HB4146 EnrolledLRB100 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) During an enrollee's plan year, a health care plan
21    shall not remove a drug from its formulary or negatively
22    change its preferred or cost-tier sharing unless, at least
23    60 days before making the formulary change, the health care
24    plan:
25            (A) provides general notification of the change in
26        its formulary to current and prospective enrollees;



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1            (B) directly notifies enrollees currently
2        receiving coverage for the drug, including information
3        on the specific drugs involved and the steps they may
4        take to request coverage determinations and
5        exceptions, including a statement that a certification
6        of medical necessity by the enrollee's prescribing
7        provider will result in continuation of coverage at the
8        existing level; and
9            (C) directly notifies by first class mail and
10        through an electronic transmission, if available, the
11        prescribing provider of all health care plan enrollees
12        currently prescribed the drug affected by the proposed
13        change; the notice shall include a one-page form by
14        which the prescribing provider can notify the health
15        care plan by first class mail that coverage of the drug
16        for the enrollee is medically necessary.
17        The notification in paragraph (C) may direct the
18    prescribing provider to an electronic portal through which
19    the prescribing provider may electronically file a
20    certification to the health care plan that coverage of the
21    drug for the enrollee is medically necessary. The
22    prescribing provider may make a secure electronic
23    signature beside the words "certification of medical
24    necessity", and this certification shall authorize
25    continuation of coverage for the drug.
26        If the prescribing provider certifies to the health



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1    care plan either in writing or electronically that the drug
2    is medically necessary for the enrollee as provided in
3    paragraph (C), a health care plan shall authorize coverage
4    for the drug prescribed based solely on the prescribing
5    provider's assertion that coverage is medically necessary,
6    and the health care plan is prohibited from making
7    modifications to the coverage related to the covered drug,
8    including, but not limited to:
9            (i) increasing the out-of-pocket costs for the
10        covered drug;
11            (ii) moving the covered drug to a more restrictive
12        tier; or
13            (iii) denying an enrollee coverage of the drug for
14        which the enrollee has been previously approved for
15        coverage by the health care plan.
16        Nothing in this item (3) prevents a health care plan
17    from removing a drug from its formulary or denying an
18    enrollee coverage if the United States Food and Drug
19    Administration has issued a statement about the drug that
20    calls into question the clinical safety of the drug, the
21    drug manufacturer has notified the United States Food and
22    Drug Administration of a manufacturing discontinuance or
23    potential discontinuance of the drug as required by Section
24    506C of the Federal Food, Drug, and Cosmetic Act, as
25    codified in 21 U.S.C. 356c, or the drug manufacturer has
26    removed the drug from the market.



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1        Nothing in this item (3) prohibits a health care plan,
2    by contract, written policy or procedure, or any other
3    agreement or course of conduct, from requiring a pharmacist
4    to effect substitutions of prescription drugs consistent
5    with Section 19.5 of the Pharmacy Practice Act, under which
6    a pharmacist may substitute an interchangeable biologic
7    for a prescribed biologic product, and Section 25 of the
8    Pharmacy Practice Act, under which a pharmacist may select
9    a generic drug determined to be therapeutically equivalent
10    by the United States Food and Drug Administration and in
11    accordance with the Illinois Food, Drug and Cosmetic Act.
12        This item (3) applies to a policy or contract that is
13    amended, delivered, issued, or renewed on or after January
14    1, 2019. This item (3) does not apply to a health plan as
15    defined in the State Employees Group Insurance Act of 1971
16    or medical assistance under Article V of the Illinois
17    Public Aid Code.
18    (b) A health care plan shall provide for continuity of care
19for new enrollees as follows:
20        (1) If a new enrollee whose physician is not a member
21    of the health care plan's provider network, but is within
22    the health care plan's service area, enrolls in the health
23    care plan, the health care plan shall permit the enrollee
24    to continue an ongoing course of treatment with the
25    enrollee's current physician during a transitional period:
26            (A) of 90 days from the effective date of



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



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1otherwise covered or to diminish or impair preexisting
2condition limitations contained in the enrollee's contract. In
3no event shall this Section be construed to prohibit the
4addition of prescription drugs to a health care plan's list of
5covered drugs during the coverage year.
6(Source: P.A. 91-617, eff. 7-1-00.)
7    Section 99. Effective date. This Act takes effect upon
8becoming law.