by a health insurance issuer
or its contracted utilization review organization may be made
available through the health insurance issuer's or its
contracted utilization review organization's secure,
password-protected website so long as the access requirements
of the website do not unreasonably restrict access.
Requirements shall be described in detail, written in easily
understandable language, and readily available to the health
care professional and health care provider at the point of
care. The website shall indicate for each service subject to
prior authorization:
(1) when prior authorization became required for
policies issued or delivered in Illinois, including the
effective date or dates and the termination date or dates,
if applicable, in Illinois;
(2) the date the Illinois-specific requirement was
listed on the health insurance issuer's or its contracted
utilization review organization's website;
(3) where applicable, the date that prior
authorization was removed for Illinois; and
(4) where applicable, access to a standardized
electronic prior authorization request transaction
process.
(c) The clinical review criteria must:

(1) be based on nationally recognized, generally
accepted standards except where State law provides its own
standard;
(2) be developed in accordance with the current
standards of a national medical accreditation entity;
(3) ensure quality of care and access to needed health
care services;
(4) be evidence-based;
(5) be sufficiently flexible to allow deviations from
norms when justified on a case-by-case basis; and
(6) be evaluated and updated, if necessary, at least
annually.
(d) A health insurance issuer shall not deny a claim for
failure to obtain prior authorization if the prior
authorization requirement was not in effect on the date of
service on the claim.
(e) A health insurance issuer or its contracted
utilization review organization shall not deem as incidental
or deny supplies or health care services that are routinely
used as part of a health care service when:
(1) an associated health care service has received
prior authorization; or
(2) prior authorization for the health care service is
not required.
(f) If a health insurance issuer intends either to
implement a new prior authorization requirement or restriction

or amend an existing requirement or restriction, the health
insurance issuer shall provide contracted health care
professionals and contracted health care providers of
enrollees written notice of the new or amended requirement or
amendment no less than 60 days before the requirement or
restriction is implemented. The written notice may be provided
in an electronic format, including email or facsimile, if the
health care professional or health care provider has agreed in
advance to receive notices electronically. The health
insurance issuer shall ensure that the new or amended
requirement is not implemented unless the health insurance
issuer's or its contracted utilization review organization's
website has been updated to reflect the new or amended
requirement or restriction.
(g) Entities using prior authorization shall make
statistics available regarding prior authorization approvals
and denials on their website in a readily accessible format.
The statistics must be updated annually and include all of the
following information:
(1) a list of all health care services, including
medications, that are subject to prior authorization;
(2) the total number of prior authorization requests
received;
(3) the number of prior authorization requests denied
during the previous plan year by the health insurance
issuer or its contracted utilization review organization

with respect to each service described in paragraph (1)
and the top 5 reasons for denial;
(4) the number of requests described in paragraph (3)
that were appealed, the number of the appealed requests
that upheld the adverse determination, and the number of
appealed requests that reversed the adverse determination;
(5) the average time between submission and response;
and
(6) any other information as the Director determines
appropriate.
(Source: P.A. 102-409, eff. 1-1-22.)
Section 6-25. The Illinois Public Aid Code is amended by
changing Section 5-16.12 as follows:
(305 ILCS 5/5-16.12)
Sec. 5-16.12. Managed Care Reform and Patient Rights Act.
The medical assistance program and other programs administered
by the Department are subject to the provisions of the Managed
Care Reform and Patient Rights Act. The Department may adopt
rules to implement those provisions. These rules shall require
compliance with that Act in the medical assistance managed
care programs and other programs administered by the
Department. The medical assistance fee-for-service program is
not subject to the provisions of the Managed Care Reform and
Patient Rights Act, except for Sections 85 and 87 of the

Managed Care Reform and Patient Rights Act and for any
definition in Section 10 of the Managed Care Reform and
Patient Rights Act that applies to Sections 85 and 87 of the
Managed Care Reform and Patient Rights Act.
Nothing in the Managed Care Reform and Patient Rights Act
shall be construed to mean that the Department is a health care
plan as defined in that Act simply because the Department
enters into contractual relationships with health care plans;
provided that this clause shall not defeat the applicability
of Sections 10, 85, and 87 of the Managed Care Reform and
Patient Rights Act to the fee-for-service program.
(Source: P.A. 91-617, eff. 1-1-00.)
Article 99.
Section 99-95. No acceleration or delay. Where this Act
makes changes in a statute that is represented in this Act by
text that is not yet or no longer in effect (for example, a
Section represented by multiple versions), the use of that
text does not accelerate or delay the taking effect of (i) the
changes made by this Act or (ii) provisions derived from any
other Public Act.