100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4146

 

Introduced , by Rep. Laura Fine

 

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. 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.


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A BILL FOR

 

HB4146LRB100 14115 SMS 28871 b

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            This paragraph (3) does not apply to a health plan
14as defined in the State Employees Group Insurance Act of 1971
15or medical assistance under Article V of the Illinois Public
16Aid Code.
17    (b) A health care plan shall provide for continuity of care
18for new enrollees as follows:
19        (1) If a new enrollee whose physician is not a member
20    of the health care plan's provider network, but is within
21    the health care plan's service area, enrolls in the health
22    care plan, the health care plan shall permit the enrollee
23    to continue an ongoing course of treatment with the
24    enrollee's current physician during a transitional period:
25            (A) of 90 days from the effective date of
26        enrollment if the enrollee has an ongoing course of

 

 

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

 

 

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1condition limitations contained in the enrollee's contract. In
2no event shall this Section be construed to prohibit the
3addition of prescription drugs to a health care plan's list of
4covered drugs during the coverage year.
5(Source: P.A. 91-617, eff. 7-1-00.)
 
6    Section 99. Effective date. This Act takes effect upon
7becoming law.