Bill Text: IL HB4146 | 2017-2018 | 100th General Assembly | Enrolled

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

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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. Provides that the provisions do not apply to a health care plan as defined in the State Employees Group Insurance Act of 1971 or medical assistance under the Illinois Public Aid Code. Effective immediately.

Spectrum: Moderate Partisan Bill (Democrat 83-15)

Status: (Passed) 2018-08-24 - Public Act . . . . . . . . . 100-1052 [HB4146 Detail]

Download: Illinois-2017-HB4146-Enrolled.html

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

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(B) if the enrollee has entered the third trimester
of pregnancy at the time of the physician's
disaffiliation, that includes the provision of
post-partum care directly related to the delivery.
(2) Notwithstanding the provisions in item (1) of this
subsection, such care shall be authorized by the health
care plan during the transitional period only if the
physician agrees:
(A) to continue to accept reimbursement from the
health care plan at the rates applicable prior to the
start of the transitional period;
(B) to adhere to the health care plan's quality
assurance requirements and to provide to the health
care plan necessary medical information related to
such care; and
(C) to otherwise adhere to the health care plan's
policies and procedures, including but not limited to
procedures regarding referrals and obtaining
preauthorizations for treatment.
(3) During an enrollee's plan year, a health care plan
shall not remove a drug from its formulary or negatively
change its preferred or cost-tier sharing unless, at least
60 days before making the formulary change, the health care
plan:
(A) provides general notification of the change in
its formulary to current and prospective enrollees;

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(B) directly notifies enrollees currently
receiving coverage for the drug, including information
on the specific drugs involved and the steps they may
take to request coverage determinations and
exceptions, including a statement that a certification
of medical necessity by the enrollee's prescribing
provider will result in continuation of coverage at the
existing level; and
(C) directly notifies by first class mail and
through an electronic transmission, if available, the
prescribing provider of all health care plan enrollees
currently prescribed the drug affected by the proposed
change; the notice shall include a one-page form by
which the prescribing provider can notify the health
care plan by first class mail that coverage of the drug
for the enrollee is medically necessary.
The notification in paragraph (C) may direct the
prescribing provider to an electronic portal through which
the prescribing provider may electronically file a
certification to the health care plan that coverage of the
drug for the enrollee is medically necessary. The
prescribing provider may make a secure electronic
signature beside the words "certification of medical
necessity", and this certification shall authorize
continuation of coverage for the drug.
If the prescribing provider certifies to the health

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care plan either in writing or electronically that the drug
is medically necessary for the enrollee as provided in
paragraph (C), a health care plan shall authorize coverage
for the drug prescribed based solely on the prescribing
provider's assertion that coverage is medically necessary,
and the health care plan is prohibited from making
modifications to the coverage related to the covered drug,
including, but not limited to:
(i) increasing the out-of-pocket costs for the
covered drug;
(ii) moving the covered drug to a more restrictive
tier; or
(iii) denying an enrollee coverage of the drug for
which the enrollee has been previously approved for
coverage by the health care plan.
Nothing in this item (3) prevents a health care plan
from removing a drug from its formulary or denying an
enrollee coverage if the United States Food and Drug
Administration has issued a statement about the drug that
calls into question the clinical safety of the drug, the
drug manufacturer has notified the United States Food and
Drug Administration of a manufacturing discontinuance or
potential discontinuance of the drug as required by Section
506C of the Federal Food, Drug, and Cosmetic Act, as
codified in 21 U.S.C. 356c, or the drug manufacturer has
removed the drug from the market.

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Nothing in this item (3) prohibits a health care plan,
by contract, written policy or procedure, or any other
agreement or course of conduct, from requiring a pharmacist
to effect substitutions of prescription drugs consistent
with Section 19.5 of the Pharmacy Practice Act, under which
a pharmacist may substitute an interchangeable biologic
for a prescribed biologic product, and Section 25 of the
Pharmacy Practice Act, under which a pharmacist may select
a generic drug determined to be therapeutically equivalent
by the United States Food and Drug Administration and in
accordance with the Illinois Food, Drug and Cosmetic Act.
This item (3) applies to a policy or contract that is
amended, delivered, issued, or renewed on or after January
1, 2019. This item (3) does not apply to a health plan as
defined in the State Employees Group Insurance Act of 1971
or medical assistance under Article V of the Illinois
Public Aid Code.
(b) A health care plan shall provide for continuity of care
for new enrollees as follows:
(1) If a new enrollee whose physician is not a member
of the health care plan's provider network, but is within
the health care plan's service area, enrolls in the health
care plan, the health care plan shall permit the enrollee
to continue an ongoing course of treatment with the
enrollee's current physician during a transitional period:
(A) of 90 days from the effective date of

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enrollment if the enrollee has an ongoing course of
treatment; or
(B) if the enrollee has entered the third trimester
of pregnancy at the effective date of enrollment, that
includes the provision of post-partum care directly
related to the delivery.
(2) If an enrollee elects to continue to receive care
from such physician pursuant to item (1) of this
subsection, such care shall be authorized by the health
care plan for the transitional period only if the physician
agrees:
(A) to accept reimbursement from the health care
plan at rates established by the health care plan; such
rates shall be the level of reimbursement applicable to
similar physicians within the health care plan for such
services;
(B) to adhere to the health care plan's quality
assurance requirements and to provide to the health
care plan necessary medical information related to
such care; and
(C) to otherwise adhere to the health care plan's
policies and procedures including, but not limited to
procedures regarding referrals and obtaining
preauthorization for treatment.
(c) In no event shall this Section be construed to require
a health care plan to provide coverage for benefits not

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otherwise covered or to diminish or impair preexisting
condition limitations contained in the enrollee's contract. In
no event shall this Section be construed to prohibit the
addition of prescription drugs to a health care plan's list of
covered drugs during the coverage year.
(Source: P.A. 91-617, eff. 7-1-00.)
Section 99. Effective date. This Act takes effect upon
becoming law.