Bill Amendment: IL HB2472 | 2023-2024 | 103rd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: INS-ADVERSE DETERMINATION
Status: 2024-07-19 - Public Act . . . . . . . . . 103-0656 [HB2472 Detail]
Download: Illinois-2023-HB2472-House_Amendment_002.html
Bill Title: INS-ADVERSE DETERMINATION
Status: 2024-07-19 - Public Act . . . . . . . . . 103-0656 [HB2472 Detail]
Download: Illinois-2023-HB2472-House_Amendment_002.html
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1 | AMENDMENT TO HOUSE BILL 2472 | ||||||
2 | AMENDMENT NO. ______. Amend House Bill 2472, AS AMENDED, | ||||||
3 | by replacing everything after the enacting clause with the | ||||||
4 | following:
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5 | "Section 5. The Illinois Insurance Code is amended by | ||||||
6 | changing Sections 143.31, 155.36, 315.6, and 370s as follows:
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7 | (215 ILCS 5/143.31) | ||||||
8 | Sec. 143.31. Uniform medical claim and billing forms. | ||||||
9 | (a) The Director shall prescribe by rule, after | ||||||
10 | consultation with providers of health care or treatment, | ||||||
11 | insurers, hospital, medical, and dental service corporations, | ||||||
12 | and other prepayment organizations, insurance claim and | ||||||
13 | billing forms that the Director determines will provide for | ||||||
14 | uniformity and simplicity in insurance claims handling. The | ||||||
15 | claim forms shall include, but need not be limited to, | ||||||
16 | information regarding the medical diagnosis, treatment, and |
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1 | prognosis of the patient, together with the details of charges | ||||||
2 | incident to the providing of care, treatment, or services, | ||||||
3 | sufficient for the purpose of meeting the proof requirements | ||||||
4 | of an insurance policy or a hospital, medical, or dental | ||||||
5 | service contract. | ||||||
6 | (b) An insurer or a provider of health care treatment may | ||||||
7 | not refuse to accept a claim or bill submitted on duly | ||||||
8 | promulgated uniform claim and billing forms. An insurer, | ||||||
9 | however, may accept claims and bills submitted on any other | ||||||
10 | form. | ||||||
11 | (c) After receipt and adjudication or readjudication of | ||||||
12 | any claim or bill with all required documentation from an | ||||||
13 | insured or provider, or a notification under 42 U.S.C. | ||||||
14 | 300gg-136, an accident Accident and health insurer shall send | ||||||
15 | explanation of benefits paid statements or claims summary | ||||||
16 | statements sent to an insured by the accident and health | ||||||
17 | insurer shall be in a format and written in a manner that | ||||||
18 | promotes understanding by the insured by setting forth all of | ||||||
19 | the following: | ||||||
20 | (1) The total dollar amount submitted to the insurer | ||||||
21 | for payment. | ||||||
22 | (2) Any reduction in the amount paid due to the | ||||||
23 | application of any co-payment , coinsurance, or deductible, | ||||||
24 | along with an explanation of the amount of the co-payment , | ||||||
25 | coinsurance, or deductible applied under the insured's | ||||||
26 | policy. |
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1 | (3) Any reduction in the amount paid due to the | ||||||
2 | application of any other policy limitation , penalty, or | ||||||
3 | exclusion set forth in the insured's policy, along with an | ||||||
4 | explanation thereof. | ||||||
5 | (4) The total dollar amount paid. | ||||||
6 | (5) The total dollar amount remaining unpaid. | ||||||
7 | (6) If applicable under 42 U.S.C. 300gg-111 or 42 | ||||||
8 | U.S.C. 300gg-115, other information required for any | ||||||
9 | explanation of benefits described in either of those | ||||||
10 | Sections. | ||||||
11 | (d) The Director may issue an order directing an accident | ||||||
12 | and health insurer to comply with subsection (c). | ||||||
13 | (e) An accident and health insurer does not violate | ||||||
14 | subsection (c) by using a document that the accident and | ||||||
15 | health insurer is required to use by the federal government or | ||||||
16 | the State. | ||||||
17 | (f) The adoption of uniform claim forms and uniform | ||||||
18 | billing forms by the Director under this Section does not | ||||||
19 | preclude an insurer, hospital, medical, or dental service | ||||||
20 | corporation, or other prepayment organization from obtaining | ||||||
21 | any necessary additional information regarding a claim from | ||||||
22 | the claimant, provider of health care or treatment, or | ||||||
23 | certifier of coverage, as may be required. | ||||||
24 | (g) On and after January 1, 1996 when billing insurers or | ||||||
25 | otherwise filing insurance claims with insurers subject to | ||||||
26 | this Section, providers of health care or treatment, medical |
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1 | services, dental services, pharmaceutical services, or medical | ||||||
2 | equipment must use the uniform claim and billing forms adopted | ||||||
3 | by the Director under this Section. | ||||||
4 | (Source: P.A. 91-357, eff. 7-29-99.)
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5 | (215 ILCS 5/155.36) | ||||||
6 | Sec. 155.36. Managed Care Reform and Patient Rights Act. | ||||||
7 | Insurance companies that transact the kinds of insurance | ||||||
8 | authorized under Class 1(b) or Class 2(a) of Section 4 of this | ||||||
9 | Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65, | ||||||
10 | 70, and 85, subsection (d) of Section 30, and the definition of | ||||||
11 | the term "emergency medical condition" in Section 10 of the | ||||||
12 | Managed Care Reform and Patient Rights Act. Except as provided | ||||||
13 | by Section 85 of the Managed Care Reform and Patient Rights | ||||||
14 | Act, no law or rule shall be construed to exempt any | ||||||
15 | utilization review program from the requirements of Section 85 | ||||||
16 | of the Managed Care Reform and Patient Rights Act with respect | ||||||
17 | to any insurance described in this Section. | ||||||
18 | (Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
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19 | (215 ILCS 5/315.6) (from Ch. 73, par. 927.6) | ||||||
20 | (Section scheduled to be repealed on January 1, 2027) | ||||||
21 | Sec. 315.6. Application of other Code provisions. Unless | ||||||
22 | otherwise provided in this amendatory Act, every fraternal | ||||||
23 | benefit society shall be governed by this amendatory Act and | ||||||
24 | shall be exempt from all other provisions of the insurance |
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1 | laws of this State not only in governmental relations with the | ||||||
2 | State but for every other purpose, except for those provisions | ||||||
3 | specified in this amendatory Act and except as follows: | ||||||
4 | (a) Sections 1, 2, 2.1, 3.1, 117, 118, 132, 132.1, | ||||||
5 | 132.2, 132.3, 132.4, 132.5, 132.6, 132.7, 133, 134, 136, | ||||||
6 | 138, 139, 140, 141, 141.01, 141.1, 141.2, 141.3, 143, | ||||||
7 | 143.31, 143c, 144.1, 147, 148, 149, 150, 151, 152, 153, | ||||||
8 | 154.5, 154.6, 154.7, 154.8, 155, 155.04, 155.05, 155.06, | ||||||
9 | 155.07, 155.08 and 408 of this Code; and | ||||||
10 | (b) Articles VIII 1/2, XII, XII 1/2, XIII, XXIV, and | ||||||
11 | XXVIII of this Code. | ||||||
12 | (Source: P.A. 98-814, eff. 1-1-15 .)
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13 | (215 ILCS 5/370s) | ||||||
14 | Sec. 370s. Managed Care Reform and Patient Rights Act. All | ||||||
15 | administrators shall comply with Sections 55 and 85 of the | ||||||
16 | Managed Care Reform and Patient Rights Act. Except as provided | ||||||
17 | by Section 85 of the Managed Care Reform and Patient Rights | ||||||
18 | Act, no law or rule shall be construed to exempt any | ||||||
19 | utilization review program from the requirements of Section 85 | ||||||
20 | of the Managed Care Reform and Patient Rights Act with respect | ||||||
21 | to any insured or beneficiary described in this Article. | ||||||
22 | (Source: P.A. 91-617, eff. 1-1-00.)
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23 | Section 10. The Dental Service Plan Act is amended by | ||||||
24 | changing Section 25 as follows:
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1 | (215 ILCS 110/25) (from Ch. 32, par. 690.25) | ||||||
2 | Sec. 25. Application of Insurance Code provisions. Dental | ||||||
3 | service plan corporations and all persons interested therein | ||||||
4 | or dealing therewith shall be subject to the provisions of | ||||||
5 | Articles IIA, XI, and XII 1/2 and Sections 3.1, 133, 136, 139, | ||||||
6 | 140, 143, 143.31, 143c, 149, 155.49, 355.2, 355.3, 367.2, 401, | ||||||
7 | 401.1, 402, 403, 403A, 408, 408.2, and 412, and subsection | ||||||
8 | (15) of Section 367 of the Illinois Insurance Code. | ||||||
9 | (Source: P.A. 103-426, eff. 8-4-23.)
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10 | Section 15. The Network Adequacy and Transparency Act is | ||||||
11 | amended by changing Section 10 as follows:
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12 | (215 ILCS 124/10) | ||||||
13 | Sec. 10. Network adequacy. | ||||||
14 | (a) An insurer providing a network plan shall file a | ||||||
15 | description of all of the following with the Director: | ||||||
16 | (1) The written policies and procedures for adding | ||||||
17 | providers to meet patient needs based on increases in the | ||||||
18 | number of beneficiaries, changes in the | ||||||
19 | patient-to-provider ratio, changes in medical and health | ||||||
20 | care capabilities, and increased demand for services. | ||||||
21 | (2) The written policies and procedures for making | ||||||
22 | referrals within and outside the network. | ||||||
23 | (3) The written policies and procedures on how the |
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1 | network plan will provide 24-hour, 7-day per week access | ||||||
2 | to network-affiliated primary care, emergency services, | ||||||
3 | and women's principal health care providers. | ||||||
4 | An insurer shall not prohibit a preferred provider from | ||||||
5 | discussing any specific or all treatment options with | ||||||
6 | beneficiaries irrespective of the insurer's position on those | ||||||
7 | treatment options or from advocating on behalf of | ||||||
8 | beneficiaries within the utilization review, grievance, or | ||||||
9 | appeals processes established by the insurer in accordance | ||||||
10 | with any rights or remedies available under applicable State | ||||||
11 | or federal law. | ||||||
12 | (b) Insurers must file for review a description of the | ||||||
13 | services to be offered through a network plan. The description | ||||||
14 | shall include all of the following: | ||||||
15 | (1) A geographic map of the area proposed to be served | ||||||
16 | by the plan by county service area and zip code, including | ||||||
17 | marked locations for preferred providers. | ||||||
18 | (2) As deemed necessary by the Department, the names, | ||||||
19 | addresses, phone numbers, and specialties of the providers | ||||||
20 | who have entered into preferred provider agreements under | ||||||
21 | the network plan. | ||||||
22 | (3) The number of beneficiaries anticipated to be | ||||||
23 | covered by the network plan. | ||||||
24 | (4) An Internet website and toll-free telephone number | ||||||
25 | for beneficiaries and prospective beneficiaries to access | ||||||
26 | current and accurate lists of preferred providers, |
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1 | additional information about the plan, as well as any | ||||||
2 | other information required by Department rule. | ||||||
3 | (5) A description of how health care services to be | ||||||
4 | rendered under the network plan are reasonably accessible | ||||||
5 | and available to beneficiaries. The description shall | ||||||
6 | address all of the following: | ||||||
7 | (A) the type of health care services to be | ||||||
8 | provided by the network plan; | ||||||
9 | (B) the ratio of physicians and other providers to | ||||||
10 | beneficiaries, by specialty and including primary care | ||||||
11 | physicians and facility-based physicians when | ||||||
12 | applicable under the contract, necessary to meet the | ||||||
13 | health care needs and service demands of the currently | ||||||
14 | enrolled population; | ||||||
15 | (C) the travel and distance standards for plan | ||||||
16 | beneficiaries in county service areas; and | ||||||
17 | (D) a description of how the use of telemedicine, | ||||||
18 | telehealth, or mobile care services may be used to | ||||||
19 | partially meet the network adequacy standards, if | ||||||
20 | applicable. | ||||||
21 | (6) A provision ensuring that whenever a beneficiary | ||||||
22 | has made a good faith effort, as evidenced by accessing | ||||||
23 | the provider directory, calling the network plan, and | ||||||
24 | calling the provider, to utilize preferred providers for a | ||||||
25 | covered service and it is determined the insurer does not | ||||||
26 | have the appropriate preferred providers due to |
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1 | insufficient number, type, unreasonable travel distance or | ||||||
2 | delay, or preferred providers refusing to provide a | ||||||
3 | covered service because it is contrary to the conscience | ||||||
4 | of the preferred providers, as protected by the Health | ||||||
5 | Care Right of Conscience Act, the insurer shall ensure, | ||||||
6 | directly or indirectly, by terms contained in the payer | ||||||
7 | contract, that the beneficiary will be provided the | ||||||
8 | covered service at no greater cost to the beneficiary than | ||||||
9 | if the service had been provided by a preferred provider. | ||||||
10 | This paragraph (6) does not apply to: (A) a beneficiary | ||||||
11 | who willfully chooses to access a non-preferred provider | ||||||
12 | for health care services available through the panel of | ||||||
13 | preferred providers, or (B) a beneficiary enrolled in a | ||||||
14 | health maintenance organization. In these circumstances, | ||||||
15 | the contractual requirements for non-preferred provider | ||||||
16 | reimbursements shall apply unless Section 356z.3a of the | ||||||
17 | Illinois Insurance Code requires otherwise. In no event | ||||||
18 | shall a beneficiary who receives care at a participating | ||||||
19 | health care facility be required to search for | ||||||
20 | participating providers under the circumstances described | ||||||
21 | in subsection (b) or (b-5) of Section 356z.3a of the | ||||||
22 | Illinois Insurance Code except under the circumstances | ||||||
23 | described in paragraph (2) of subsection (b-5). | ||||||
24 | (7) A provision that the beneficiary shall receive | ||||||
25 | emergency care coverage such that payment for this | ||||||
26 | coverage is not dependent upon whether the emergency |
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1 | services are performed by a preferred or non-preferred | ||||||
2 | provider and the coverage shall be at the same benefit | ||||||
3 | level as if the service or treatment had been rendered by a | ||||||
4 | preferred provider. For purposes of this paragraph (7), | ||||||
5 | "the same benefit level" means that the beneficiary is | ||||||
6 | provided the covered service at no greater cost to the | ||||||
7 | beneficiary than if the service had been provided by a | ||||||
8 | preferred provider. This provision shall be consistent | ||||||
9 | with Section 356z.3a of the Illinois Insurance Code. | ||||||
10 | (8) A limitation that complies with subsections (d) | ||||||
11 | and (e) of Section 55 of the Prior Authorization Reform | ||||||
12 | Act , if the plan provides that the beneficiary will incur | ||||||
13 | a penalty for failing to pre-certify inpatient hospital | ||||||
14 | treatment, the penalty may not exceed $1,000 per | ||||||
15 | occurrence in addition to the plan cost sharing | ||||||
16 | provisions . | ||||||
17 | (c) The network plan shall demonstrate to the Director a | ||||||
18 | minimum ratio of providers to plan beneficiaries as required | ||||||
19 | by the Department. | ||||||
20 | (1) The ratio of physicians or other providers to plan | ||||||
21 | beneficiaries shall be established annually by the | ||||||
22 | Department in consultation with the Department of Public | ||||||
23 | Health based upon the guidance from the federal Centers | ||||||
24 | for Medicare and Medicaid Services. The Department shall | ||||||
25 | not establish ratios for vision or dental providers who | ||||||
26 | provide services under dental-specific or vision-specific |
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1 | benefits. The Department shall consider establishing | ||||||
2 | ratios for the following physicians or other providers: | ||||||
3 | (A) Primary Care; | ||||||
4 | (B) Pediatrics; | ||||||
5 | (C) Cardiology; | ||||||
6 | (D) Gastroenterology; | ||||||
7 | (E) General Surgery; | ||||||
8 | (F) Neurology; | ||||||
9 | (G) OB/GYN; | ||||||
10 | (H) Oncology/Radiation; | ||||||
11 | (I) Ophthalmology; | ||||||
12 | (J) Urology; | ||||||
13 | (K) Behavioral Health; | ||||||
14 | (L) Allergy/Immunology; | ||||||
15 | (M) Chiropractic; | ||||||
16 | (N) Dermatology; | ||||||
17 | (O) Endocrinology; | ||||||
18 | (P) Ears, Nose, and Throat (ENT)/Otolaryngology; | ||||||
19 | (Q) Infectious Disease; | ||||||
20 | (R) Nephrology; | ||||||
21 | (S) Neurosurgery; | ||||||
22 | (T) Orthopedic Surgery; | ||||||
23 | (U) Physiatry/Rehabilitative; | ||||||
24 | (V) Plastic Surgery; | ||||||
25 | (W) Pulmonary; | ||||||
26 | (X) Rheumatology; |
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1 | (Y) Anesthesiology; | ||||||
2 | (Z) Pain Medicine; | ||||||
3 | (AA) Pediatric Specialty Services; | ||||||
4 | (BB) Outpatient Dialysis; and | ||||||
5 | (CC) HIV. | ||||||
6 | (2) The Director shall establish a process for the | ||||||
7 | review of the adequacy of these standards, along with an | ||||||
8 | assessment of additional specialties to be included in the | ||||||
9 | list under this subsection (c). | ||||||
10 | (d) The network plan shall demonstrate to the Director | ||||||
11 | maximum travel and distance standards for plan beneficiaries, | ||||||
12 | which shall be established annually by the Department in | ||||||
13 | consultation with the Department of Public Health based upon | ||||||
14 | the guidance from the federal Centers for Medicare and | ||||||
15 | Medicaid Services. These standards shall consist of the | ||||||
16 | maximum minutes or miles to be traveled by a plan beneficiary | ||||||
17 | for each county type, such as large counties, metro counties, | ||||||
18 | or rural counties as defined by Department rule. | ||||||
19 | The maximum travel time and distance standards must | ||||||
20 | include standards for each physician and other provider | ||||||
21 | category listed for which ratios have been established. | ||||||
22 | The Director shall establish a process for the review of | ||||||
23 | the adequacy of these standards along with an assessment of | ||||||
24 | additional specialties to be included in the list under this | ||||||
25 | subsection (d). | ||||||
26 | (d-5)(1) Every insurer shall ensure that beneficiaries |
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1 | have timely and proximate access to treatment for mental, | ||||||
2 | emotional, nervous, or substance use disorders or conditions | ||||||
3 | in accordance with the provisions of paragraph (4) of | ||||||
4 | subsection (a) of Section 370c of the Illinois Insurance Code. | ||||||
5 | Insurers shall use a comparable process, strategy, evidentiary | ||||||
6 | standard, and other factors in the development and application | ||||||
7 | of the network adequacy standards for timely and proximate | ||||||
8 | access to treatment for mental, emotional, nervous, or | ||||||
9 | substance use disorders or conditions and those for the access | ||||||
10 | to treatment for medical and surgical conditions. As such, the | ||||||
11 | network adequacy standards for timely and proximate access | ||||||
12 | shall equally be applied to treatment facilities and providers | ||||||
13 | for mental, emotional, nervous, or substance use disorders or | ||||||
14 | conditions and specialists providing medical or surgical | ||||||
15 | benefits pursuant to the parity requirements of Section 370c.1 | ||||||
16 | of the Illinois Insurance Code and the federal Paul Wellstone | ||||||
17 | and Pete Domenici Mental Health Parity and Addiction Equity | ||||||
18 | Act of 2008. Notwithstanding the foregoing, the network | ||||||
19 | adequacy standards for timely and proximate access to | ||||||
20 | treatment for mental, emotional, nervous, or substance use | ||||||
21 | disorders or conditions shall, at a minimum, satisfy the | ||||||
22 | following requirements: | ||||||
23 | (A) For beneficiaries residing in the metropolitan | ||||||
24 | counties of Cook, DuPage, Kane, Lake, McHenry, and Will, | ||||||
25 | network adequacy standards for timely and proximate access | ||||||
26 | to treatment for mental, emotional, nervous, or substance |
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1 | use disorders or conditions means a beneficiary shall not | ||||||
2 | have to travel longer than 30 minutes or 30 miles from the | ||||||
3 | beneficiary's residence to receive outpatient treatment | ||||||
4 | for mental, emotional, nervous, or substance use disorders | ||||||
5 | or conditions. Beneficiaries shall not be required to wait | ||||||
6 | longer than 10 business days between requesting an initial | ||||||
7 | appointment and being seen by the facility or provider of | ||||||
8 | mental, emotional, nervous, or substance use disorders or | ||||||
9 | conditions for outpatient treatment or to wait longer than | ||||||
10 | 20 business days between requesting a repeat or follow-up | ||||||
11 | appointment and being seen by the facility or provider of | ||||||
12 | mental, emotional, nervous, or substance use disorders or | ||||||
13 | conditions for outpatient treatment; however, subject to | ||||||
14 | the protections of paragraph (3) of this subsection, a | ||||||
15 | network plan shall not be held responsible if the | ||||||
16 | beneficiary or provider voluntarily chooses to schedule an | ||||||
17 | appointment outside of these required time frames. | ||||||
18 | (B) For beneficiaries residing in Illinois counties | ||||||
19 | other than those counties listed in subparagraph (A) of | ||||||
20 | this paragraph, network adequacy standards for timely and | ||||||
21 | proximate access to treatment for mental, emotional, | ||||||
22 | nervous, or substance use disorders or conditions means a | ||||||
23 | beneficiary shall not have to travel longer than 60 | ||||||
24 | minutes or 60 miles from the beneficiary's residence to | ||||||
25 | receive outpatient treatment for mental, emotional, | ||||||
26 | nervous, or substance use disorders or conditions. |
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1 | Beneficiaries shall not be required to wait longer than 10 | ||||||
2 | business days between requesting an initial appointment | ||||||
3 | and being seen by the facility or provider of mental, | ||||||
4 | emotional, nervous, or substance use disorders or | ||||||
5 | conditions for outpatient treatment or to wait longer than | ||||||
6 | 20 business days between requesting a repeat or follow-up | ||||||
7 | appointment and being seen by the facility or provider of | ||||||
8 | mental, emotional, nervous, or substance use disorders or | ||||||
9 | conditions for outpatient treatment; however, subject to | ||||||
10 | the protections of paragraph (3) of this subsection, a | ||||||
11 | network plan shall not be held responsible if the | ||||||
12 | beneficiary or provider voluntarily chooses to schedule an | ||||||
13 | appointment outside of these required time frames. | ||||||
14 | (2) For beneficiaries residing in all Illinois counties, | ||||||
15 | network adequacy standards for timely and proximate access to | ||||||
16 | treatment for mental, emotional, nervous, or substance use | ||||||
17 | disorders or conditions means a beneficiary shall not have to | ||||||
18 | travel longer than 60 minutes or 60 miles from the | ||||||
19 | beneficiary's residence to receive inpatient or residential | ||||||
20 | treatment for mental, emotional, nervous, or substance use | ||||||
21 | disorders or conditions. | ||||||
22 | (3) If there is no in-network facility or provider | ||||||
23 | available for a beneficiary to receive timely and proximate | ||||||
24 | access to treatment for mental, emotional, nervous, or | ||||||
25 | substance use disorders or conditions in accordance with the | ||||||
26 | network adequacy standards outlined in this subsection, the |
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1 | insurer shall provide necessary exceptions to its network to | ||||||
2 | ensure admission and treatment with a provider or at a | ||||||
3 | treatment facility in accordance with the network adequacy | ||||||
4 | standards in this subsection. | ||||||
5 | (e) Except for network plans solely offered as a group | ||||||
6 | health plan, these ratio and time and distance standards apply | ||||||
7 | to the lowest cost-sharing tier of any tiered network. | ||||||
8 | (f) The network plan may consider use of other health care | ||||||
9 | service delivery options, such as telemedicine or telehealth, | ||||||
10 | mobile clinics, and centers of excellence, or other ways of | ||||||
11 | delivering care to partially meet the requirements set under | ||||||
12 | this Section. | ||||||
13 | (g) Except for the requirements set forth in subsection | ||||||
14 | (d-5), insurers who are not able to comply with the provider | ||||||
15 | ratios and time and distance standards established by the | ||||||
16 | Department may request an exception to these requirements from | ||||||
17 | the Department. The Department may grant an exception in the | ||||||
18 | following circumstances: | ||||||
19 | (1) if no providers or facilities meet the specific | ||||||
20 | time and distance standard in a specific service area and | ||||||
21 | the insurer (i) discloses information on the distance and | ||||||
22 | travel time points that beneficiaries would have to travel | ||||||
23 | beyond the required criterion to reach the next closest | ||||||
24 | contracted provider outside of the service area and (ii) | ||||||
25 | provides contact information, including names, addresses, | ||||||
26 | and phone numbers for the next closest contracted provider |
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1 | or facility; | ||||||
2 | (2) if patterns of care in the service area do not | ||||||
3 | support the need for the requested number of provider or | ||||||
4 | facility type and the insurer provides data on local | ||||||
5 | patterns of care, such as claims data, referral patterns, | ||||||
6 | or local provider interviews, indicating where the | ||||||
7 | beneficiaries currently seek this type of care or where | ||||||
8 | the physicians currently refer beneficiaries, or both; or | ||||||
9 | (3) other circumstances deemed appropriate by the | ||||||
10 | Department consistent with the requirements of this Act. | ||||||
11 | (h) Insurers are required to report to the Director any | ||||||
12 | material change to an approved network plan within 15 days | ||||||
13 | after the change occurs and any change that would result in | ||||||
14 | failure to meet the requirements of this Act. Upon notice from | ||||||
15 | the insurer, the Director shall reevaluate the network plan's | ||||||
16 | compliance with the network adequacy and transparency | ||||||
17 | standards of this Act. | ||||||
18 | (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; | ||||||
19 | 102-1117, eff. 1-13-23.)
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20 | Section 20. The Health Maintenance Organization Act is | ||||||
21 | amended by changing Section 5-3 as follows:
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22 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | ||||||
23 | Sec. 5-3. Insurance Code provisions. | ||||||
24 | (a) Health Maintenance Organizations shall be subject to |
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1 | the provisions of Sections 133, 134, 136, 137, 139, 140, | ||||||
2 | 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, | ||||||
3 | 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, | ||||||
4 | 155.49, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, | ||||||
5 | 356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | ||||||
6 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||
7 | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | ||||||
8 | 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, | ||||||
9 | 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | ||||||
10 | 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, | ||||||
11 | 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | ||||||
12 | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | ||||||
13 | 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | ||||||
14 | 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
15 | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||||||
16 | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | ||||||
17 | subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||||||
18 | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||||||
19 | Illinois Insurance Code. | ||||||
20 | (b) For purposes of the Illinois Insurance Code, except | ||||||
21 | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||||||
22 | Health Maintenance Organizations in the following categories | ||||||
23 | are deemed to be "domestic companies": | ||||||
24 | (1) a corporation authorized under the Dental Service | ||||||
25 | Plan Act or the Voluntary Health Services Plans Act; | ||||||
26 | (2) a corporation organized under the laws of this |
| |||||||
| |||||||
1 | State; or | ||||||
2 | (3) a corporation organized under the laws of another | ||||||
3 | state, 30% or more of the enrollees of which are residents | ||||||
4 | of this State, except a corporation subject to | ||||||
5 | substantially the same requirements in its state of | ||||||
6 | organization as is a "domestic company" under Article VIII | ||||||
7 | 1/2 of the Illinois Insurance Code. | ||||||
8 | (c) In considering the merger, consolidation, or other | ||||||
9 | acquisition of control of a Health Maintenance Organization | ||||||
10 | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||||||
11 | (1) the Director shall give primary consideration to | ||||||
12 | the continuation of benefits to enrollees and the | ||||||
13 | financial conditions of the acquired Health Maintenance | ||||||
14 | Organization after the merger, consolidation, or other | ||||||
15 | acquisition of control takes effect; | ||||||
16 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
17 | Section 131.8 of the Illinois Insurance Code shall not | ||||||
18 | apply and (ii) the Director, in making his determination | ||||||
19 | with respect to the merger, consolidation, or other | ||||||
20 | acquisition of control, need not take into account the | ||||||
21 | effect on competition of the merger, consolidation, or | ||||||
22 | other acquisition of control; | ||||||
23 | (3) the Director shall have the power to require the | ||||||
24 | following information: | ||||||
25 | (A) certification by an independent actuary of the | ||||||
26 | adequacy of the reserves of the Health Maintenance |
| |||||||
| |||||||
1 | Organization sought to be acquired; | ||||||
2 | (B) pro forma financial statements reflecting the | ||||||
3 | combined balance sheets of the acquiring company and | ||||||
4 | the Health Maintenance Organization sought to be | ||||||
5 | acquired as of the end of the preceding year and as of | ||||||
6 | a date 90 days prior to the acquisition, as well as pro | ||||||
7 | forma financial statements reflecting projected | ||||||
8 | combined operation for a period of 2 years; | ||||||
9 | (C) a pro forma business plan detailing an | ||||||
10 | acquiring party's plans with respect to the operation | ||||||
11 | of the Health Maintenance Organization sought to be | ||||||
12 | acquired for a period of not less than 3 years; and | ||||||
13 | (D) such other information as the Director shall | ||||||
14 | require. | ||||||
15 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
16 | Insurance Code and this Section 5-3 shall apply to the sale by | ||||||
17 | any health maintenance organization of greater than 10% of its | ||||||
18 | enrollee population (including , without limitation , the health | ||||||
19 | maintenance organization's right, title, and interest in and | ||||||
20 | to its health care certificates). | ||||||
21 | (e) In considering any management contract or service | ||||||
22 | agreement subject to Section 141.1 of the Illinois Insurance | ||||||
23 | Code, the Director (i) shall, in addition to the criteria | ||||||
24 | specified in Section 141.2 of the Illinois Insurance Code, | ||||||
25 | take into account the effect of the management contract or | ||||||
26 | service agreement on the continuation of benefits to enrollees |
| |||||||
| |||||||
1 | and the financial condition of the health maintenance | ||||||
2 | organization to be managed or serviced, and (ii) need not take | ||||||
3 | into account the effect of the management contract or service | ||||||
4 | agreement on competition. | ||||||
5 | (f) Except for small employer groups as defined in the | ||||||
6 | Small Employer Rating, Renewability and Portability Health | ||||||
7 | Insurance Act and except for medicare supplement policies as | ||||||
8 | defined in Section 363 of the Illinois Insurance Code, a | ||||||
9 | Health Maintenance Organization may by contract agree with a | ||||||
10 | group or other enrollment unit to effect refunds or charge | ||||||
11 | additional premiums under the following terms and conditions: | ||||||
12 | (i) the amount of, and other terms and conditions with | ||||||
13 | respect to, the refund or additional premium are set forth | ||||||
14 | in the group or enrollment unit contract agreed in advance | ||||||
15 | of the period for which a refund is to be paid or | ||||||
16 | additional premium is to be charged (which period shall | ||||||
17 | not be less than one year); and | ||||||
18 | (ii) the amount of the refund or additional premium | ||||||
19 | shall not exceed 20% of the Health Maintenance | ||||||
20 | Organization's profitable or unprofitable experience with | ||||||
21 | respect to the group or other enrollment unit for the | ||||||
22 | period (and, for purposes of a refund or additional | ||||||
23 | premium, the profitable or unprofitable experience shall | ||||||
24 | be calculated taking into account a pro rata share of the | ||||||
25 | Health Maintenance Organization's administrative and | ||||||
26 | marketing expenses, but shall not include any refund to be |
| |||||||
| |||||||
1 | made or additional premium to be paid pursuant to this | ||||||
2 | subsection (f)). The Health Maintenance Organization and | ||||||
3 | the group or enrollment unit may agree that the profitable | ||||||
4 | or unprofitable experience may be calculated taking into | ||||||
5 | account the refund period and the immediately preceding 2 | ||||||
6 | plan years. | ||||||
7 | The Health Maintenance Organization shall include a | ||||||
8 | statement in the evidence of coverage issued to each enrollee | ||||||
9 | describing the possibility of a refund or additional premium, | ||||||
10 | and upon request of any group or enrollment unit, provide to | ||||||
11 | the group or enrollment unit a description of the method used | ||||||
12 | to calculate (1) the Health Maintenance Organization's | ||||||
13 | profitable experience with respect to the group or enrollment | ||||||
14 | unit and the resulting refund to the group or enrollment unit | ||||||
15 | or (2) the Health Maintenance Organization's unprofitable | ||||||
16 | experience with respect to the group or enrollment unit and | ||||||
17 | the resulting additional premium to be paid by the group or | ||||||
18 | enrollment unit. | ||||||
19 | In no event shall the Illinois Health Maintenance | ||||||
20 | Organization Guaranty Association be liable to pay any | ||||||
21 | contractual obligation of an insolvent organization to pay any | ||||||
22 | refund authorized under this Section. | ||||||
23 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
24 | if any, is conditioned on the rules being adopted in | ||||||
25 | accordance with all provisions of the Illinois Administrative | ||||||
26 | Procedure Act and all rules and procedures of the Joint |
| |||||||
| |||||||
1 | Committee on Administrative Rules; any purported rule not so | ||||||
2 | adopted, for whatever reason, is unauthorized. | ||||||
3 | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||||||
4 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
5 | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||||||
6 | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||||||
7 | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||||||
8 | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||||||
9 | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||||||
10 | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||||||
11 | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
12 | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
| ||||||
13 | Section 25. The Limited Health Service Organization Act is | ||||||
14 | amended by changing Section 4003 as follows:
| ||||||
15 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) | ||||||
16 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
17 | health service organizations shall be subject to the | ||||||
18 | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | ||||||
19 | 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153, | ||||||
20 | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, | ||||||
21 | 355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, | ||||||
22 | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | ||||||
23 | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | ||||||
24 | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, |
| |||||||
| |||||||
1 | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, | ||||||
2 | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, | ||||||
3 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. | ||||||
4 | Nothing in this Section shall require a limited health care | ||||||
5 | plan to cover any service that is not a limited health service. | ||||||
6 | For purposes of the Illinois Insurance Code, except for | ||||||
7 | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited | ||||||
8 | health service organizations in the following categories are | ||||||
9 | deemed to be domestic companies: | ||||||
10 | (1) a corporation under the laws of this State; or | ||||||
11 | (2) a corporation organized under the laws of another | ||||||
12 | state, 30% or more of the enrollees of which are residents | ||||||
13 | of this State, except a corporation subject to | ||||||
14 | substantially the same requirements in its state of | ||||||
15 | organization as is a domestic company under Article VIII | ||||||
16 | 1/2 of the Illinois Insurance Code. | ||||||
17 | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||||||
18 | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | ||||||
19 | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | ||||||
20 | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | ||||||
21 | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | ||||||
22 | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
23 | eff. 1-1-24; revised 8-29-23.)
| ||||||
24 | Section 30. The Managed Care Reform and Patient Rights Act | ||||||
25 | is amended by changing Sections 10, 45, and 85 as follows:
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| |||||||
1 | (215 ILCS 134/10) | ||||||
2 | Sec. 10. Definitions. In this Act: | ||||||
3 | For a health care plan under Section 45 or for a | ||||||
4 | utilization review program under Section 85, "adverse | ||||||
5 | determination" has the meaning given to that term in Section | ||||||
6 | 10 of the Health Carrier External Review Act "Adverse | ||||||
7 | determination" means a determination by a health care plan | ||||||
8 | under Section 45 or by a utilization review program under | ||||||
9 | Section 85 that a health care service is not medically | ||||||
10 | necessary . | ||||||
11 | "Clinical peer" means a health care professional who is in | ||||||
12 | the same profession and the same or similar specialty as the | ||||||
13 | health care provider who typically manages the medical | ||||||
14 | condition, procedures, or treatment under review. | ||||||
15 | "Department" means the Department of Insurance. | ||||||
16 | "Emergency medical condition" means a medical condition | ||||||
17 | manifesting itself by acute symptoms of sufficient severity, | ||||||
18 | regardless of the final diagnosis given, such that a prudent | ||||||
19 | layperson, who possesses an average knowledge of health and | ||||||
20 | medicine, could reasonably expect the absence of immediate | ||||||
21 | medical attention to result in: | ||||||
22 | (1) placing the health of the individual (or, with | ||||||
23 | respect to a pregnant woman, the health of the woman or her | ||||||
24 | unborn child) in serious jeopardy; | ||||||
25 | (2) serious impairment to bodily functions; |
| |||||||
| |||||||
1 | (3) serious dysfunction of any bodily organ or part; | ||||||
2 | (4) inadequately controlled pain; or | ||||||
3 | (5) with respect to a pregnant woman who is having | ||||||
4 | contractions: | ||||||
5 | (A) inadequate time to complete a safe transfer to | ||||||
6 | another hospital before delivery; or | ||||||
7 | (B) a transfer to another hospital may pose a | ||||||
8 | threat to the health or safety of the woman or unborn | ||||||
9 | child. | ||||||
10 | "Emergency medical screening examination" means a medical | ||||||
11 | screening examination and evaluation by a physician licensed | ||||||
12 | to practice medicine in all its branches, or to the extent | ||||||
13 | permitted by applicable laws, by other appropriately licensed | ||||||
14 | personnel under the supervision of or in collaboration with a | ||||||
15 | physician licensed to practice medicine in all its branches to | ||||||
16 | determine whether the need for emergency services exists. | ||||||
17 | "Emergency services" means, with respect to an enrollee of | ||||||
18 | a health care plan, transportation services, including but not | ||||||
19 | limited to ambulance services, and covered inpatient and | ||||||
20 | outpatient hospital services furnished by a provider qualified | ||||||
21 | to furnish those services that are needed to evaluate or | ||||||
22 | stabilize an emergency medical condition. "Emergency services" | ||||||
23 | does not refer to post-stabilization medical services. | ||||||
24 | "Enrollee" means any person and his or her dependents | ||||||
25 | enrolled in or covered by a health care plan. | ||||||
26 | "Health care plan" means a plan, including, but not |
| |||||||
| |||||||
1 | limited to, a health maintenance organization, a managed care | ||||||
2 | community network as defined in the Illinois Public Aid Code, | ||||||
3 | or an accountable care entity as defined in the Illinois | ||||||
4 | Public Aid Code that receives capitated payments to cover | ||||||
5 | medical services from the Department of Healthcare and Family | ||||||
6 | Services, that establishes, operates, or maintains a network | ||||||
7 | of health care providers that has entered into an agreement | ||||||
8 | with the plan to provide health care services to enrollees to | ||||||
9 | whom the plan has the ultimate obligation to arrange for the | ||||||
10 | provision of or payment for services through organizational | ||||||
11 | arrangements for ongoing quality assurance, utilization review | ||||||
12 | programs, or dispute resolution. Nothing in this definition | ||||||
13 | shall be construed to mean that an independent practice | ||||||
14 | association or a physician hospital organization that | ||||||
15 | subcontracts with a health care plan is, for purposes of that | ||||||
16 | subcontract, a health care plan. | ||||||
17 | For purposes of this definition, "health care plan" shall | ||||||
18 | not include the following: | ||||||
19 | (1) indemnity health insurance policies including | ||||||
20 | those using a contracted provider network; | ||||||
21 | (2) health care plans that offer only dental or only | ||||||
22 | vision coverage; | ||||||
23 | (3) preferred provider administrators, as defined in | ||||||
24 | Section 370g(g) of the Illinois Insurance Code; | ||||||
25 | (4) employee or employer self-insured health benefit | ||||||
26 | plans under the federal Employee Retirement Income |
| |||||||
| |||||||
1 | Security Act of 1974; | ||||||
2 | (5) health care provided pursuant to the Workers' | ||||||
3 | Compensation Act or the Workers' Occupational Diseases | ||||||
4 | Act; and | ||||||
5 | (6) except with respect to subsections (a) and (b) of | ||||||
6 | Section 65 and subsection (a-5) of Section 70, | ||||||
7 | not-for-profit voluntary health services plans with health | ||||||
8 | maintenance organization authority in existence as of | ||||||
9 | January 1, 1999 that are affiliated with a union and that | ||||||
10 | only extend coverage to union members and their | ||||||
11 | dependents. | ||||||
12 | "Health care professional" means a physician, a registered | ||||||
13 | professional nurse, or other individual appropriately licensed | ||||||
14 | or registered to provide health care services. | ||||||
15 | "Health care provider" means any physician, hospital | ||||||
16 | facility, facility licensed under the Nursing Home Care Act, | ||||||
17 | long-term care facility as defined in Section 1-113 of the | ||||||
18 | Nursing Home Care Act, or other person that is licensed or | ||||||
19 | otherwise authorized to deliver health care services. Nothing | ||||||
20 | in this Act shall be construed to define Independent Practice | ||||||
21 | Associations or Physician-Hospital Organizations as health | ||||||
22 | care providers. | ||||||
23 | "Health care services" means any services included in the | ||||||
24 | furnishing to any individual of medical care, or the | ||||||
25 | hospitalization incident to the furnishing of such care, as | ||||||
26 | well as the furnishing to any person of any and all other |
| |||||||
| |||||||
1 | services for the purpose of preventing, alleviating, curing, | ||||||
2 | or healing human illness or injury including behavioral | ||||||
3 | health, mental health, home health, and pharmaceutical | ||||||
4 | services and products. | ||||||
5 | "Medical director" means a physician licensed in any state | ||||||
6 | to practice medicine in all its branches appointed by a health | ||||||
7 | care plan. | ||||||
8 | "Person" means a corporation, association, partnership, | ||||||
9 | limited liability company, sole proprietorship, or any other | ||||||
10 | legal entity. | ||||||
11 | "Physician" means a person licensed under the Medical | ||||||
12 | Practice Act of 1987. | ||||||
13 | "Post-stabilization medical services" means health care | ||||||
14 | services provided to an enrollee that are furnished in a | ||||||
15 | licensed hospital by a provider that is qualified to furnish | ||||||
16 | such services, and determined to be medically necessary and | ||||||
17 | directly related to the emergency medical condition following | ||||||
18 | stabilization. | ||||||
19 | "Stabilization" means, with respect to an emergency | ||||||
20 | medical condition, to provide such medical treatment of the | ||||||
21 | condition as may be necessary to assure, within reasonable | ||||||
22 | medical probability, that no material deterioration of the | ||||||
23 | condition is likely to result. | ||||||
24 | "Utilization review" means the evaluation , including any | ||||||
25 | evaluation based on an algorithmic automated process, of the | ||||||
26 | medical necessity, appropriateness, and efficiency of the use |
| |||||||
| |||||||
1 | of health care services, procedures, and facilities. | ||||||
2 | "Utilization review program" means a program established | ||||||
3 | by a person to perform utilization review. | ||||||
4 | (Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
| ||||||
5 | (215 ILCS 134/45) | ||||||
6 | Sec. 45. Health care services appeals, complaints, and | ||||||
7 | external independent reviews. | ||||||
8 | (a) A health care plan shall establish and maintain an | ||||||
9 | appeals procedure as outlined in this Act. Compliance with | ||||||
10 | this Act's appeals procedures shall satisfy a health care | ||||||
11 | plan's obligation to provide appeal procedures under any other | ||||||
12 | State law or rules. All appeals of a health care plan's | ||||||
13 | administrative determinations and complaints regarding its | ||||||
14 | administrative decisions shall be handled as required under | ||||||
15 | Section 50. | ||||||
16 | (b) When an appeal concerns a decision or action by a | ||||||
17 | health care plan, its employees, or its subcontractors that | ||||||
18 | relates to (i) health care services, including, but not | ||||||
19 | limited to, procedures or treatments, for an enrollee with an | ||||||
20 | ongoing course of treatment ordered by a health care provider, | ||||||
21 | the denial of which could significantly increase the risk to | ||||||
22 | an enrollee's health, or (ii) a treatment referral, service, | ||||||
23 | procedure, or other health care service, the denial of which | ||||||
24 | could significantly increase the risk to an enrollee's health, | ||||||
25 | the health care plan must allow for the filing of an appeal |
| |||||||
| |||||||
1 | either orally or in writing. Upon submission of the appeal, a | ||||||
2 | health care plan must notify the party filing the appeal, as | ||||||
3 | soon as possible, but in no event more than 24 hours after the | ||||||
4 | submission of the appeal, of all information that the plan | ||||||
5 | requires to evaluate the appeal. The health care plan shall | ||||||
6 | render a decision on the appeal within 24 hours after receipt | ||||||
7 | of the required information. The health care plan shall notify | ||||||
8 | the party filing the appeal and the enrollee, enrollee's | ||||||
9 | primary care physician, and any health care provider who | ||||||
10 | recommended the health care service involved in the appeal of | ||||||
11 | its decision orally followed-up by a written notice of the | ||||||
12 | determination. | ||||||
13 | (c) For all appeals related to health care services | ||||||
14 | including, but not limited to, procedures or treatments for an | ||||||
15 | enrollee and not covered by subsection (b) above, the health | ||||||
16 | care plan shall establish a procedure for the filing of such | ||||||
17 | appeals. Upon submission of an appeal under this subsection, a | ||||||
18 | health care plan must notify the party filing an appeal, | ||||||
19 | within 3 business days, of all information that the plan | ||||||
20 | requires to evaluate the appeal. The health care plan shall | ||||||
21 | render a decision on the appeal within 15 business days after | ||||||
22 | receipt of the required information. The health care plan | ||||||
23 | shall notify the party filing the appeal, the enrollee, the | ||||||
24 | enrollee's primary care physician, and any health care | ||||||
25 | provider who recommended the health care service involved in | ||||||
26 | the appeal orally of its decision followed-up by a written |
| |||||||
| |||||||
1 | notice of the determination. | ||||||
2 | (d) An appeal under subsection (b) or (c) may be filed by | ||||||
3 | the enrollee, the enrollee's designee or guardian, the | ||||||
4 | enrollee's primary care physician, or the enrollee's health | ||||||
5 | care provider. A health care plan shall designate a clinical | ||||||
6 | peer to review appeals, because these appeals pertain to | ||||||
7 | medical or clinical matters and such an appeal must be | ||||||
8 | reviewed by an appropriate health care professional. No one | ||||||
9 | reviewing an appeal may have had any involvement in the | ||||||
10 | initial determination that is the subject of the appeal. The | ||||||
11 | written notice of determination required under subsections (b) | ||||||
12 | and (c) shall include (i) clear and detailed reasons for the | ||||||
13 | determination, (ii) the medical or clinical criteria for the | ||||||
14 | determination, which shall be based upon sound clinical | ||||||
15 | evidence and reviewed on a periodic basis, and (iii) in the | ||||||
16 | case of an adverse determination, the procedures for | ||||||
17 | requesting an external independent review as provided by the | ||||||
18 | Illinois Health Carrier External Review Act. | ||||||
19 | (e) If an appeal filed under subsection (b) or (c) is | ||||||
20 | denied for a reason including, but not limited to, the | ||||||
21 | service, procedure, or treatment is not viewed as medically | ||||||
22 | necessary, denial of specific tests or procedures, denial of | ||||||
23 | referral to specialist physicians or denial of hospitalization | ||||||
24 | requests or length of stay requests, any involved party may | ||||||
25 | request an external independent review as provided by the | ||||||
26 | Illinois Health Carrier External Review Act. |
| |||||||
| |||||||
1 | (f) Until July 1, 2013, if an external independent review | ||||||
2 | decision made pursuant to the Illinois Health Carrier External | ||||||
3 | Review Act upholds a determination adverse to the covered | ||||||
4 | person, the covered person has the right to appeal the final | ||||||
5 | decision to the Department; if the external review decision is | ||||||
6 | found by the Director to have been arbitrary and capricious, | ||||||
7 | then the Director, with consultation from a licensed medical | ||||||
8 | professional, may overturn the external review decision and | ||||||
9 | require the health carrier to pay for the health care service | ||||||
10 | or treatment; such decision, if any, shall be made solely on | ||||||
11 | the legal or medical merits of the claim. If an external review | ||||||
12 | decision is overturned by the Director pursuant to this | ||||||
13 | Section and the health carrier so requests, then the Director | ||||||
14 | shall assign a new independent review organization to | ||||||
15 | reconsider the overturned decision. The new independent review | ||||||
16 | organization shall follow subsection (d) of Section 40 of the | ||||||
17 | Health Carrier External Review Act in rendering a decision. | ||||||
18 | (g) Future contractual or employment action by the health | ||||||
19 | care plan regarding the patient's physician or other health | ||||||
20 | care provider shall not be based solely on the physician's or | ||||||
21 | other health care provider's participation in health care | ||||||
22 | services appeals, complaints, or external independent reviews | ||||||
23 | under the Illinois Health Carrier External Review Act. | ||||||
24 | (h) Nothing in this Section shall be construed to require | ||||||
25 | a health care plan to pay for a health care service not covered | ||||||
26 | under the enrollee's certificate of coverage or policy. |
| |||||||
| |||||||
1 | (i) Even if a health care plan or other utilization review | ||||||
2 | program uses an algorithmic automated process in the course of | ||||||
3 | utilization review for medical necessity, the health care plan | ||||||
4 | or other utilization review program shall ensure that only a | ||||||
5 | clinical peer makes any adverse determination based on medical | ||||||
6 | necessity and that any subsequent appeal is processed as | ||||||
7 | required by this Section, including the restriction that only | ||||||
8 | a clinical peer may review an appeal. A health care plan or | ||||||
9 | other utilization review program using an automated process | ||||||
10 | shall have the accreditation and the policies and procedures | ||||||
11 | required by subsection (b-10) of Section 85 of this Act. | ||||||
12 | (Source: P.A. 96-857, eff. 7-1-10 .)
| ||||||
13 | (215 ILCS 134/85) | ||||||
14 | Sec. 85. Utilization review program registration. | ||||||
15 | (a) No person may conduct a utilization review program in | ||||||
16 | this State unless once every 2 years the person registers the | ||||||
17 | utilization review program with the Department and provides | ||||||
18 | proof of current accreditation for itself and its | ||||||
19 | subcontractors certifies compliance with the Health | ||||||
20 | Utilization Management Standards of the Utilization Review | ||||||
21 | Accreditation Commission, the National Committee for Quality | ||||||
22 | Assurance, or another accreditation entity authorized under | ||||||
23 | this Section Health Utilization Management Standards of the | ||||||
24 | American Accreditation Healthcare Commission (URAC) sufficient | ||||||
25 | to achieve American Accreditation Healthcare Commission (URAC) |
| |||||||
| |||||||
1 | accreditation or submits evidence of accreditation by the | ||||||
2 | American Accreditation Healthcare Commission (URAC) for its | ||||||
3 | Health Utilization Management Standards. Nothing in this Act | ||||||
4 | shall be construed to require a health care plan or its | ||||||
5 | subcontractors to become American Accreditation Healthcare | ||||||
6 | Commission (URAC) accredited . | ||||||
7 | (b) In addition, the Director of the Department, in | ||||||
8 | consultation with the Director of the Department of Public | ||||||
9 | Health, may certify alternative utilization review standards | ||||||
10 | of national accreditation organizations or entities in order | ||||||
11 | for plans to comply with this Section. Any alternative | ||||||
12 | utilization review standards shall meet or exceed those | ||||||
13 | standards required under subsection (a). | ||||||
14 | (b-5) The Department shall recognize the Accreditation | ||||||
15 | Association for Ambulatory Health Care among the list of | ||||||
16 | accreditors from which utilization organizations may receive | ||||||
17 | accreditation and qualify for reduced registration and renewal | ||||||
18 | fees. | ||||||
19 | (b-10) Utilization review programs that use algorithmic | ||||||
20 | automated processes to decide whether to render adverse | ||||||
21 | determinations based on medical necessity in the course of | ||||||
22 | utilization review shall use objective, evidence-based | ||||||
23 | criteria compliant with the accreditation requirements of the | ||||||
24 | Health Utilization Management Standards of the Utilization | ||||||
25 | Review Accreditation Commission or the National Committee for | ||||||
26 | Quality Assurance (NCQA) and shall provide proof of such |
| |||||||
| |||||||
1 | compliance to the Department with the registration required | ||||||
2 | under subsection (a), including any renewal registrations. | ||||||
3 | Nothing in this subsection supersedes paragraph (2) of | ||||||
4 | subsection (e). The utilization review program shall include, | ||||||
5 | with its registration materials, attachments that contain | ||||||
6 | policies and procedures: | ||||||
7 | (1) to ensure that licensed physicians with relevant | ||||||
8 | board certifications establish all criteria that the | ||||||
9 | algorithmic automated process uses for utilization review; | ||||||
10 | and | ||||||
11 | (2) for a program integrity system that, both before | ||||||
12 | new or revised criteria are used for utilization review | ||||||
13 | and when implementation errors in the algorithmic | ||||||
14 | automated process are identified after new or revised | ||||||
15 | criteria go into effect, requires licensed physicians with | ||||||
16 | relevant board certifications to verify that the | ||||||
17 | algorithmic automated process and corrections to it yield | ||||||
18 | results consistent with the criteria for their certified | ||||||
19 | field. | ||||||
20 | (c) The provisions of this Section do not apply to: | ||||||
21 | (1) persons providing utilization review program | ||||||
22 | services only to the federal government; | ||||||
23 | (2) self-insured health plans under the federal | ||||||
24 | Employee Retirement Income Security Act of 1974, however, | ||||||
25 | this Section does apply to persons conducting a | ||||||
26 | utilization review program on behalf of these health |
| |||||||
| |||||||
1 | plans; | ||||||
2 | (3) hospitals and medical groups performing | ||||||
3 | utilization review activities for internal purposes unless | ||||||
4 | the utilization review program is conducted for another | ||||||
5 | person. | ||||||
6 | Nothing in this Act prohibits a health care plan or other | ||||||
7 | entity from contractually requiring an entity designated in | ||||||
8 | item (3) of this subsection to adhere to the utilization | ||||||
9 | review program requirements of this Act. | ||||||
10 | (d) This registration shall include submission of all of | ||||||
11 | the following information regarding utilization review program | ||||||
12 | activities: | ||||||
13 | (1) The name, address, and telephone number of the | ||||||
14 | utilization review programs. | ||||||
15 | (2) The organization and governing structure of the | ||||||
16 | utilization review programs. | ||||||
17 | (3) The number of lives for which utilization review | ||||||
18 | is conducted by each utilization review program. | ||||||
19 | (4) Hours of operation of each utilization review | ||||||
20 | program. | ||||||
21 | (5) Description of the grievance process for each | ||||||
22 | utilization review program. | ||||||
23 | (6) Number of covered lives for which utilization | ||||||
24 | review was conducted for the previous calendar year for | ||||||
25 | each utilization review program. | ||||||
26 | (7) Written policies and procedures for protecting |
| |||||||
| |||||||
1 | confidential information according to applicable State and | ||||||
2 | federal laws for each utilization review program. | ||||||
3 | (e) (1) A utilization review program shall have written | ||||||
4 | procedures for assuring that patient-specific information | ||||||
5 | obtained during the process of utilization review will be: | ||||||
6 | (A) kept confidential in accordance with applicable | ||||||
7 | State and federal laws; and | ||||||
8 | (B) shared only with the enrollee, the enrollee's | ||||||
9 | designee, the enrollee's health care provider, and those | ||||||
10 | who are authorized by law to receive the information. | ||||||
11 | Summary data shall not be considered confidential if it | ||||||
12 | does not provide information to allow identification of | ||||||
13 | individual patients or health care providers. | ||||||
14 | (2) Only a clinical peer health care professional may | ||||||
15 | make adverse determinations regarding the medical | ||||||
16 | necessity of health care services during the course of | ||||||
17 | utilization review. Either a health care professional or | ||||||
18 | an accredited algorithmic automated process, or both in | ||||||
19 | combination, may certify the medical necessity of a health | ||||||
20 | care service in accordance with accreditation standards. | ||||||
21 | Nothing in this subsection prohibits an accredited | ||||||
22 | algorithmic automated process from being used to refer a | ||||||
23 | case to a clinical peer for a potential adverse | ||||||
24 | determination. | ||||||
25 | (3) When making retrospective reviews, utilization | ||||||
26 | review programs shall base reviews solely on the medical |
| |||||||
| |||||||
1 | information available to the attending physician or | ||||||
2 | ordering provider at the time the health care services | ||||||
3 | were provided. This paragraph includes billing records and | ||||||
4 | diagnosis or procedure codes that substantively contain | ||||||
5 | the same medical information to an equal or lesser degree | ||||||
6 | of specificity as the records the attending physician or | ||||||
7 | ordering provider directly consulted at the time health | ||||||
8 | care services were provided. | ||||||
9 | (4) When making prospective, concurrent, and | ||||||
10 | retrospective determinations, utilization review programs | ||||||
11 | shall collect only information that is necessary to make | ||||||
12 | the determination and shall not routinely require health | ||||||
13 | care providers to numerically code diagnoses or procedures | ||||||
14 | to be considered for certification, unless required under | ||||||
15 | State or federal Medicare or Medicaid rules or | ||||||
16 | regulations, but may request such code if available, or | ||||||
17 | routinely request copies of medical records of all | ||||||
18 | enrollees reviewed. During prospective or concurrent | ||||||
19 | review, copies of medical records shall only be required | ||||||
20 | when necessary to verify that the health care services | ||||||
21 | subject to review are medically necessary. In these cases, | ||||||
22 | only the necessary or relevant sections of the medical | ||||||
23 | record shall be required. | ||||||
24 | (f) If the Department finds that a utilization review | ||||||
25 | program is not in compliance with this Section, the Department | ||||||
26 | shall issue a corrective action plan and allow a reasonable |
| |||||||
| |||||||
1 | amount of time for compliance with the plan. If the | ||||||
2 | utilization review program does not come into compliance, the | ||||||
3 | Department may issue a cease and desist order. Before issuing | ||||||
4 | a cease and desist order under this Section, the Department | ||||||
5 | shall provide the utilization review program with a written | ||||||
6 | notice of the reasons for the order and allow a reasonable | ||||||
7 | amount of time to supply additional information demonstrating | ||||||
8 | compliance with requirements of this Section and to request a | ||||||
9 | hearing. The hearing notice shall be sent by certified mail, | ||||||
10 | return receipt requested, and the hearing shall be conducted | ||||||
11 | in accordance with the Illinois Administrative Procedure Act. | ||||||
12 | (g) A utilization review program subject to a corrective | ||||||
13 | action may continue to conduct business until a final decision | ||||||
14 | has been issued by the Department. | ||||||
15 | (h) Any adverse determination made by a health care plan | ||||||
16 | or its subcontractors may be appealed in accordance with | ||||||
17 | subsection (f) of Section 45. | ||||||
18 | (i) The Director may by rule establish a registration fee | ||||||
19 | for each person conducting a utilization review program. All | ||||||
20 | fees paid to and collected by the Director under this Section | ||||||
21 | shall be deposited into the Insurance Producer Administration | ||||||
22 | Fund. | ||||||
23 | (Source: P.A. 99-111, eff. 1-1-16 .)
| ||||||
24 | Section 35. The Voluntary Health Services Plans Act is | ||||||
25 | amended by changing Section 10 as follows:
|
| |||||||
| |||||||
1 | (215 ILCS 165/10) (from Ch. 32, par. 604) | ||||||
2 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
3 | services plan corporations and all persons interested therein | ||||||
4 | or dealing therewith shall be subject to the provisions of | ||||||
5 | Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, | ||||||
6 | 143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, | ||||||
7 | 355b, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, | ||||||
8 | 356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, | ||||||
9 | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | ||||||
10 | 356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, | ||||||
11 | 356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, | ||||||
12 | 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | ||||||
13 | 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, | ||||||
14 | 356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401, | ||||||
15 | 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) | ||||||
16 | and (15) of Section 367 of the Illinois Insurance Code. | ||||||
17 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
18 | any, is conditioned on the rules being adopted in accordance | ||||||
19 | with all provisions of the Illinois Administrative Procedure | ||||||
20 | Act and all rules and procedures of the Joint Committee on | ||||||
21 | Administrative Rules; any purported rule not so adopted, for | ||||||
22 | whatever reason, is unauthorized. | ||||||
23 | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||||||
24 | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. | ||||||
25 | 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, |
| |||||||
| |||||||
1 | eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | ||||||
2 | 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. | ||||||
3 | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||||||
4 | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||||||
5 | 103-551, eff. 8-11-23; revised 8-29-23.)
| ||||||
6 | Section 40. The Health Carrier External Review Act is | ||||||
7 | amended by changing Section 10 as follows:
| ||||||
8 | (215 ILCS 180/10) | ||||||
9 | Sec. 10. Definitions. For the purposes of this Act: | ||||||
10 | "Adverse determination" means: | ||||||
11 | (1) a determination by a health carrier or its | ||||||
12 | designee utilization review organization that, based upon | ||||||
13 | the health information provided for a covered person , a | ||||||
14 | request for a benefit , including any quantity, frequency, | ||||||
15 | duration, or other measurement of a benefit, under the | ||||||
16 | health carrier's health benefit plan upon application of | ||||||
17 | any utilization review technique does not meet the health | ||||||
18 | carrier's requirements for medical necessity, | ||||||
19 | appropriateness, health care setting, level of care, or | ||||||
20 | effectiveness or is determined to be experimental or | ||||||
21 | investigational and the requested benefit is therefore | ||||||
22 | denied, reduced, or terminated or payment is not provided | ||||||
23 | or made, in whole or in part, for the benefit; | ||||||
24 | (2) the denial, reduction, or termination of or |
| |||||||
| |||||||
1 | failure to provide or make payment, in whole or in part, | ||||||
2 | for a benefit based on a determination by a health carrier | ||||||
3 | or its designee utilization review organization that a | ||||||
4 | preexisting condition was present before the effective | ||||||
5 | date of coverage; or | ||||||
6 | (3) a rescission of coverage determination, which does | ||||||
7 | not include a cancellation or discontinuance of coverage | ||||||
8 | that is attributable to a failure to timely pay required | ||||||
9 | premiums or contributions towards the cost of coverage. | ||||||
10 | "Adverse determination" includes unilateral | ||||||
11 | determinations that replace the requested health care service | ||||||
12 | with an approval of an alternative health care service without | ||||||
13 | the agreement of the covered person or the covered person's | ||||||
14 | attending provider for the requested health care service, or | ||||||
15 | that condition approval of the requested service on first | ||||||
16 | trying an alternative health care service, either if the | ||||||
17 | request was made under a medical exceptions procedure, or if | ||||||
18 | all of the following are true: (1) the requested service was | ||||||
19 | not excluded by name, description, or service category under | ||||||
20 | the written terms of coverage, (2) the alternative health care | ||||||
21 | service poses no greater risk to the patient based on | ||||||
22 | generally accepted standards of care, and (3) the alternative | ||||||
23 | health care service is at least as likely to produce the same | ||||||
24 | or better effect on the covered person's health as the | ||||||
25 | requested service based on generally accepted standards of | ||||||
26 | care. "Adverse determination" includes determinations made |
| |||||||
| |||||||
1 | based on any source of health information pertaining to the | ||||||
2 | covered person that is used to deny, reduce, replace, | ||||||
3 | condition, or terminate the benefit or payment. "Adverse | ||||||
4 | determination" includes determinations made in response to a | ||||||
5 | request for authorization when the request was submitted by | ||||||
6 | the health care provider regardless of whether the provider | ||||||
7 | gave notice to or obtained the consent of the covered person or | ||||||
8 | authorized representative to file the request. "Adverse | ||||||
9 | determination" does not include substitutions performed under | ||||||
10 | Section 19.5 or 25 of the Pharmacy Practice Act. | ||||||
11 | "Authorized representative" means: | ||||||
12 | (1) a person to whom a covered person has given | ||||||
13 | express written consent to represent the covered person | ||||||
14 | for purposes of this Law; | ||||||
15 | (2) a person authorized by law to provide substituted | ||||||
16 | consent for a covered person; | ||||||
17 | (3) a family member of the covered person or the | ||||||
18 | covered person's treating health care professional when | ||||||
19 | the covered person is unable to provide consent; | ||||||
20 | (4) a health care provider when the covered person's | ||||||
21 | health benefit plan requires that a request for a benefit | ||||||
22 | under the plan be initiated by the health care provider; | ||||||
23 | or | ||||||
24 | (5) in the case of an urgent care request, a health | ||||||
25 | care provider with knowledge of the covered person's | ||||||
26 | medical condition. |
| |||||||
| |||||||
1 | "Best evidence" means evidence based on: | ||||||
2 | (1) randomized clinical trials; | ||||||
3 | (2) if randomized clinical trials are not available, | ||||||
4 | then cohort studies or case-control studies; | ||||||
5 | (3) if items (1) and (2) are not available, then | ||||||
6 | case-series; or | ||||||
7 | (4) if items (1), (2), and (3) are not available, then | ||||||
8 | expert opinion. | ||||||
9 | "Case-series" means an evaluation of a series of patients | ||||||
10 | with a particular outcome, without the use of a control group. | ||||||
11 | "Clinical review criteria" means the written screening | ||||||
12 | procedures, decision abstracts, clinical protocols, and | ||||||
13 | practice guidelines used by a health carrier to determine the | ||||||
14 | necessity and appropriateness of health care services. | ||||||
15 | "Cohort study" means a prospective evaluation of 2 groups | ||||||
16 | of patients with only one group of patients receiving specific | ||||||
17 | intervention. | ||||||
18 | "Concurrent review" means a review conducted during a | ||||||
19 | patient's stay or course of treatment in a facility, the | ||||||
20 | office of a health care professional, or other inpatient or | ||||||
21 | outpatient health care setting. | ||||||
22 | "Covered benefits" or "benefits" means those health care | ||||||
23 | services to which a covered person is entitled under the terms | ||||||
24 | of a health benefit plan. | ||||||
25 | "Covered person" means a policyholder, subscriber, | ||||||
26 | enrollee, or other individual participating in a health |
| |||||||
| |||||||
1 | benefit plan. | ||||||
2 | "Director" means the Director of the Department of | ||||||
3 | Insurance. | ||||||
4 | "Emergency medical condition" means a medical condition | ||||||
5 | manifesting itself by acute symptoms of sufficient severity, | ||||||
6 | including, but not limited to, severe pain, such that a | ||||||
7 | prudent layperson who possesses an average knowledge of health | ||||||
8 | and medicine could reasonably expect the absence of immediate | ||||||
9 | medical attention to result in: | ||||||
10 | (1) placing the health of the individual or, with | ||||||
11 | respect to a pregnant woman, the health of the woman or her | ||||||
12 | unborn child, in serious jeopardy; | ||||||
13 | (2) serious impairment to bodily functions; or | ||||||
14 | (3) serious dysfunction of any bodily organ or part. | ||||||
15 | "Emergency services" means health care items and services | ||||||
16 | furnished or required to evaluate and treat an emergency | ||||||
17 | medical condition. | ||||||
18 | "Evidence-based standard" means the conscientious, | ||||||
19 | explicit, and judicious use of the current best evidence based | ||||||
20 | on an overall systematic review of the research in making | ||||||
21 | decisions about the care of individual patients. | ||||||
22 | "Expert opinion" means a belief or an interpretation by | ||||||
23 | specialists with experience in a specific area about the | ||||||
24 | scientific evidence pertaining to a particular service, | ||||||
25 | intervention, or therapy. | ||||||
26 | "Facility" means an institution providing health care |
| |||||||
| |||||||
1 | services or a health care setting. | ||||||
2 | "Final adverse determination" means an adverse | ||||||
3 | determination involving a covered benefit that has been upheld | ||||||
4 | by a health carrier, or its designee utilization review | ||||||
5 | organization, at the completion of the health carrier's | ||||||
6 | internal grievance process procedures as set forth by the | ||||||
7 | Managed Care Reform and Patient Rights Act or as set forth for | ||||||
8 | any additional authorization or internal appeal process | ||||||
9 | provided by contract between the health carrier and the | ||||||
10 | provider. "Final adverse determination" includes | ||||||
11 | determinations made in an appeal of a denial of prior | ||||||
12 | authorization when the appeal was submitted by the health care | ||||||
13 | provider regardless of whether the provider gave notice to or | ||||||
14 | obtained the consent of the covered person or authorized | ||||||
15 | representative to file an internal appeal . | ||||||
16 | "Health benefit plan" means a policy, contract, | ||||||
17 | certificate, plan, or agreement offered or issued by a health | ||||||
18 | carrier to provide, deliver, arrange for, pay for, or | ||||||
19 | reimburse any of the costs of health care services. | ||||||
20 | "Health care provider" or "provider" means a physician, | ||||||
21 | hospital facility, or other health care practitioner licensed, | ||||||
22 | accredited, or certified to perform specified health care | ||||||
23 | services consistent with State law, responsible for | ||||||
24 | recommending health care services on behalf of a covered | ||||||
25 | person. | ||||||
26 | "Health care services" means services for the diagnosis, |
| |||||||
| |||||||
1 | prevention, treatment, cure, or relief of a health condition, | ||||||
2 | illness, injury, or disease. | ||||||
3 | "Health carrier" means an entity subject to the insurance | ||||||
4 | laws and regulations of this State, or subject to the | ||||||
5 | jurisdiction of the Director, that contracts or offers to | ||||||
6 | contract to provide, deliver, arrange for, pay for, or | ||||||
7 | reimburse any of the costs of health care services, including | ||||||
8 | a sickness and accident insurance company, a health | ||||||
9 | maintenance organization, or any other entity providing a plan | ||||||
10 | of health insurance, health benefits, or health care services. | ||||||
11 | "Health carrier" also means Limited Health Service | ||||||
12 | Organizations (LHSO) and Voluntary Health Service Plans. | ||||||
13 | "Health information" means information or data, whether | ||||||
14 | oral or recorded in any form or medium, and personal facts or | ||||||
15 | information about events or relationships that relate to: | ||||||
16 | (1) the past, present, or future physical, mental, or | ||||||
17 | behavioral health or condition of an individual or a | ||||||
18 | member of the individual's family; | ||||||
19 | (2) the provision of health care services to an | ||||||
20 | individual; or | ||||||
21 | (3) payment for the provision of health care services | ||||||
22 | to an individual. | ||||||
23 | "Independent review organization" means an entity that | ||||||
24 | conducts independent external reviews of adverse | ||||||
25 | determinations and final adverse determinations. | ||||||
26 | "Medical or scientific evidence" means evidence found in |
| |||||||
| |||||||
1 | the following sources: | ||||||
2 | (1) peer-reviewed scientific studies published in or | ||||||
3 | accepted for publication by medical journals that meet | ||||||
4 | nationally recognized requirements for scientific | ||||||
5 | manuscripts and that submit most of their published | ||||||
6 | articles for review by experts who are not part of the | ||||||
7 | editorial staff; | ||||||
8 | (2) peer-reviewed medical literature, including | ||||||
9 | literature relating to therapies reviewed and approved by | ||||||
10 | a qualified institutional review board, biomedical | ||||||
11 | compendia, and other medical literature that meet the | ||||||
12 | criteria of the National Institutes of Health's Library of | ||||||
13 | Medicine for indexing in Index Medicus (Medline) and | ||||||
14 | Elsevier Science Ltd. for indexing in Excerpta Medicus | ||||||
15 | (EMBASE); | ||||||
16 | (3) medical journals recognized by the Secretary of | ||||||
17 | Health and Human Services under Section 1861(t)(2) of the | ||||||
18 | federal Social Security Act; | ||||||
19 | (4) the following standard reference compendia: | ||||||
20 | (a) The American Hospital Formulary Service-Drug | ||||||
21 | Information; | ||||||
22 | (b) Drug Facts and Comparisons; | ||||||
23 | (c) The American Dental Association Accepted | ||||||
24 | Dental Therapeutics; and | ||||||
25 | (d) The United States Pharmacopoeia-Drug | ||||||
26 | Information; |
| |||||||
| |||||||
1 | (5) findings, studies, or research conducted by or | ||||||
2 | under the auspices of federal government agencies and | ||||||
3 | nationally recognized federal research institutes, | ||||||
4 | including: | ||||||
5 | (a) the federal Agency for Healthcare Research and | ||||||
6 | Quality; | ||||||
7 | (b) the National Institutes of Health; | ||||||
8 | (c) the National Cancer Institute; | ||||||
9 | (d) the National Academy of Sciences; | ||||||
10 | (e) the Centers for Medicare & Medicaid Services; | ||||||
11 | (f) the federal Food and Drug Administration; and | ||||||
12 | (g) any national board recognized by the National | ||||||
13 | Institutes of Health for the purpose of evaluating the | ||||||
14 | medical value of health care services; or | ||||||
15 | (6) any other medical or scientific evidence that is | ||||||
16 | comparable to the sources listed in items (1) through (5). | ||||||
17 | "Person" means an individual, a corporation, a | ||||||
18 | partnership, an association, a joint venture, a joint stock | ||||||
19 | company, a trust, an unincorporated organization, any similar | ||||||
20 | entity, or any combination of the foregoing. | ||||||
21 | "Prospective review" means a review conducted prior to an | ||||||
22 | admission or the provision of a health care service or a course | ||||||
23 | of treatment in accordance with a health carrier's requirement | ||||||
24 | that the health care service or course of treatment, in whole | ||||||
25 | or in part, be approved prior to its provision. | ||||||
26 | "Protected health information" means health information |
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1 | (i) that identifies an individual who is the subject of the | ||||||
2 | information; or (ii) with respect to which there is a | ||||||
3 | reasonable basis to believe that the information could be used | ||||||
4 | to identify an individual. | ||||||
5 | "Randomized clinical trial" means a controlled prospective | ||||||
6 | study of patients that have been randomized into an | ||||||
7 | experimental group and a control group at the beginning of the | ||||||
8 | study with only the experimental group of patients receiving a | ||||||
9 | specific intervention, which includes study of the groups for | ||||||
10 | variables and anticipated outcomes over time. | ||||||
11 | "Retrospective review" means any review of a request for a | ||||||
12 | benefit that is not a concurrent or prospective review | ||||||
13 | request. "Retrospective review" does not include the review of | ||||||
14 | a claim that is limited to veracity of documentation or | ||||||
15 | accuracy of coding. | ||||||
16 | "Utilization review" has the meaning provided by the | ||||||
17 | Managed Care Reform and Patient Rights Act. | ||||||
18 | "Utilization review organization" means a utilization | ||||||
19 | review program as defined in the Managed Care Reform and | ||||||
20 | Patient Rights Act. | ||||||
21 | (Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12; | ||||||
22 | 98-756, eff. 7-16-14.)
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23 | Section 45. The Prior Authorization Reform Act is amended | ||||||
24 | by changing Section 55 as follows:
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1 | (215 ILCS 200/55) | ||||||
2 | Sec. 55. Denial or penalty . | ||||||
3 | (a) The health insurance issuer or its contracted | ||||||
4 | utilization review organization may not revoke or further | ||||||
5 | limit, condition, or restrict a previously issued prior | ||||||
6 | authorization approval while it remains valid under this Act. | ||||||
7 | (b) Notwithstanding any other provision of law, if a claim | ||||||
8 | is properly coded and submitted timely to a health insurance | ||||||
9 | issuer, the health insurance issuer shall make payment | ||||||
10 | according to the terms of coverage on claims for health care | ||||||
11 | services for which prior authorization was required and | ||||||
12 | approval received before the rendering of health care | ||||||
13 | services, unless one of the following occurs: | ||||||
14 | (1) it is timely determined that the enrollee's health | ||||||
15 | care professional or health care provider knowingly | ||||||
16 | provided health care services that required prior | ||||||
17 | authorization from the health insurance issuer or its | ||||||
18 | contracted utilization review organization without first | ||||||
19 | obtaining prior authorization for those health care | ||||||
20 | services; | ||||||
21 | (2) it is timely determined that the health care | ||||||
22 | services claimed were not performed; | ||||||
23 | (3) it is timely determined that the health care | ||||||
24 | services rendered were contrary to the instructions of the | ||||||
25 | health insurance issuer or its contracted utilization | ||||||
26 | review organization or delegated reviewer if contact was |
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1 | made between those parties before the service being | ||||||
2 | rendered; | ||||||
3 | (4) it is timely determined that the enrollee | ||||||
4 | receiving such health care services was not an enrollee of | ||||||
5 | the health care plan; or | ||||||
6 | (5) the approval was based upon a material | ||||||
7 | misrepresentation by the enrollee, health care | ||||||
8 | professional, or health care provider; as used in this | ||||||
9 | paragraph (5), "material" means a fact or situation that | ||||||
10 | is not merely technical in nature and results or could | ||||||
11 | result in a substantial change in the situation. | ||||||
12 | (c) Nothing in this Section shall preclude a utilization | ||||||
13 | review organization or a health insurance issuer from | ||||||
14 | performing post-service reviews of health care claims for | ||||||
15 | purposes of payment integrity or for the prevention of fraud, | ||||||
16 | waste, or abuse. | ||||||
17 | (d) If a health insurance issuer imposes a monetary | ||||||
18 | penalty on the enrollee for the enrollee's, health care | ||||||
19 | professional's, or health care provider's failure to obtain | ||||||
20 | any form of prior authorization for a health care service, the | ||||||
21 | penalty may not exceed the lesser of: | ||||||
22 | (1) the actual cost of the health care service; or | ||||||
23 | (2) $1,000 per occurrence in addition to the plan | ||||||
24 | cost-sharing provisions. | ||||||
25 | (e) A health insurance issuer may not require both the | ||||||
26 | enrollee and the health care professional or health care |
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1 | provider to obtain any form of prior authorization for the | ||||||
2 | same instance of a health care service, nor otherwise require | ||||||
3 | more than one prior authorization for the same instance of a | ||||||
4 | health care service. | ||||||
5 | (Source: P.A. 102-409, eff. 1-1-22 .)
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