Bill Amendment: IL HB0711 | 2021-2022 | 102nd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: PRIOR AUTHORIZATION REFORM ACT
Status: 2021-08-19 - Public Act . . . . . . . . . 102-0409 [HB0711 Detail]
Download: Illinois-2021-HB0711-House_Amendment_001.html
Bill Title: PRIOR AUTHORIZATION REFORM ACT
Status: 2021-08-19 - Public Act . . . . . . . . . 102-0409 [HB0711 Detail]
Download: Illinois-2021-HB0711-House_Amendment_001.html
| |||||||
| |||||||
| |||||||
1 | AMENDMENT TO HOUSE BILL 711
| ||||||
2 | AMENDMENT NO. ______. Amend House Bill 711 by replacing | ||||||
3 | everything after the enacting clause with the following:
| ||||||
4 | "Section 1. Short title. This Act may be cited as the Prior | ||||||
5 | Authorization Reform Act.
| ||||||
6 | Section 5. Purpose. The General Assembly hereby finds and | ||||||
7 | declares that:
| ||||||
8 | (1) the health care professional-patient relationship | ||||||
9 | is paramount and should not be subject to third-party | ||||||
10 | intrusion;
| ||||||
11 | (2) prior authorization programs shall be subject to | ||||||
12 | member coverage agreements and medical policies but shall | ||||||
13 | not hinder the independent medical judgment of a physician | ||||||
14 | or health care provider; and
| ||||||
15 | (3) prior authorization programs must be transparent | ||||||
16 | to ensure a fair and consistent process for health care |
| |||||||
| |||||||
1 | providers and patients.
| ||||||
2 | Section 10. Applicability; scope. This Act applies to | ||||||
3 | health insurance coverage as defined in the Illinois Health | ||||||
4 | Insurance Portability and Accountability Act, and policies | ||||||
5 | issued or delivered in this State to the Department of | ||||||
6 | Healthcare and Family Services and providing coverage to | ||||||
7 | persons who are enrolled under Article V of the Illinois | ||||||
8 | Public Aid Code or under the Children's Health Insurance | ||||||
9 | Program Act, amended, delivered, issued, or renewed on or | ||||||
10 | after the effective date of this Act, with the exception of | ||||||
11 | employee or employer self-insured health benefit plans under | ||||||
12 | the federal Employee Retirement Income Security Act of 1974, | ||||||
13 | health care provided pursuant to the Workers' Compensation Act | ||||||
14 | or the Workers' Occupational Diseases Act, and State employee | ||||||
15 | health plans. This Act does not diminish a health care plan's | ||||||
16 | duties and responsibilities under other federal or State law | ||||||
17 | or rules promulgated thereunder.
| ||||||
18 | Section 15. Definitions. As used in this Act:
| ||||||
19 | "Adverse determination" has the meaning given to that term | ||||||
20 | in Section 10 of the Health Carrier External Review Act.
| ||||||
21 | "Appeal" means a formal request, either orally or in | ||||||
22 | writing, to reconsider an adverse determination.
| ||||||
23 | "Approval" means a determination by a utilization review | ||||||
24 | organization that a health care service has been reviewed and, |
| |||||||
| |||||||
1 | based on the information provided, satisfies the utilization | ||||||
2 | review organization's requirements for medical necessity and | ||||||
3 | appropriateness.
| ||||||
4 | "Clinical review criteria" has the meaning given to that | ||||||
5 | term in Section 10 of the Health Carrier External Review Act.
| ||||||
6 | "Department" means the Department of Insurance.
| ||||||
7 | "Emergency medical condition" has the meaning given to | ||||||
8 | that term in Section 10 of the Managed Care Reform and Patient | ||||||
9 | Rights Act.
| ||||||
10 | "Emergency services" has the meaning given to that term in | ||||||
11 | federal health insurance reform requirements for the group and | ||||||
12 | individual health insurance markets, 45 CFR 147.138.
| ||||||
13 | "Enrollee" has the meaning given to that term in Section | ||||||
14 | 10 of the Managed Care Reform and Patient Rights Act.
| ||||||
15 | "Health care professional" has the meaning given to that | ||||||
16 | term in Section 10 of the Managed Care Reform and Patient | ||||||
17 | Rights Act.
| ||||||
18 | "Health care provider" has the meaning given to that term | ||||||
19 | in Section 10 of the Managed Care Reform and Patient Rights | ||||||
20 | Act.
| ||||||
21 | "Health care service" means any services or level of | ||||||
22 | services included in the furnishing to an individual of | ||||||
23 | medical care or the hospitalization incident to the furnishing | ||||||
24 | of such care, as well as the furnishing to any person of any | ||||||
25 | other services for the purpose of preventing, alleviating, | ||||||
26 | curing, or healing human illness or injury, including |
| |||||||
| |||||||
1 | behavioral health, mental health, home health, and | ||||||
2 | pharmaceutical services and products.
| ||||||
3 | "Health insurance issuer" has the meaning given to that | ||||||
4 | term in Section 5 of the Illinois Health Insurance Portability | ||||||
5 | and Accountability Act.
| ||||||
6 | "Medically necessary" means a health care professional | ||||||
7 | exercising prudent clinical judgment would provide care to a | ||||||
8 | patient for the purpose of preventing, diagnosing, or treating | ||||||
9 | an illness, injury, disease, or its symptoms and that are: (i) | ||||||
10 | in accordance with generally accepted standards of medical | ||||||
11 | practice; (ii) clinically appropriate in terms of type, | ||||||
12 | frequency, extent, site, and duration and are considered | ||||||
13 | effective for the patient's illness, injury, or disease; and | ||||||
14 | (iii) not primarily for the convenience of the patient, | ||||||
15 | treating physician, other health care professional, caregiver, | ||||||
16 | family member, or other interested party, but focused on what | ||||||
17 | is best for the patient's health outcome.
| ||||||
18 | "Physician" means a person licensed under the Medical | ||||||
19 | Practice Act of 1987 to practice medicine in all its branches.
| ||||||
20 | "Prior authorization" means the process by which | ||||||
21 | utilization review organizations determine the medical | ||||||
22 | necessity and medical appropriateness of otherwise covered | ||||||
23 | health care services before the rendering of such health care | ||||||
24 | services. "Prior authorization" includes any utilization | ||||||
25 | review organization's requirement that an enrollee, health | ||||||
26 | care professional, or health care provider notify the |
| |||||||
| |||||||
1 | utilization review organization before, at the time of, or | ||||||
2 | concurrent to providing a health care service.
| ||||||
3 | "Urgent health care service" means a health care service | ||||||
4 | with respect to which the application of the time periods for | ||||||
5 | making a non-expedited prior authorization that in the opinion | ||||||
6 | of a health care professional with knowledge of the enrollee's | ||||||
7 | medical condition:
| ||||||
8 | (1) could seriously jeopardize the life or health of | ||||||
9 | the enrollee or the ability of the enrollee to regain | ||||||
10 | maximum function; or
| ||||||
11 | (2) could subject the enrollee to severe pain that | ||||||
12 | cannot be adequately managed without the care or treatment | ||||||
13 | that is the subject of the utilization review.
| ||||||
14 | "Urgent health care service" does not include emergency | ||||||
15 | services.
| ||||||
16 | "Utilization review organization" has the meaning given to | ||||||
17 | that term in 50 Ill. Adm. Code 4520.30.
| ||||||
18 | Section 20. Disclosure and review of prior authorization | ||||||
19 | requirements.
| ||||||
20 | (a) A health insurance issuer shall maintain a complete | ||||||
21 | list of services for which prior authorization is required, | ||||||
22 | including for all services where prior authorization is | ||||||
23 | performed by an entity under contract with the health | ||||||
24 | insurance issuer.
| ||||||
25 | (b) A health insurance issuer shall make any current prior |
| |||||||
| |||||||
1 | authorization requirements and restrictions, including the | ||||||
2 | written clinical review criteria, readily accessible and | ||||||
3 | conspicuously posted on its website to enrollees, health care | ||||||
4 | professionals, and health care providers. Content published by | ||||||
5 | a third party and licensed for use by a health insurance issuer | ||||||
6 | or its contracted utilization review organization may be made | ||||||
7 | available through the health insurance issuer's or its | ||||||
8 | contracted utilization review organization's secure, | ||||||
9 | password-protected website so long as the access requirements | ||||||
10 | of the website do not unreasonably restrict access. | ||||||
11 | Requirements shall be described in detail, written in easily | ||||||
12 | understandable language, and readily available to the health | ||||||
13 | care professional and health care provider at the point of | ||||||
14 | care. The website shall indicate for each service subject to | ||||||
15 | prior authorization:
| ||||||
16 | (1) when prior authorization became required for | ||||||
17 | policies issued or delivered in Illinois, including the | ||||||
18 | effective date or dates and the termination date or dates, | ||||||
19 | if applicable, in Illinois;
| ||||||
20 | (2) the date the Illinois-specific requirement was | ||||||
21 | listed on the health insurance issuer's or its contracted | ||||||
22 | utilization review organization's website; and
| ||||||
23 | (3) where applicable, the date that prior | ||||||
24 | authorization was removed for Illinois.
| ||||||
25 | (c) The clinical review criteria must:
| ||||||
26 | (1) be based on nationally recognized, generally |
| |||||||
| |||||||
1 | accepted standards except where State law provides its own | ||||||
2 | standard;
| ||||||
3 | (2) be developed in accordance with the current | ||||||
4 | standards of a national medical accreditation entity;
| ||||||
5 | (3) ensure quality of care and access to needed health | ||||||
6 | care services;
| ||||||
7 | (4) be evidence-based;
| ||||||
8 | (5) be sufficiently flexible to allow deviations from | ||||||
9 | norms when justified on a case-by-case basis;
and | ||||||
10 | (6) be evaluated and updated, if necessary, at least | ||||||
11 | annually. | ||||||
12 | (d) A health insurance issuer shall not deny a claim for | ||||||
13 | failure to obtain prior authorization if the prior | ||||||
14 | authorization requirement was not in effect on the date of | ||||||
15 | service on the claim.
| ||||||
16 | (e) Neither a health insurance issuer nor a contracted | ||||||
17 | utilization review organization shall deny prior authorization | ||||||
18 | of a health care service solely based on the grounds that:
| ||||||
19 | (1) no independently developed, evidence-based | ||||||
20 | standards can be derived from reliable scientific evidence | ||||||
21 | or documents published by professional societies;
| ||||||
22 | (2) evidence-based standards conflict;
or | ||||||
23 | (3) evidence-based standards from expert consensus | ||||||
24 | panels do not exist.
| ||||||
25 | (f) A health insurance issuer or its contracted | ||||||
26 | utilization review organization shall not deem as incidental |
| |||||||
| |||||||
1 | or deny supplies or health care services that are routinely | ||||||
2 | used as part of a health care service when:
| ||||||
3 | (1) an associated health care service has received | ||||||
4 | prior authorization; or
| ||||||
5 | (2) prior authorization for the health care service is | ||||||
6 | not required.
| ||||||
7 | (g) If a health insurance issuer intends either to | ||||||
8 | implement a new prior authorization requirement or restriction | ||||||
9 | or amend an existing requirement or restriction, the health | ||||||
10 | insurance issuer shall provide enrollees, contracted health | ||||||
11 | care professionals, and contracted health care providers of | ||||||
12 | enrollees written notice of the new or amended requirement or | ||||||
13 | amendment no less than 60 days before the requirement or | ||||||
14 | restriction is implemented. The written notice may be provided | ||||||
15 | in an electronic format, including email or facsimile, if the | ||||||
16 | enrollee, health care professional, or health care provider | ||||||
17 | has agreed in advance to receive notices electronically. The | ||||||
18 | health insurance issuer shall ensure that the new or amended | ||||||
19 | requirement is not implemented unless the health insurance | ||||||
20 | issuer's or its contracted utilization review organization's | ||||||
21 | website has been updated to reflect the new or amended | ||||||
22 | requirement or restriction.
| ||||||
23 | (h) Entities utilizing prior authorization shall make | ||||||
24 | statistics available regarding prior authorization approvals | ||||||
25 | and denials on their website in a readily accessible format. | ||||||
26 | The categories must be updated quarterly and include all of |
| |||||||
| |||||||
1 | the following information:
| ||||||
2 | (1) a list of all health care services, including | ||||||
3 | medications, that are subject to prior authorization;
| ||||||
4 | (2) the total number of prior authorization requests | ||||||
5 | received;
| ||||||
6 | (3) the number of prior authorization requests denied | ||||||
7 | during the previous plan year by the health insurance | ||||||
8 | issuer or its contracted utilization review organization | ||||||
9 | with respect to each service described in paragraph (1) | ||||||
10 | and the top 5 reasons for denial;
| ||||||
11 | (4) the number of requests described in paragraph (3) | ||||||
12 | that were appealed, the number of the appealed requests | ||||||
13 | that upheld the adverse determination, and the number of | ||||||
14 | appealed requests that reversed the adverse determination;
| ||||||
15 | (5) the average time between submission and response;
| ||||||
16 | and | ||||||
17 | (6) any other information as the Director determines | ||||||
18 | appropriate.
| ||||||
19 | Section 25. Health insurance issuer's and its contracted | ||||||
20 | utilization review organization's obligations with respect to | ||||||
21 | prior authorizations in nonurgent circumstances. If a health | ||||||
22 | insurance issuer requires prior authorization of a health care | ||||||
23 | service, the health insurance issuer or its contracted | ||||||
24 | utilization review organization must make an approval or | ||||||
25 | adverse determination and notify the enrollee, the enrollee's |
| |||||||
| |||||||
1 | health care professional, and the enrollee's health care | ||||||
2 | provider of the approval or adverse determination as required | ||||||
3 | by applicable law, but no later than 72 hours after obtaining | ||||||
4 | all necessary information to make the approval or adverse | ||||||
5 | determination. As used in this Section, "necessary | ||||||
6 | information" includes the results of any face-to-face clinical | ||||||
7 | evaluation or second opinion that may be required.
| ||||||
8 | Section 30. Health insurance issuer's and its contracted | ||||||
9 | utilization review organization's obligations with respect to | ||||||
10 | prior authorizations concerning urgent health care services.
| ||||||
11 | (a) A health insurance issuer or its contracted | ||||||
12 | utilization review organization must render an approval or | ||||||
13 | adverse determination concerning urgent care services and any | ||||||
14 | services for any current or prospective resident of a skilled | ||||||
15 | nursing facility and notify the enrollee, the enrollee's | ||||||
16 | health care professional, and the enrollee's health care | ||||||
17 | provider of that approval or adverse determination not later | ||||||
18 | than 24 hours after receiving all information needed to | ||||||
19 | complete the review of the requested health care services.
| ||||||
20 | (b) To facilitate the rendering of a prior authorization | ||||||
21 | determination in conformance with this Section, a health | ||||||
22 | insurance issuer or its contracted utilization review | ||||||
23 | organization must establish and provide access to a hotline | ||||||
24 | that is staffed 24 hours per day, 7 days per week by | ||||||
25 | appropriately trained and licensed clinical personnel who have |
| |||||||
| |||||||
1 | access to physicians for consultation, designated by the plan | ||||||
2 | to make such determinations for prior authorization concerning | ||||||
3 | urgent care services.
| ||||||
4 | Section 35. Health insurance issuer's and its contracted | ||||||
5 | utilization review organization's obligations with respect to | ||||||
6 | prior authorization concerning emergency health care services.
| ||||||
7 | (a) A health insurance issuer shall cover emergency health | ||||||
8 | care services necessary to screen and stabilize an enrollee. | ||||||
9 | If a health care professional or health care provider | ||||||
10 | certifies in writing to a health insurance issuer within 72 | ||||||
11 | hours after an enrollee's admission that the enrollee's | ||||||
12 | condition required emergency health care services, that | ||||||
13 | certification shall create a presumption that the emergency | ||||||
14 | health care services were medically necessary and such | ||||||
15 | presumption may be rebutted only if the health insurance | ||||||
16 | issuer or its contracted utilization review organization can | ||||||
17 | establish, with clear and convincing evidence, that the | ||||||
18 | emergency health care services were not medically necessary.
| ||||||
19 | (b) If an enrollee receives an emergency health care | ||||||
20 | service that requires immediate post-evaluation or | ||||||
21 | post-stabilization services, a health insurance issuer or its | ||||||
22 | contracted utilization review organization shall make a prior | ||||||
23 | authorization determination within 60 minutes after receiving | ||||||
24 | a request; if the prior authorization determination is not | ||||||
25 | made within 60 minutes, the services shall be deemed approved.
|
| |||||||
| |||||||
1 | Section 40. Personnel qualified to make adverse | ||||||
2 | determinations of a prior authorization request. A health | ||||||
3 | insurance issuer or its contracted utilization review | ||||||
4 | organization must ensure that all adverse determinations are | ||||||
5 | made by a physician when the request is by a physician or a | ||||||
6 | representative of a physician. The physician must:
| ||||||
7 | (1) possess a current and valid nonrestricted license | ||||||
8 | to practice medicine in all its branches in any United | ||||||
9 | States jurisdiction;
| ||||||
10 | (2) practice in the same or similar specialty as the | ||||||
11 | physician who typically manages the medical condition or | ||||||
12 | disease or provides the health care service involved in | ||||||
13 | the request; and
| ||||||
14 | (3) have experience treating patients with the medical | ||||||
15 | condition or disease for which the health care service is | ||||||
16 | being requested.
| ||||||
17 | Notwithstanding the foregoing, a licensed health care | ||||||
18 | professional who satisfies the requirements of this Section | ||||||
19 | may make an adverse determination of a prior authorization | ||||||
20 | request submitted by a health care professional licensed in | ||||||
21 | the same profession.
| ||||||
22 | Section 45. Consultation before issuing an adverse | ||||||
23 | determination of a prior authorization. If a health insurance | ||||||
24 | issuer or its contracted utilization review organization is |
| |||||||
| |||||||
1 | questioning the medical necessity of a health care service, | ||||||
2 | the health insurance issuer or its contracted utilization | ||||||
3 | review organization must notify the enrollee's health care | ||||||
4 | professional and health care provider that medical necessity | ||||||
5 | is being questioned. Before issuing an adverse determination, | ||||||
6 | the enrollee's health care professional and health care | ||||||
7 | provider must have the opportunity to discuss the medical | ||||||
8 | necessity of the health care service on the telephone or by | ||||||
9 | other agreeable method with the health care professional who | ||||||
10 | will be responsible for issuing the prior authorization | ||||||
11 | determination of the health care service under review.
| ||||||
12 | Section 50. Requirements applicable to the physician who | ||||||
13 | can review consultations and appeals. A health insurance | ||||||
14 | issuer or its contracted utilization review organization must | ||||||
15 | ensure that all appeals are reviewed by a physician. The | ||||||
16 | physician must:
| ||||||
17 | (1) possess a current and valid nonrestricted license | ||||||
18 | to practice medicine in any United States jurisdiction;
| ||||||
19 | (2) be currently in active practice in the same or | ||||||
20 | similar specialty as a physician who typically manages the | ||||||
21 | medical condition or disease;
| ||||||
22 | (3) be knowledgeable of, and have experience | ||||||
23 | providing, the health care services under appeal;
| ||||||
24 | (4) not have been directly involved in making the | ||||||
25 | adverse determination; and
|
| |||||||
| |||||||
1 | (5) consider all known clinical aspects of the health | ||||||
2 | care service under review, including, but not limited to, | ||||||
3 | a review of all pertinent medical records provided to the | ||||||
4 | health insurance issuer or its contracted utilization | ||||||
5 | review organization by the enrollee's health care | ||||||
6 | professional or health care provider and any medical | ||||||
7 | literature provided to the health insurance issuer or its | ||||||
8 | contracted utilization review organization by the health | ||||||
9 | care professional or health care provider.
| ||||||
10 | Section 55. Review of prior authorization requirements. A | ||||||
11 | health insurance issuer shall periodically review its prior | ||||||
12 | authorization requirements and consider removal of prior | ||||||
13 | authorization requirements:
| ||||||
14 | (1) where a medication or procedure prescribed is | ||||||
15 | customary and properly indicated or is a treatment for the | ||||||
16 | clinical indication as supported by peer-reviewed medical | ||||||
17 | publications;
or | ||||||
18 | (2) for patients currently managed with an established | ||||||
19 | treatment regimen.
| ||||||
20 | Section 60. Denial.
| ||||||
21 | (a) The health insurance issuer or its contracted | ||||||
22 | utilization review organization may not revoke, limit, | ||||||
23 | condition, or restrict a previously issued prior authorization | ||||||
24 | approval.
|
| |||||||
| |||||||
1 | (b) Notwithstanding any other provision of law, if a claim | ||||||
2 | is properly coded and submitted timely to a health insurance | ||||||
3 | issuer, the health insurance issuer shall make payment on | ||||||
4 | claims for health care services for which prior authorization | ||||||
5 | was required and approval received before the rendering of | ||||||
6 | health care services, unless one of the following occurs:
| ||||||
7 | (1) it is timely determined that the enrollee's health | ||||||
8 | care professional or health care provider knowingly | ||||||
9 | provided health care services that required prior | ||||||
10 | authorization from the health insurance issuer or its | ||||||
11 | contracted utilization review organization without first | ||||||
12 | obtaining prior authorization for those health care | ||||||
13 | services;
| ||||||
14 | (2) it is timely determined that the health care | ||||||
15 | services claimed were not performed;
| ||||||
16 | (3) it is timely determined that the health care | ||||||
17 | services rendered were contrary to the instructions of the | ||||||
18 | health insurance issuer or its contracted utilization | ||||||
19 | review organization or delegated physician reviewer if | ||||||
20 | contact was made between those parties before the service | ||||||
21 | being rendered;
| ||||||
22 | (4) it is timely determined that the enrollee | ||||||
23 | receiving such health care services was not an enrollee of | ||||||
24 | the health care plan; or
| ||||||
25 | (5) the approval was based upon a material | ||||||
26 | misrepresentation by the enrollee or health care provider; |
| |||||||
| |||||||
1 | as used in this paragraph (5), "material" means a fact or | ||||||
2 | situation that is not merely technical in nature and | ||||||
3 | results or could result in a substantial change in the | ||||||
4 | situation.
| ||||||
5 | Section 65. Length of prior authorization approval. A | ||||||
6 | prior authorization approval shall be valid for the lesser of | ||||||
7 | 12 months after the date the health care professional or | ||||||
8 | health care provider receives the prior authorization approval | ||||||
9 | or the length of treatment as determined by the patient's | ||||||
10 | health care professional, and the approval period shall be | ||||||
11 | effective regardless of any changes, including any changes in | ||||||
12 | dosage for a prescription drug prescribed by the health care | ||||||
13 | professional. This Section shall not apply to the prescription | ||||||
14 | of benzodiazepines or Schedule II narcotic drugs, such as | ||||||
15 | opioids. Except to the extent required by medical exceptions | ||||||
16 | processes for prescription drugs, nothing in this Section | ||||||
17 | shall require a policy to cover any care, treatment, or | ||||||
18 | services for any health condition that the terms of coverage | ||||||
19 | otherwise completely exclude from the policy's covered | ||||||
20 | benefits without regard for whether the care, treatment, or | ||||||
21 | services are medically necessary.
| ||||||
22 | Section 70. Length of prior authorization approval for | ||||||
23 | treatment for chronic or long-term conditions. If a health | ||||||
24 | insurance issuer requires a prior authorization for a |
| |||||||
| |||||||
1 | recurring health care service or maintenance medication for | ||||||
2 | the treatment of a chronic or long-term condition, the | ||||||
3 | approval shall remain valid for the lesser of 12 months from | ||||||
4 | the date the health care professional or health care provider | ||||||
5 | receives the prior authorization approval or the length of the | ||||||
6 | treatment as determined by the patient's health care | ||||||
7 | professional. Except to the extent required by medical | ||||||
8 | exceptions processes for prescription drugs, nothing in this | ||||||
9 | Section shall require a policy to cover any care, treatment, | ||||||
10 | or services for any health condition that the terms of | ||||||
11 | coverage otherwise completely exclude from the policy's | ||||||
12 | covered benefits without regard for whether the care, | ||||||
13 | treatment, or services are medically necessary.
| ||||||
14 | Section 75. Continuity of care for enrollees.
| ||||||
15 | (a) On receipt of information documenting a prior | ||||||
16 | authorization approval from the enrollee or from the | ||||||
17 | enrollee's health care professional or health care provider, a | ||||||
18 | health insurance issuer shall honor a prior authorization | ||||||
19 | granted to an enrollee from a previous health insurance issuer | ||||||
20 | or its contracted utilization review organization for at least | ||||||
21 | the initial 90 days of an enrollee's coverage under a new | ||||||
22 | health plan.
| ||||||
23 | (b) During the time period described in subsection (a), a | ||||||
24 | health insurance issuer or its contracted utilization review | ||||||
25 | organization may perform its own review to grant a prior |
| |||||||
| |||||||
1 | authorization approval subject to the terms of the member's | ||||||
2 | coverage agreement.
| ||||||
3 | (c) If there is a change in coverage of or approval | ||||||
4 | criteria for a previously authorized health care service, the | ||||||
5 | change in coverage or approval criteria does not affect an | ||||||
6 | enrollee who received prior authorization approval before the | ||||||
7 | effective date of the change for the remainder of the | ||||||
8 | enrollee's plan year.
| ||||||
9 | (d) Except to the extent required by medical exceptions | ||||||
10 | processes for prescription drugs, nothing in this Section | ||||||
11 | shall require a policy to cover any care, treatment, or | ||||||
12 | services for any health condition that the terms of coverage | ||||||
13 | otherwise completely exclude from the policy's covered | ||||||
14 | benefits without regard for whether the care, treatment, or | ||||||
15 | services are medically necessary.
| ||||||
16 | Section 80. Health care services deemed authorized if a | ||||||
17 | health insurance issuer or its contracted utilization review | ||||||
18 | organization fails to comply with the requirements of this | ||||||
19 | Act. A failure by a health insurance issuer or its contracted | ||||||
20 | utilization review organization to comply with the deadlines | ||||||
21 | and other requirements specified in this Act shall result in | ||||||
22 | any health care services subject to review to be automatically | ||||||
23 | deemed authorized by the health insurance issuer or its | ||||||
24 | contracted utilization review organization.
|
| |||||||
| |||||||
1 | Section 85. Severability. If any provision of this Act or | ||||||
2 | its application to any person or circumstance is held invalid, | ||||||
3 | the invalidity does not affect other provisions or | ||||||
4 | applications of this Act that can be given effect without the | ||||||
5 | invalid provision or application, and to this end the | ||||||
6 | provisions of this Act are declared to be severable.
| ||||||
7 | Section 90. Administration and enforcement.
| ||||||
8 | (a) The Department shall enforce the provisions of this | ||||||
9 | Act pursuant to the enforcement powers granted to it by law. To | ||||||
10 | enforce the provisions of this Act, the Director is hereby | ||||||
11 | granted specific authority to issue a cease and desist order | ||||||
12 | or require a utilization review organization or health | ||||||
13 | insurance issuer to submit a plan of correction for violations | ||||||
14 | of this Act, or both, in accordance with the requirements and | ||||||
15 | authority set forth in Section 85 of the Managed Care Reform | ||||||
16 | and Patient Rights Act. Subject to the provisions of the | ||||||
17 | Illinois Administrative Procedure Act, the Director may, | ||||||
18 | pursuant to Section 403A of the Illinois Insurance Code, | ||||||
19 | impose upon a utilization review organization or health | ||||||
20 | insurance issuer an administrative fine not to exceed $250,000 | ||||||
21 | for failure to submit a requested plan of correction, failure | ||||||
22 | to comply with its plan of correction, or repeated violations | ||||||
23 | of this Act.
| ||||||
24 | (b) Any person who believes that his or her utilization | ||||||
25 | review organization or health insurance issuer is in violation |
| |||||||
| |||||||
1 | of the provisions of this Act may file a complaint with the | ||||||
2 | Department. The Department shall review all complaints | ||||||
3 | received and investigate all complaints that it deems to state | ||||||
4 | a potential violation. The Department shall fairly, | ||||||
5 | efficiently, and timely review and investigate complaints. | ||||||
6 | Utilization review organizations found to be in violation of | ||||||
7 | this Act shall be penalized in accordance with this Section.
| ||||||
8 | (c) The Department of Healthcare and Family Services shall | ||||||
9 | enforce the provisions of this Act as it applies to persons | ||||||
10 | enrolled under Article V of the Illinois Public Aid Code or | ||||||
11 | under the Children's Health Insurance Program Act.
| ||||||
12 | Section 900. The Illinois Insurance Code is amended by | ||||||
13 | changing Section 370g as follows:
| ||||||
14 | (215 ILCS 5/370g) (from Ch. 73, par. 982g)
| ||||||
15 | Sec. 370g. Definitions. As used in this Article, the | ||||||
16 | following definitions
apply:
| ||||||
17 | (a) "Health care services" means health care services or | ||||||
18 | products
rendered or sold by a provider within the scope of the | ||||||
19 | provider's license
or legal authorization. The term includes, | ||||||
20 | but is not limited to, hospital,
medical, surgical, dental, | ||||||
21 | vision and pharmaceutical services or products.
| ||||||
22 | (b) "Insurer" means an insurance company or a health | ||||||
23 | service corporation
authorized in this State to issue policies | ||||||
24 | or subscriber contracts which
reimburse for expenses of health |
| |||||||
| |||||||
1 | care services.
| ||||||
2 | (c) "Insured" means an individual entitled to | ||||||
3 | reimbursement for expenses
of health care services under a | ||||||
4 | policy or subscriber contract issued or
administered by an | ||||||
5 | insurer.
| ||||||
6 | (d) "Provider" means an individual or entity duly licensed | ||||||
7 | or legally
authorized to provide health care services.
| ||||||
8 | (e) "Noninstitutional provider" means any person licensed | ||||||
9 | under the Medical
Practice Act of 1987, as now or hereafter | ||||||
10 | amended.
| ||||||
11 | (f) "Beneficiary" means an individual entitled to | ||||||
12 | reimbursement for
expenses of or the discount of provider fees | ||||||
13 | for health care services under
a program where the beneficiary | ||||||
14 | has an incentive to utilize the services of a
provider which | ||||||
15 | has entered into an agreement or arrangement with an
| ||||||
16 | administrator.
| ||||||
17 | (g) "Administrator" means any person, partnership or | ||||||
18 | corporation, other
than an insurer or health maintenance | ||||||
19 | organization holding a certificate of
authority under the | ||||||
20 | "Health Maintenance Organization Act", as now or hereafter
| ||||||
21 | amended, that arranges, contracts with, or administers | ||||||
22 | contracts with a
provider whereby beneficiaries are provided | ||||||
23 | an incentive to use the services of
such provider.
| ||||||
24 | (h) "Emergency medical condition" has the meaning given to | ||||||
25 | that term in Section 10 of the Managed Care Reform and Patient | ||||||
26 | Rights Act. means a medical condition manifesting
itself
by
|
| |||||||
| |||||||
1 | acute symptoms of sufficient severity (including severe
pain) | ||||||
2 | such that a prudent
layperson, who possesses an average | ||||||
3 | knowledge of health and medicine, could
reasonably expect the | ||||||
4 | absence of immediate medical attention to result in:
| ||||||
5 | (1) placing the health of the individual (or, with | ||||||
6 | respect to a pregnant
woman, the
health of the woman or her | ||||||
7 | unborn child) in serious jeopardy;
| ||||||
8 | (2) serious
impairment to bodily functions; or
| ||||||
9 | (3) serious dysfunction of any bodily organ
or part.
| ||||||
10 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
11 | Section 905. The Managed Care Reform and Patient Rights | ||||||
12 | Act is amended by changing Sections 10 and 65 as follows:
| ||||||
13 | (215 ILCS 134/10)
| ||||||
14 | Sec. 10. Definitions.
| ||||||
15 | "Adverse determination" means a determination by a health | ||||||
16 | care plan under
Section 45 or by a utilization review program | ||||||
17 | under Section
85 that
a health care service is not medically | ||||||
18 | necessary.
| ||||||
19 | "Clinical peer" means a health care professional who is in | ||||||
20 | the same
profession and the same or similar specialty as the | ||||||
21 | health care provider who
typically manages the medical | ||||||
22 | condition, procedures, or treatment under
review.
| ||||||
23 | "Department" means the Department of Insurance.
| ||||||
24 | "Emergency medical condition" means a medical condition |
| |||||||
| |||||||
1 | manifesting itself by
acute symptoms of sufficient severity, | ||||||
2 | regardless of the final diagnosis given, such that a prudent
| ||||||
3 | layperson, who possesses an average knowledge of health and | ||||||
4 | medicine, could
reasonably expect the absence of immediate | ||||||
5 | medical attention to result in:
| ||||||
6 | (1) placing the health of the individual (or, with | ||||||
7 | respect to a pregnant
woman, the
health of the woman or her | ||||||
8 | unborn child) in serious jeopardy;
| ||||||
9 | (2) serious
impairment to bodily functions;
| ||||||
10 | (3) serious dysfunction of any bodily organ
or part;
| ||||||
11 | (4) inadequately controlled pain; or | ||||||
12 | (5) with respect to a pregnant woman who is having | ||||||
13 | contractions: | ||||||
14 | (A) inadequate time to complete a safe transfer to | ||||||
15 | another hospital before delivery; or | ||||||
16 | (B) a transfer to another hospital may pose a | ||||||
17 | threat to the health or safety of the woman or unborn | ||||||
18 | child. | ||||||
19 | "Emergency medical screening examination" means a medical | ||||||
20 | screening
examination and
evaluation by a physician licensed | ||||||
21 | to practice medicine in all its branches, or
to the extent | ||||||
22 | permitted
by applicable laws, by other appropriately licensed | ||||||
23 | personnel under the
supervision of or in
collaboration with a | ||||||
24 | physician licensed to practice medicine in all its
branches to | ||||||
25 | determine whether
the need for emergency services exists.
| ||||||
26 | "Emergency services" means, with respect to an enrollee of |
| |||||||
| |||||||
1 | a health care
plan,
transportation services, including but not | ||||||
2 | limited to ambulance services, and
covered inpatient and | ||||||
3 | outpatient hospital services
furnished by a provider
qualified | ||||||
4 | to furnish those services that are needed to evaluate or | ||||||
5 | stabilize an
emergency medical condition. "Emergency services" | ||||||
6 | does not
refer to post-stabilization medical services.
| ||||||
7 | "Enrollee" means any person and his or her dependents | ||||||
8 | enrolled in or covered
by a health care plan.
| ||||||
9 | "Health care plan" means a plan, including, but not | ||||||
10 | limited to, a health maintenance organization, a managed care | ||||||
11 | community network as defined in the Illinois Public Aid Code, | ||||||
12 | or an accountable care entity as defined in the Illinois | ||||||
13 | Public Aid Code that receives capitated payments to cover | ||||||
14 | medical services from the Department of Healthcare and Family | ||||||
15 | Services, that establishes, operates, or maintains a
network | ||||||
16 | of health care providers that has entered into an agreement | ||||||
17 | with the
plan to provide health care services to enrollees to | ||||||
18 | whom the plan has the
ultimate obligation to arrange for the | ||||||
19 | provision of or payment for services
through organizational | ||||||
20 | arrangements for ongoing quality assurance,
utilization review | ||||||
21 | programs, or dispute resolution.
Nothing in this definition | ||||||
22 | shall be construed to mean that an independent
practice | ||||||
23 | association or a physician hospital organization that | ||||||
24 | subcontracts
with
a health care plan is, for purposes of that | ||||||
25 | subcontract, a health care plan.
| ||||||
26 | For purposes of this definition, "health care plan" shall |
| |||||||
| |||||||
1 | not include the
following:
| ||||||
2 | (1) indemnity health insurance policies including | ||||||
3 | those using a contracted
provider network;
| ||||||
4 | (2) health care plans that offer only dental or only | ||||||
5 | vision coverage;
| ||||||
6 | (3) preferred provider administrators, as defined in | ||||||
7 | Section 370g(g) of
the
Illinois Insurance Code;
| ||||||
8 | (4) employee or employer self-insured health benefit | ||||||
9 | plans under the
federal Employee Retirement Income | ||||||
10 | Security Act of 1974;
| ||||||
11 | (5) health care provided pursuant to the Workers' | ||||||
12 | Compensation Act or the
Workers' Occupational Diseases | ||||||
13 | Act; and
| ||||||
14 | (6) not-for-profit voluntary health services plans | ||||||
15 | with health maintenance
organization
authority in | ||||||
16 | existence as of January 1, 1999 that are affiliated with a | ||||||
17 | union
and that
only extend coverage to union members and | ||||||
18 | their dependents.
| ||||||
19 | "Health care professional" means a physician, a registered | ||||||
20 | professional
nurse,
or other individual appropriately licensed | ||||||
21 | or registered
to provide health care services.
| ||||||
22 | "Health care provider" means any physician, hospital | ||||||
23 | facility, facility licensed under the Nursing Home Care Act, | ||||||
24 | long-term care facility as defined in Section 1-113 of the | ||||||
25 | Nursing Home Care Act, or other
person that is licensed or | ||||||
26 | otherwise authorized to deliver health care
services. Nothing |
| |||||||
| |||||||
1 | in this
Act shall be construed to define Independent Practice | ||||||
2 | Associations or
Physician-Hospital Organizations as health | ||||||
3 | care providers.
| ||||||
4 | "Health care services" means any services included in the | ||||||
5 | furnishing to any
individual of medical care, or the
| ||||||
6 | hospitalization incident to the furnishing of such care, as | ||||||
7 | well as the
furnishing to any person of
any and all other | ||||||
8 | services for the purpose of preventing,
alleviating, curing, | ||||||
9 | or healing human illness or injury including behavioral | ||||||
10 | health, mental health, home health ,
and pharmaceutical | ||||||
11 | services and products.
| ||||||
12 | "Medical director" means a physician licensed in any state | ||||||
13 | to practice
medicine in all its
branches appointed by a health | ||||||
14 | care plan.
| ||||||
15 | "Person" means a corporation, association, partnership,
| ||||||
16 | limited liability company, sole proprietorship, or any other | ||||||
17 | legal entity.
| ||||||
18 | "Physician" means a person licensed under the Medical
| ||||||
19 | Practice Act of 1987.
| ||||||
20 | "Post-stabilization medical services" means health care | ||||||
21 | services
provided to an enrollee that are furnished in a | ||||||
22 | licensed hospital by a provider
that is qualified to furnish | ||||||
23 | such services, and determined to be medically
necessary and | ||||||
24 | directly related to the emergency medical condition following
| ||||||
25 | stabilization.
| ||||||
26 | "Stabilization" means, with respect to an emergency |
| |||||||
| |||||||
1 | medical condition, to
provide such medical treatment of the | ||||||
2 | condition as may be necessary to assure,
within reasonable | ||||||
3 | medical probability, that no material deterioration
of the | ||||||
4 | condition is likely to result.
| ||||||
5 | "Utilization review" means the evaluation of the medical | ||||||
6 | necessity,
appropriateness, and efficiency of the use of | ||||||
7 | health care services, procedures,
and facilities.
| ||||||
8 | "Utilization review program" means a program established | ||||||
9 | by a person to
perform utilization review.
| ||||||
10 | (Source: P.A. 101-452, eff. 1-1-20 .)
| ||||||
11 | (215 ILCS 134/65)
| ||||||
12 | Sec. 65. Emergency services prior to stabilization.
| ||||||
13 | (a) A health care plan
that provides or that is required by | ||||||
14 | law to provide coverage for emergency
services shall provide | ||||||
15 | coverage such that payment under this coverage is not
| ||||||
16 | dependent upon whether the services are performed by a plan or | ||||||
17 | non-plan health
care provider and without regard to prior | ||||||
18 | authorization. This coverage shall be
at the same benefit | ||||||
19 | level as if the services or treatment had been rendered by
the | ||||||
20 | health care plan physician licensed to practice medicine in | ||||||
21 | all
its branches or health care provider.
| ||||||
22 | (b) Prior authorization or approval by the plan shall not | ||||||
23 | be required for
emergency services.
| ||||||
24 | (c) Coverage and payment shall only be retrospectively | ||||||
25 | denied under the
following circumstances:
|
| |||||||
| |||||||
1 | (1) upon reasonable determination that the emergency | ||||||
2 | services claimed were
never performed;
| ||||||
3 | (2) upon timely determination that the emergency | ||||||
4 | evaluation and treatment
were
rendered to an enrollee who | ||||||
5 | sought emergency services and whose circumstance
did not | ||||||
6 | meet the definition of emergency medical condition;
| ||||||
7 | (3) upon determination that the patient receiving such | ||||||
8 | services was not an
enrollee of the health care plan; or
| ||||||
9 | (4) upon material misrepresentation by the enrollee or | ||||||
10 | health care
provider; "material" means a fact or situation | ||||||
11 | that is not merely technical in
nature and results or | ||||||
12 | could result in a substantial change in the situation.
| ||||||
13 | (d) When an enrollee presents to a hospital seeking | ||||||
14 | emergency services,
the determination as to whether the need | ||||||
15 | for those
services exists shall be made for purposes of | ||||||
16 | treatment by a
physician licensed to practice medicine in all | ||||||
17 | its branches or, to the extent
permitted by applicable law, by | ||||||
18 | other appropriately licensed
personnel under the supervision | ||||||
19 | of
or in collaboration with a physician licensed to practice | ||||||
20 | medicine in all its
branches.
The physician or other
| ||||||
21 | appropriate personnel shall indicate in the patient's chart | ||||||
22 | the results of the
emergency medical screening examination.
| ||||||
23 | (e) The appropriate use of the 911 emergency telephone | ||||||
24 | system or its local
equivalent shall not be discouraged or | ||||||
25 | penalized by the health care plan when
an emergency medical | ||||||
26 | condition exists.
This provision shall not imply that the use |
| |||||||
| |||||||
1 | of 911 or its local equivalent is a
factor in determining the | ||||||
2 | existence of an emergency medical condition.
| ||||||
3 | (f) The medical director's or his or her designee's
| ||||||
4 | determination of whether the enrollee meets the standard of an | ||||||
5 | emergency
medical condition shall be based solely upon the | ||||||
6 | presenting symptoms documented
in the medical record at the | ||||||
7 | time care was
sought.
Only a clinical peer may make an adverse | ||||||
8 | determination.
| ||||||
9 | (g) Nothing in this Section shall prohibit the imposition | ||||||
10 | of deductibles,
copayments, and co-insurance.
Nothing in this | ||||||
11 | Section alters the prohibition on billing enrollees contained
| ||||||
12 | in the Health Maintenance Organization Act.
| ||||||
13 | (h) This Section shall apply to the types of companies | ||||||
14 | subject to Section 155.36 of the Illinois Insurance Code. | ||||||
15 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
16 | Section 910. The Illinois Public Aid Code is amended by | ||||||
17 | adding Section 5-5.12d as follows:
| ||||||
18 | (305 ILCS 5/5-5.12d new) | ||||||
19 | Sec. 5-5.12d. Managed care organization prior | ||||||
20 | authorization of health care services. | ||||||
21 | (a) As used in this Section, "health care service" has the | ||||||
22 | meaning given to that term in the Prior Authorization Reform | ||||||
23 | Act. | ||||||
24 | (b) Notwithstanding any other provision of law to the |
| |||||||
| |||||||
1 | contrary, all managed care organizations shall comply with the | ||||||
2 | requirements of the Prior Authorization Reform Act.
| ||||||
3 | Section 999. Effective date. This Act takes effect January | ||||||
4 | 1, 2022.".
|