Sen. Heather A. Steans

Filed: 5/18/2018





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2    AMENDMENT NO. ______. Amend House Bill 4146 by replacing
3everything after the enacting clause with the following:
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



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1    treatment with that physician during a transitional
2    period:
3            (A) of 90 days from the date of the notice of
4        physician's termination from the health care plan to
5        the enrollee of the physician's disaffiliation from
6        the health care plan if the enrollee has an ongoing
7        course of treatment; or
8            (B) if the enrollee has entered the third trimester
9        of pregnancy at the time of the physician's
10        disaffiliation, that includes the provision of
11        post-partum care directly related to the delivery.
12        (2) Notwithstanding the provisions in item (1) of this
13    subsection, such care shall be authorized by the health
14    care plan during the transitional period only if the
15    physician agrees:
16            (A) to continue to accept reimbursement from the
17        health care plan at the rates applicable prior to the
18        start of the transitional period;
19            (B) to adhere to the health care plan's quality
20        assurance requirements and to provide to the health
21        care plan necessary medical information related to
22        such care; and
23            (C) to otherwise adhere to the health care plan's
24        policies and procedures, including but not limited to
25        procedures regarding referrals and obtaining
26        preauthorizations for treatment.



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1        (3) During an enrollee's plan year, a health care plan
2    shall not remove a drug from its formulary or negatively
3    change its preferred or cost-tier sharing unless, at least
4    60 days before making the formulary change, the health care
5    plan:
6            (A) provides general notification of the change in
7        its formulary to current and prospective enrollees;
8            (B) directly notifies enrollees currently
9        receiving coverage for the drug, including information
10        on the specific drugs involved and the steps they may
11        take to request coverage determinations and
12        exceptions, including a statement that a certification
13        of medical necessity by the enrollee's prescribing
14        provider will result in continuation of coverage at the
15        existing level; and
16            (C) directly notifies by first class mail and
17        through an electronic transmission, if available, the
18        prescribing provider of all health care plan enrollees
19        currently prescribed the drug affected by the proposed
20        change; the notice shall include a one-page form by
21        which the prescribing provider can notify the health
22        care plan by first class mail that coverage of the drug
23        for the enrollee is medically necessary.
24        The notification in paragraph (C) may direct the
25    prescribing provider to an electronic portal through which
26    the prescribing provider may electronically file a



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1    certification to the health care plan that coverage of the
2    drug for the enrollee is medically necessary. The
3    prescribing provider may make a secure electronic
4    signature beside the words "certification of medical
5    necessity", and this certification shall authorize
6    continuation of coverage for the drug.
7        If the prescribing provider certifies to the health
8    care plan either in writing or electronically that the drug
9    is medically necessary for the enrollee as provided in
10    paragraph (C), a health care plan shall authorize coverage
11    for the drug prescribed based solely on the prescribing
12    provider's assertion that coverage is medically necessary,
13    and the health care plan is prohibited from making
14    modifications to the coverage related to the covered drug,
15    including, but not limited to:
16            (i) increasing the out-of-pocket costs for the
17        covered drug;
18            (ii) moving the covered drug to a more restrictive
19        tier; or
20            (iii) denying an enrollee coverage of the drug for
21        which the enrollee has been previously approved for
22        coverage by the health care plan.
23        Nothing in this item (3) prevents a health care plan
24    from removing a drug from its formulary or denying an
25    enrollee coverage if the United States Food and Drug
26    Administration has issued a statement about the drug that



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1    calls into question the clinical safety of the drug, the
2    drug manufacturer has notified the United States Food and
3    Drug Administration of a manufacturing discontinuance or
4    potential discontinuance of the drug as required by Section
5    506C of the Federal Food, Drug, and Cosmetic Act, as
6    codified in 21 U.S.C. 356c, or the drug manufacturer has
7    removed the drug from the market.
8        Nothing in this item (3) prohibits a health care plan,
9    by contract, written policy or procedure, or any other
10    agreement or course of conduct, from requiring a pharmacist
11    to effect substitutions of prescription drugs consistent
12    with Section 19.5 of the Pharmacy Practice Act, under which
13    a pharmacist may substitute an interchangeable biologic
14    for a prescribed biologic product, and Section 25 of the
15    Pharmacy Practice Act, under which a pharmacist may select
16    a generic drug determined to be therapeutically equivalent
17    by the United States Food and Drug Administration and in
18    accordance with the Illinois Food, Drug and Cosmetic Act.
19        This item (3) applies to a policy or contract that is
20    amended, delivered, issued, or renewed on or after January
21    1, 2019. This item (3) does not apply to a health plan as
22    defined in the State Employees Group Insurance Act of 1971
23    or medical assistance under Article V of the Illinois
24    Public Aid Code.
25    (b) A health care plan shall provide for continuity of care
26for new enrollees as follows:



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1        (1) If a new enrollee whose physician is not a member
2    of the health care plan's provider network, but is within
3    the health care plan's service area, enrolls in the health
4    care plan, the health care plan shall permit the enrollee
5    to continue an ongoing course of treatment with the
6    enrollee's current physician during a transitional period:
7            (A) of 90 days from the effective date of
8        enrollment if the enrollee has an ongoing course of
9        treatment; or
10            (B) if the enrollee has entered the third trimester
11        of pregnancy at the effective date of enrollment, that
12        includes the provision of post-partum care directly
13        related to the delivery.
14        (2) If an enrollee elects to continue to receive care
15    from such physician pursuant to item (1) of this
16    subsection, such care shall be authorized by the health
17    care plan for the transitional period only if the physician
18    agrees:
19            (A) to accept reimbursement from the health care
20        plan at rates established by the health care plan; such
21        rates shall be the level of reimbursement applicable to
22        similar physicians within the health care plan for such
23        services;
24            (B) to adhere to the health care plan's quality
25        assurance requirements and to provide to the health
26        care plan necessary medical information related to



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1        such care; and
2            (C) to otherwise adhere to the health care plan's
3        policies and procedures including, but not limited to
4        procedures regarding referrals and obtaining
5        preauthorization for treatment.
6    (c) In no event shall this Section be construed to require
7a health care plan to provide coverage for benefits not
8otherwise covered or to diminish or impair preexisting
9condition limitations contained in the enrollee's contract. In
10no event shall this Section be construed to prohibit the
11addition of prescription drugs to a health care plan's list of
12covered drugs during the coverage year.
13(Source: P.A. 91-617, eff. 7-1-00.)
14    Section 99. Effective date. This Act takes effect upon
15becoming law.".