Bill Text: IL HB2694 | 2017-2018 | 100th General Assembly | Introduced


Bill Title: Amends the Managed Care Reform and Patient Rights Act. In provisions concerning transition of services, provides that the health care plan shall not modify an enrollee's coverage of a drug during the plan year if the drug has been previously approved for coverage by the plan for a medical condition, the plan's prescribing provider continues to prescribe the drug for the medical condition, and the patient continues to be an enrollee of the health care plan. Provides specific prohibited modifications of drug coverage in the health plan. Provides that the provisions do not prohibit a health care plan from requiring a pharmacist to effect generic substitutions of prescription drugs. Provides that the provisions do not prohibit the addition of prescription drugs to a health care plan's list of covered drugs during the coverage year. Effective immediately.

Spectrum: Slight Partisan Bill (Democrat 10-5)

Status: (Introduced) 2017-05-17 - Added Co-Sponsor Rep. Dave Severin [HB2694 Detail]

Download: Illinois-2017-HB2694-Introduced.html


100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB2694

Introduced , by Rep. Gregory Harris

SYNOPSIS AS INTRODUCED:
215 ILCS 134/25

Amends the Managed Care Reform and Patient Rights Act. In provisions concerning transition of services, provides that the health care plan shall not modify an enrollee's coverage of a drug during the plan year if the drug has been previously approved for coverage by the plan for a medical condition, the plan's prescribing provider continues to prescribe the drug for the medical condition, and the patient continues to be an enrollee of the health care plan. Provides specific prohibited modifications of drug coverage in the health plan. Provides that the provisions do not prohibit a health care plan from requiring a pharmacist to effect generic substitutions of prescription drugs. Provides that the provisions do not prohibit the addition of prescription drugs to a health care plan's list of covered drugs during the coverage year. Effective immediately.
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A BILL FOR

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1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The Managed Care Reform and Patient Rights Act
5is amended by changing Section 25 as follows:
6 (215 ILCS 134/25)
7 Sec. 25. Transition of services.
8 (a) A health care plan shall provide for continuity of care
9for its enrollees as follows:
10 (1) If an enrollee's physician leaves the health care
11 plan's network of health care providers for reasons other
12 than termination of a contract in situations involving
13 imminent harm to a patient or a final disciplinary action
14 by a State licensing board and the physician remains within
15 the health care plan's service area, the health care plan
16 shall permit the enrollee to continue an ongoing course of
17 treatment with that physician during a transitional
18 period:
19 (A) of 90 days from the date of the notice of
20 physician's termination from the health care plan to
21 the enrollee of the physician's disaffiliation from
22 the health care plan if the enrollee has an ongoing
23 course of treatment; or

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1 (B) if the enrollee has entered the third trimester
2 of pregnancy at the time of the physician's
3 disaffiliation, that includes the provision of
4 post-partum care directly related to the delivery.
5 (2) Notwithstanding the provisions in item (1) of this
6 subsection, such care shall be authorized by the health
7 care plan during the transitional period only if the
8 physician agrees:
9 (A) to continue to accept reimbursement from the
10 health care plan at the rates applicable prior to the
11 start of the transitional period;
12 (B) to adhere to the health care plan's quality
13 assurance requirements and to provide to the health
14 care plan necessary medical information related to
15 such care; and
16 (C) to otherwise adhere to the health care plan's
17 policies and procedures, including but not limited to
18 procedures regarding referrals and obtaining
19 preauthorizations for treatment.
20 (3) The health care plan shall not modify an enrollee's
21 coverage of a drug during the plan year for any enrollee if
22 the drug has been previously approved for coverage by the
23 plan for a medical condition of the enrollee, the plan's
24 prescribing provider continues to prescribe the drug for
25 the medical condition, and the patient continues to be an
26 enrollee of the health care plan. Prohibited modifications

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1 referred to in this paragraph (3) include, but are not
2 limited to:
3 (A) increasing the out-of-pocket costs for a
4 covered drug;
5 (B) moving a prescription drug to a more
6 restrictive tier; or
7 (C) removing a prescription drug from a formulary.
8 This paragraph (3) does not prohibit a health care
9 plan, by contract, written policy or procedure, or any
10 other agreement or course of conduct, from requiring a
11 pharmacist to effect generic substitutions of prescription
12 drugs.
13 (b) A health care plan shall provide for continuity of care
14for new enrollees as follows:
15 (1) If a new enrollee whose physician is not a member
16 of the health care plan's provider network, but is within
17 the health care plan's service area, enrolls in the health
18 care plan, the health care plan shall permit the enrollee
19 to continue an ongoing course of treatment with the
20 enrollee's current physician during a transitional period:
21 (A) of 90 days from the effective date of
22 enrollment if the enrollee has an ongoing course of
23 treatment; or
24 (B) if the enrollee has entered the third trimester
25 of pregnancy at the effective date of enrollment, that
26 includes the provision of post-partum care directly

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1 related to the delivery.
2 (2) If an enrollee elects to continue to receive care
3 from such physician pursuant to item (1) of this
4 subsection, such care shall be authorized by the health
5 care plan for the transitional period only if the physician
6 agrees:
7 (A) to accept reimbursement from the health care
8 plan at rates established by the health care plan; such
9 rates shall be the level of reimbursement applicable to
10 similar physicians within the health care plan for such
11 services;
12 (B) to adhere to the health care plan's quality
13 assurance requirements and to provide to the health
14 care plan necessary medical information related to
15 such care; and
16 (C) to otherwise adhere to the health care plan's
17 policies and procedures including, but not limited to
18 procedures regarding referrals and obtaining
19 preauthorization for treatment.
20 (c) In no event shall this Section be construed to require
21a health care plan to provide coverage for benefits not
22otherwise covered or to diminish or impair preexisting
23condition limitations contained in the enrollee's contract. In
24no event shall this Section be construed to prohibit the
25addition of prescription drugs to a health care plan's list of
26covered drugs during the coverage year.

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1(Source: P.A. 91-617, eff. 7-1-00.)
2 Section 99. Effective date. This Act takes effect upon
3becoming law.
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