HB2472 EnrolledLRB103 28761 BMS 55144 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 Illinois Insurance Code is amended by
5changing Sections 143.31, 155.36, 315.6, and 370s as follows:
 
6    (215 ILCS 5/143.31)
7    Sec. 143.31. Uniform medical claim and billing forms.
8    (a) The Director shall prescribe by rule, after
9consultation with providers of health care or treatment,
10insurers, hospital, medical, and dental service corporations,
11and other prepayment organizations, insurance claim and
12billing forms that the Director determines will provide for
13uniformity and simplicity in insurance claims handling. The
14claim forms shall include, but need not be limited to,
15information regarding the medical diagnosis, treatment, and
16prognosis of the patient, together with the details of charges
17incident to the providing of care, treatment, or services,
18sufficient for the purpose of meeting the proof requirements
19of an insurance policy or a hospital, medical, or dental
20service contract.
21    (b) An insurer or a provider of health care treatment may
22not refuse to accept a claim or bill submitted on duly
23promulgated uniform claim and billing forms. An insurer,

 

 

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1however, may accept claims and bills submitted on any other
2form.
3    (c) After receipt and adjudication or readjudication of
4any claim or bill with all required documentation from an
5insured or provider, or a notification under 42 U.S.C.
6300gg-136, an accident Accident and health insurer shall send
7explanation of benefits paid statements or claims summary
8statements sent to an insured by the accident and health
9insurer shall be in a format and written in a manner that
10promotes understanding by the insured by setting forth all of
11the following:
12        (1) The total dollar amount submitted to the insurer
13    for payment.
14        (2) Any reduction in the amount paid due to the
15    application of any co-payment, coinsurance, or deductible,
16    along with an explanation of the amount of the co-payment,
17    coinsurance, or deductible applied under the insured's
18    policy.
19        (3) Any reduction in the amount paid due to the
20    application of any other policy limitation, penalty, or
21    exclusion set forth in the insured's policy, along with an
22    explanation thereof.
23        (4) The total dollar amount paid.
24        (5) The total dollar amount remaining unpaid.
25        (6) If applicable under 42 U.S.C. 300gg-111 or 42
26    U.S.C. 300gg-115, other information required for any

 

 

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1    explanation of benefits described in either of those
2    Sections.
3    (d) The Director may issue an order directing an accident
4and health insurer to comply with subsection (c).
5    (e) An accident and health insurer does not violate
6subsection (c) by using a document that the accident and
7health insurer is required to use by the federal government or
8the State.
9    (f) The adoption of uniform claim forms and uniform
10billing forms by the Director under this Section does not
11preclude an insurer, hospital, medical, or dental service
12corporation, or other prepayment organization from obtaining
13any necessary additional information regarding a claim from
14the claimant, provider of health care or treatment, or
15certifier of coverage, as may be required.
16    (g) On and after January 1, 1996 when billing insurers or
17otherwise filing insurance claims with insurers subject to
18this Section, providers of health care or treatment, medical
19services, dental services, pharmaceutical services, or medical
20equipment must use the uniform claim and billing forms adopted
21by the Director under this Section.
22(Source: P.A. 91-357, eff. 7-29-99.)
 
23    (215 ILCS 5/155.36)
24    Sec. 155.36. Managed Care Reform and Patient Rights Act.
25Insurance companies that transact the kinds of insurance

 

 

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1authorized under Class 1(b) or Class 2(a) of Section 4 of this
2Code shall comply with Sections 25, 45, 45.1, 45.2, 45.3, 65,
370, and 85, subsection (d) of Section 30, and the definition of
4the term "emergency medical condition" in Section 10 of the
5Managed Care Reform and Patient Rights Act. Except as provided
6by Section 85 of the Managed Care Reform and Patient Rights
7Act, no law or rule shall be construed to exempt any
8utilization review program from the requirements of Section 85
9of the Managed Care Reform and Patient Rights Act with respect
10to any insurance described in this Section.
11(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
12    (215 ILCS 5/315.6)  (from Ch. 73, par. 927.6)
13    (Section scheduled to be repealed on January 1, 2027)
14    Sec. 315.6. Application of other Code provisions. Unless
15otherwise provided in this amendatory Act, every fraternal
16benefit society shall be governed by this amendatory Act and
17shall be exempt from all other provisions of the insurance
18laws of this State not only in governmental relations with the
19State but for every other purpose, except for those provisions
20specified in this amendatory Act and except as follows:
21        (a) Sections 1, 2, 2.1, 3.1, 117, 118, 132, 132.1,
22    132.2, 132.3, 132.4, 132.5, 132.6, 132.7, 133, 134, 136,
23    138, 139, 140, 141, 141.01, 141.1, 141.2, 141.3, 143,
24    143.31, 143c, 144.1, 147, 148, 149, 150, 151, 152, 153,
25    154.5, 154.6, 154.7, 154.8, 155, 155.04, 155.05, 155.06,

 

 

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1    155.07, 155.08 and 408 of this Code; and
2        (b) Articles VIII 1/2, XII, XII 1/2, XIII, XXIV, and
3    XXVIII of this Code.
4(Source: P.A. 98-814, eff. 1-1-15.)
 
5    (215 ILCS 5/370s)
6    Sec. 370s. Managed Care Reform and Patient Rights Act. All
7administrators shall comply with Sections 55 and 85 of the
8Managed Care Reform and Patient Rights Act. Except as provided
9by Section 85 of the Managed Care Reform and Patient Rights
10Act, no law or rule shall be construed to exempt any
11utilization review program from the requirements of Section 85
12of the Managed Care Reform and Patient Rights Act with respect
13to any insured or beneficiary described in this Article.
14(Source: P.A. 91-617, eff. 1-1-00.)
 
15    Section 10. The Dental Service Plan Act is amended by
16changing Section 25 as follows:
 
17    (215 ILCS 110/25)  (from Ch. 32, par. 690.25)
18    Sec. 25. Application of Insurance Code provisions. Dental
19service plan corporations and all persons interested therein
20or dealing therewith shall be subject to the provisions of
21Articles IIA, XI, and XII 1/2 and Sections 3.1, 133, 136, 139,
22140, 143, 143.31, 143c, 149, 155.49, 355.2, 355.3, 367.2, 401,
23401.1, 402, 403, 403A, 408, 408.2, and 412, and subsection

 

 

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1(15) of Section 367 of the Illinois Insurance Code.
2(Source: P.A. 103-426, eff. 8-4-23.)
 
3    Section 15. The Network Adequacy and Transparency Act is
4amended by changing Section 10 as follows:
 
5    (215 ILCS 124/10)
6    Sec. 10. Network adequacy.
7    (a) An insurer providing a network plan shall file a
8description of all of the following with the Director:
9        (1) The written policies and procedures for adding
10    providers to meet patient needs based on increases in the
11    number of beneficiaries, changes in the
12    patient-to-provider ratio, changes in medical and health
13    care capabilities, and increased demand for services.
14        (2) The written policies and procedures for making
15    referrals within and outside the network.
16        (3) The written policies and procedures on how the
17    network plan will provide 24-hour, 7-day per week access
18    to network-affiliated primary care, emergency services,
19    and women's principal health care providers.
20    An insurer shall not prohibit a preferred provider from
21discussing any specific or all treatment options with
22beneficiaries irrespective of the insurer's position on those
23treatment options or from advocating on behalf of
24beneficiaries within the utilization review, grievance, or

 

 

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1appeals processes established by the insurer in accordance
2with any rights or remedies available under applicable State
3or federal law.
4    (b) Insurers must file for review a description of the
5services to be offered through a network plan. The description
6shall include all of the following:
7        (1) A geographic map of the area proposed to be served
8    by the plan by county service area and zip code, including
9    marked locations for preferred providers.
10        (2) As deemed necessary by the Department, the names,
11    addresses, phone numbers, and specialties of the providers
12    who have entered into preferred provider agreements under
13    the network plan.
14        (3) The number of beneficiaries anticipated to be
15    covered by the network plan.
16        (4) An Internet website and toll-free telephone number
17    for beneficiaries and prospective beneficiaries to access
18    current and accurate lists of preferred providers,
19    additional information about the plan, as well as any
20    other information required by Department rule.
21        (5) A description of how health care services to be
22    rendered under the network plan are reasonably accessible
23    and available to beneficiaries. The description shall
24    address all of the following:
25            (A) the type of health care services to be
26        provided by the network plan;

 

 

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1            (B) the ratio of physicians and other providers to
2        beneficiaries, by specialty and including primary care
3        physicians and facility-based physicians when
4        applicable under the contract, necessary to meet the
5        health care needs and service demands of the currently
6        enrolled population;
7            (C) the travel and distance standards for plan
8        beneficiaries in county service areas; and
9            (D) a description of how the use of telemedicine,
10        telehealth, or mobile care services may be used to
11        partially meet the network adequacy standards, if
12        applicable.
13        (6) A provision ensuring that whenever a beneficiary
14    has made a good faith effort, as evidenced by accessing
15    the provider directory, calling the network plan, and
16    calling the provider, to utilize preferred providers for a
17    covered service and it is determined the insurer does not
18    have the appropriate preferred providers due to
19    insufficient number, type, unreasonable travel distance or
20    delay, or preferred providers refusing to provide a
21    covered service because it is contrary to the conscience
22    of the preferred providers, as protected by the Health
23    Care Right of Conscience Act, the insurer shall ensure,
24    directly or indirectly, by terms contained in the payer
25    contract, that the beneficiary will be provided the
26    covered service at no greater cost to the beneficiary than

 

 

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1    if the service had been provided by a preferred provider.
2    This paragraph (6) does not apply to: (A) a beneficiary
3    who willfully chooses to access a non-preferred provider
4    for health care services available through the panel of
5    preferred providers, or (B) a beneficiary enrolled in a
6    health maintenance organization. In these circumstances,
7    the contractual requirements for non-preferred provider
8    reimbursements shall apply unless Section 356z.3a of the
9    Illinois Insurance Code requires otherwise. In no event
10    shall a beneficiary who receives care at a participating
11    health care facility be required to search for
12    participating providers under the circumstances described
13    in subsection (b) or (b-5) of Section 356z.3a of the
14    Illinois Insurance Code except under the circumstances
15    described in paragraph (2) of subsection (b-5).
16        (7) A provision that the beneficiary shall receive
17    emergency care coverage such that payment for this
18    coverage is not dependent upon whether the emergency
19    services are performed by a preferred or non-preferred
20    provider and the coverage shall be at the same benefit
21    level as if the service or treatment had been rendered by a
22    preferred provider. For purposes of this paragraph (7),
23    "the same benefit level" means that the beneficiary is
24    provided the covered service at no greater cost to the
25    beneficiary than if the service had been provided by a
26    preferred provider. This provision shall be consistent

 

 

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1    with Section 356z.3a of the Illinois Insurance Code.
2        (8) A limitation that complies with subsections (d)
3    and (e) of Section 55 of the Prior Authorization Reform
4    Act , if the plan provides that the beneficiary will incur
5    a penalty for failing to pre-certify inpatient hospital
6    treatment, the penalty may not exceed $1,000 per
7    occurrence in addition to the plan cost sharing
8    provisions.
9    (c) The network plan shall demonstrate to the Director a
10minimum ratio of providers to plan beneficiaries as required
11by the Department.
12        (1) The ratio of physicians or other providers to plan
13    beneficiaries shall be established annually by the
14    Department in consultation with the Department of Public
15    Health based upon the guidance from the federal Centers
16    for Medicare and Medicaid Services. The Department shall
17    not establish ratios for vision or dental providers who
18    provide services under dental-specific or vision-specific
19    benefits. The Department shall consider establishing
20    ratios for the following physicians or other providers:
21            (A) Primary Care;
22            (B) Pediatrics;
23            (C) Cardiology;
24            (D) Gastroenterology;
25            (E) General Surgery;
26            (F) Neurology;

 

 

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1            (G) OB/GYN;
2            (H) Oncology/Radiation;
3            (I) Ophthalmology;
4            (J) Urology;
5            (K) Behavioral Health;
6            (L) Allergy/Immunology;
7            (M) Chiropractic;
8            (N) Dermatology;
9            (O) Endocrinology;
10            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
11            (Q) Infectious Disease;
12            (R) Nephrology;
13            (S) Neurosurgery;
14            (T) Orthopedic Surgery;
15            (U) Physiatry/Rehabilitative;
16            (V) Plastic Surgery;
17            (W) Pulmonary;
18            (X) Rheumatology;
19            (Y) Anesthesiology;
20            (Z) Pain Medicine;
21            (AA) Pediatric Specialty Services;
22            (BB) Outpatient Dialysis; and
23            (CC) HIV.
24        (2) The Director shall establish a process for the
25    review of the adequacy of these standards, along with an
26    assessment of additional specialties to be included in the

 

 

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1    list under this subsection (c).
2    (d) The network plan shall demonstrate to the Director
3maximum travel and distance standards for plan beneficiaries,
4which shall be established annually by the Department in
5consultation with the Department of Public Health based upon
6the guidance from the federal Centers for Medicare and
7Medicaid Services. These standards shall consist of the
8maximum minutes or miles to be traveled by a plan beneficiary
9for each county type, such as large counties, metro counties,
10or rural counties as defined by Department rule.
11    The maximum travel time and distance standards must
12include standards for each physician and other provider
13category listed for which ratios have been established.
14    The Director shall establish a process for the review of
15the adequacy of these standards along with an assessment of
16additional specialties to be included in the list under this
17subsection (d).
18    (d-5)(1) Every insurer shall ensure that beneficiaries
19have timely and proximate access to treatment for mental,
20emotional, nervous, or substance use disorders or conditions
21in accordance with the provisions of paragraph (4) of
22subsection (a) of Section 370c of the Illinois Insurance Code.
23Insurers shall use a comparable process, strategy, evidentiary
24standard, and other factors in the development and application
25of the network adequacy standards for timely and proximate
26access to treatment for mental, emotional, nervous, or

 

 

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1substance use disorders or conditions and those for the access
2to treatment for medical and surgical conditions. As such, the
3network adequacy standards for timely and proximate access
4shall equally be applied to treatment facilities and providers
5for mental, emotional, nervous, or substance use disorders or
6conditions and specialists providing medical or surgical
7benefits pursuant to the parity requirements of Section 370c.1
8of the Illinois Insurance Code and the federal Paul Wellstone
9and Pete Domenici Mental Health Parity and Addiction Equity
10Act of 2008. Notwithstanding the foregoing, the network
11adequacy standards for timely and proximate access to
12treatment for mental, emotional, nervous, or substance use
13disorders or conditions shall, at a minimum, satisfy the
14following requirements:
15        (A) For beneficiaries residing in the metropolitan
16    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
17    network adequacy standards for timely and proximate access
18    to treatment for mental, emotional, nervous, or substance
19    use disorders or conditions means a beneficiary shall not
20    have to travel longer than 30 minutes or 30 miles from the
21    beneficiary's residence to receive outpatient treatment
22    for mental, emotional, nervous, or substance use disorders
23    or conditions. Beneficiaries shall not be required to wait
24    longer than 10 business days between requesting an initial
25    appointment and being seen by the facility or provider of
26    mental, emotional, nervous, or substance use disorders or

 

 

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1    conditions for outpatient treatment or to wait longer than
2    20 business days between requesting a repeat or follow-up
3    appointment and being seen by the facility or provider of
4    mental, emotional, nervous, or substance use disorders or
5    conditions for outpatient treatment; however, subject to
6    the protections of paragraph (3) of this subsection, a
7    network plan shall not be held responsible if the
8    beneficiary or provider voluntarily chooses to schedule an
9    appointment outside of these required time frames.
10        (B) For beneficiaries residing in Illinois counties
11    other than those counties listed in subparagraph (A) of
12    this paragraph, network adequacy standards for timely and
13    proximate access to treatment for mental, emotional,
14    nervous, or substance use disorders or conditions means a
15    beneficiary shall not have to travel longer than 60
16    minutes or 60 miles from the beneficiary's residence to
17    receive outpatient treatment for mental, emotional,
18    nervous, or substance use disorders or conditions.
19    Beneficiaries shall not be required to wait longer than 10
20    business days between requesting an initial appointment
21    and being seen by the facility or provider of mental,
22    emotional, nervous, or substance use disorders or
23    conditions for outpatient treatment or to wait longer than
24    20 business days between requesting a repeat or follow-up
25    appointment and being seen by the facility or provider of
26    mental, emotional, nervous, or substance use disorders or

 

 

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1    conditions for outpatient treatment; however, subject to
2    the protections of paragraph (3) of this subsection, a
3    network plan shall not be held responsible if the
4    beneficiary or provider voluntarily chooses to schedule an
5    appointment outside of these required time frames.
6    (2) For beneficiaries residing in all Illinois counties,
7network adequacy standards for timely and proximate access to
8treatment for mental, emotional, nervous, or substance use
9disorders or conditions means a beneficiary shall not have to
10travel longer than 60 minutes or 60 miles from the
11beneficiary's residence to receive inpatient or residential
12treatment for mental, emotional, nervous, or substance use
13disorders or conditions.
14    (3) If there is no in-network facility or provider
15available for a beneficiary to receive timely and proximate
16access to treatment for mental, emotional, nervous, or
17substance use disorders or conditions in accordance with the
18network adequacy standards outlined in this subsection, the
19insurer shall provide necessary exceptions to its network to
20ensure admission and treatment with a provider or at a
21treatment facility in accordance with the network adequacy
22standards in this subsection.
23    (e) Except for network plans solely offered as a group
24health plan, these ratio and time and distance standards apply
25to the lowest cost-sharing tier of any tiered network.
26    (f) The network plan may consider use of other health care

 

 

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1service delivery options, such as telemedicine or telehealth,
2mobile clinics, and centers of excellence, or other ways of
3delivering care to partially meet the requirements set under
4this Section.
5    (g) Except for the requirements set forth in subsection
6(d-5), insurers who are not able to comply with the provider
7ratios and time and distance standards established by the
8Department may request an exception to these requirements from
9the Department. The Department may grant an exception in the
10following circumstances:
11        (1) if no providers or facilities meet the specific
12    time and distance standard in a specific service area and
13    the insurer (i) discloses information on the distance and
14    travel time points that beneficiaries would have to travel
15    beyond the required criterion to reach the next closest
16    contracted provider outside of the service area and (ii)
17    provides contact information, including names, addresses,
18    and phone numbers for the next closest contracted provider
19    or facility;
20        (2) if patterns of care in the service area do not
21    support the need for the requested number of provider or
22    facility type and the insurer provides data on local
23    patterns of care, such as claims data, referral patterns,
24    or local provider interviews, indicating where the
25    beneficiaries currently seek this type of care or where
26    the physicians currently refer beneficiaries, or both; or

 

 

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1        (3) other circumstances deemed appropriate by the
2    Department consistent with the requirements of this Act.
3    (h) Insurers are required to report to the Director any
4material change to an approved network plan within 15 days
5after the change occurs and any change that would result in
6failure to meet the requirements of this Act. Upon notice from
7the insurer, the Director shall reevaluate the network plan's
8compliance with the network adequacy and transparency
9standards of this Act.
10(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
11102-1117, eff. 1-13-23.)
 
12    Section 20. The Health Maintenance Organization Act is
13amended by changing Section 5-3 as follows:
 
14    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
15    Sec. 5-3. Insurance Code provisions.
16    (a) Health Maintenance Organizations shall be subject to
17the provisions of Sections 133, 134, 136, 137, 139, 140,
18141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
19152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
20155.49, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q,
21356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
22356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
23356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
24356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,

 

 

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1356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
2356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
3356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,
4356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
5356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
6356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
7368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
8408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
9subsection (2) of Section 367, and Articles IIA, VIII 1/2,
10XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
11Illinois Insurance Code.
12    (b) For purposes of the Illinois Insurance Code, except
13for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
14Health Maintenance Organizations in the following categories
15are deemed to be "domestic companies":
16        (1) a corporation authorized under the Dental Service
17    Plan Act or the Voluntary Health Services Plans Act;
18        (2) a corporation organized under the laws of this
19    State; or
20        (3) a corporation organized under the laws of another
21    state, 30% or more of the enrollees of which are residents
22    of this State, except a corporation subject to
23    substantially the same requirements in its state of
24    organization as is a "domestic company" under Article VIII
25    1/2 of the Illinois Insurance Code.
26    (c) In considering the merger, consolidation, or other

 

 

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1acquisition of control of a Health Maintenance Organization
2pursuant to Article VIII 1/2 of the Illinois Insurance Code,
3        (1) the Director shall give primary consideration to
4    the continuation of benefits to enrollees and the
5    financial conditions of the acquired Health Maintenance
6    Organization after the merger, consolidation, or other
7    acquisition of control takes effect;
8        (2)(i) the criteria specified in subsection (1)(b) of
9    Section 131.8 of the Illinois Insurance Code shall not
10    apply and (ii) the Director, in making his determination
11    with respect to the merger, consolidation, or other
12    acquisition of control, need not take into account the
13    effect on competition of the merger, consolidation, or
14    other acquisition of control;
15        (3) the Director shall have the power to require the
16    following information:
17            (A) certification by an independent actuary of the
18        adequacy of the reserves of the Health Maintenance
19        Organization sought to be acquired;
20            (B) pro forma financial statements reflecting the
21        combined balance sheets of the acquiring company and
22        the Health Maintenance Organization sought to be
23        acquired as of the end of the preceding year and as of
24        a date 90 days prior to the acquisition, as well as pro
25        forma financial statements reflecting projected
26        combined operation for a period of 2 years;

 

 

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1            (C) a pro forma business plan detailing an
2        acquiring party's plans with respect to the operation
3        of the Health Maintenance Organization sought to be
4        acquired for a period of not less than 3 years; and
5            (D) such other information as the Director shall
6        require.
7    (d) The provisions of Article VIII 1/2 of the Illinois
8Insurance Code and this Section 5-3 shall apply to the sale by
9any health maintenance organization of greater than 10% of its
10enrollee population (including, without limitation, the health
11maintenance organization's right, title, and interest in and
12to its health care certificates).
13    (e) In considering any management contract or service
14agreement subject to Section 141.1 of the Illinois Insurance
15Code, the Director (i) shall, in addition to the criteria
16specified in Section 141.2 of the Illinois Insurance Code,
17take into account the effect of the management contract or
18service agreement on the continuation of benefits to enrollees
19and the financial condition of the health maintenance
20organization to be managed or serviced, and (ii) need not take
21into account the effect of the management contract or service
22agreement on competition.
23    (f) Except for small employer groups as defined in the
24Small Employer Rating, Renewability and Portability Health
25Insurance Act and except for medicare supplement policies as
26defined in Section 363 of the Illinois Insurance Code, a

 

 

HB2472 Enrolled- 21 -LRB103 28761 BMS 55144 b

1Health Maintenance Organization may by contract agree with a
2group or other enrollment unit to effect refunds or charge
3additional premiums under the following terms and conditions:
4        (i) the amount of, and other terms and conditions with
5    respect to, the refund or additional premium are set forth
6    in the group or enrollment unit contract agreed in advance
7    of the period for which a refund is to be paid or
8    additional premium is to be charged (which period shall
9    not be less than one year); and
10        (ii) the amount of the refund or additional premium
11    shall not exceed 20% of the Health Maintenance
12    Organization's profitable or unprofitable experience with
13    respect to the group or other enrollment unit for the
14    period (and, for purposes of a refund or additional
15    premium, the profitable or unprofitable experience shall
16    be calculated taking into account a pro rata share of the
17    Health Maintenance Organization's administrative and
18    marketing expenses, but shall not include any refund to be
19    made or additional premium to be paid pursuant to this
20    subsection (f)). The Health Maintenance Organization and
21    the group or enrollment unit may agree that the profitable
22    or unprofitable experience may be calculated taking into
23    account the refund period and the immediately preceding 2
24    plan years.
25    The Health Maintenance Organization shall include a
26statement in the evidence of coverage issued to each enrollee

 

 

HB2472 Enrolled- 22 -LRB103 28761 BMS 55144 b

1describing the possibility of a refund or additional premium,
2and upon request of any group or enrollment unit, provide to
3the group or enrollment unit a description of the method used
4to calculate (1) the Health Maintenance Organization's
5profitable experience with respect to the group or enrollment
6unit and the resulting refund to the group or enrollment unit
7or (2) the Health Maintenance Organization's unprofitable
8experience with respect to the group or enrollment unit and
9the resulting additional premium to be paid by the group or
10enrollment unit.
11    In no event shall the Illinois Health Maintenance
12Organization Guaranty Association be liable to pay any
13contractual obligation of an insolvent organization to pay any
14refund authorized under this Section.
15    (g) Rulemaking authority to implement Public Act 95-1045,
16if any, is conditioned on the rules being adopted in
17accordance with all provisions of the Illinois Administrative
18Procedure Act and all rules and procedures of the Joint
19Committee on Administrative Rules; any purported rule not so
20adopted, for whatever reason, is unauthorized.
21(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
22102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
231-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
24eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
25102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
261-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,

 

 

HB2472 Enrolled- 23 -LRB103 28761 BMS 55144 b

1eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
2103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
36-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
4eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
5    Section 25. The Limited Health Service Organization Act is
6amended by changing Section 4003 as follows:
 
7    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
8    Sec. 4003. Illinois Insurance Code provisions. Limited
9health service organizations shall be subject to the
10provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
11141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153,
12154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49,
13355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10,
14356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
15356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
16356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
17364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
18444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
19XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
20Nothing in this Section shall require a limited health care
21plan to cover any service that is not a limited health service.
22For purposes of the Illinois Insurance Code, except for
23Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
24health service organizations in the following categories are

 

 

HB2472 Enrolled- 24 -LRB103 28761 BMS 55144 b

1deemed to be domestic companies:
2        (1) a corporation under the laws of this State; or
3        (2) a corporation organized under the laws of another
4    state, 30% or more of the enrollees of which are residents
5    of this State, except a corporation subject to
6    substantially the same requirements in its state of
7    organization as is a domestic company under Article VIII
8    1/2 of the Illinois Insurance Code.
9(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
10102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
111-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
12eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
13102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
141-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
15eff. 1-1-24; revised 8-29-23.)
 
16    Section 30. The Managed Care Reform and Patient Rights Act
17is amended by changing Sections 10, 45, and 85 as follows:
 
18    (215 ILCS 134/10)
19    Sec. 10. Definitions. In this Act:
20    For a health care plan under Section 45 or for a
21utilization review program under Section 85, "adverse
22determination" has the meaning given to that term in Section
2310 of the Health Carrier External Review Act "Adverse
24determination" means a determination by a health care plan

 

 

HB2472 Enrolled- 25 -LRB103 28761 BMS 55144 b

1under Section 45 or by a utilization review program under
2Section 85 that a health care service is not medically
3necessary.
4    "Clinical peer" means a health care professional who is in
5the same profession and the same or similar specialty as the
6health care provider who typically manages the medical
7condition, procedures, or treatment under review.
8    "Department" means the Department of Insurance.
9    "Emergency medical condition" means a medical condition
10manifesting itself by acute symptoms of sufficient severity,
11regardless of the final diagnosis given, such that a prudent
12layperson, who possesses an average knowledge of health and
13medicine, could reasonably expect the absence of immediate
14medical attention to result in:
15        (1) placing the health of the individual (or, with
16    respect to a pregnant woman, the health of the woman or her
17    unborn child) in serious jeopardy;
18        (2) serious impairment to bodily functions;
19        (3) serious dysfunction of any bodily organ or part;
20        (4) inadequately controlled pain; or
21        (5) with respect to a pregnant woman who is having
22    contractions:
23            (A) inadequate time to complete a safe transfer to
24        another hospital before delivery; or
25            (B) a transfer to another hospital may pose a
26        threat to the health or safety of the woman or unborn

 

 

HB2472 Enrolled- 26 -LRB103 28761 BMS 55144 b

1        child.
2    "Emergency medical screening examination" means a medical
3screening examination and evaluation by a physician licensed
4to practice medicine in all its branches, or to the extent
5permitted by applicable laws, by other appropriately licensed
6personnel under the supervision of or in collaboration with a
7physician licensed to practice medicine in all its branches to
8determine whether the need for emergency services exists.
9    "Emergency services" means, with respect to an enrollee of
10a health care plan, transportation services, including but not
11limited to ambulance services, and covered inpatient and
12outpatient hospital services furnished by a provider qualified
13to furnish those services that are needed to evaluate or
14stabilize an emergency medical condition. "Emergency services"
15does not refer to post-stabilization medical services.
16    "Enrollee" means any person and his or her dependents
17enrolled in or covered by a health care plan.
18    "Health care plan" means a plan, including, but not
19limited to, a health maintenance organization, a managed care
20community network as defined in the Illinois Public Aid Code,
21or an accountable care entity as defined in the Illinois
22Public Aid Code that receives capitated payments to cover
23medical services from the Department of Healthcare and Family
24Services, that establishes, operates, or maintains a network
25of health care providers that has entered into an agreement
26with the plan to provide health care services to enrollees to

 

 

HB2472 Enrolled- 27 -LRB103 28761 BMS 55144 b

1whom the plan has the ultimate obligation to arrange for the
2provision of or payment for services through organizational
3arrangements for ongoing quality assurance, utilization review
4programs, or dispute resolution. Nothing in this definition
5shall be construed to mean that an independent practice
6association or a physician hospital organization that
7subcontracts with a health care plan is, for purposes of that
8subcontract, a health care plan.
9    For purposes of this definition, "health care plan" shall
10not include the following:
11        (1) indemnity health insurance policies including
12    those using a contracted provider network;
13        (2) health care plans that offer only dental or only
14    vision coverage;
15        (3) preferred provider administrators, as defined in
16    Section 370g(g) of the Illinois Insurance Code;
17        (4) employee or employer self-insured health benefit
18    plans under the federal Employee Retirement Income
19    Security Act of 1974;
20        (5) health care provided pursuant to the Workers'
21    Compensation Act or the Workers' Occupational Diseases
22    Act; and
23        (6) except with respect to subsections (a) and (b) of
24    Section 65 and subsection (a-5) of Section 70,
25    not-for-profit voluntary health services plans with health
26    maintenance organization authority in existence as of

 

 

HB2472 Enrolled- 28 -LRB103 28761 BMS 55144 b

1    January 1, 1999 that are affiliated with a union and that
2    only extend coverage to union members and their
3    dependents.
4    "Health care professional" means a physician, a registered
5professional nurse, or other individual appropriately licensed
6or registered to provide health care services.
7    "Health care provider" means any physician, hospital
8facility, facility licensed under the Nursing Home Care Act,
9long-term care facility as defined in Section 1-113 of the
10Nursing Home Care Act, or other person that is licensed or
11otherwise authorized to deliver health care services. Nothing
12in this Act shall be construed to define Independent Practice
13Associations or Physician-Hospital Organizations as health
14care providers.
15    "Health care services" means any services included in the
16furnishing to any individual of medical care, or the
17hospitalization incident to the furnishing of such care, as
18well as the furnishing to any person of any and all other
19services for the purpose of preventing, alleviating, curing,
20or healing human illness or injury including behavioral
21health, mental health, home health, and pharmaceutical
22services and products.
23    "Medical director" means a physician licensed in any state
24to practice medicine in all its branches appointed by a health
25care plan.
26    "Person" means a corporation, association, partnership,

 

 

HB2472 Enrolled- 29 -LRB103 28761 BMS 55144 b

1limited liability company, sole proprietorship, or any other
2legal entity.
3    "Physician" means a person licensed under the Medical
4Practice Act of 1987.
5    "Post-stabilization medical services" means health care
6services provided to an enrollee that are furnished in a
7licensed hospital by a provider that is qualified to furnish
8such services, and determined to be medically necessary and
9directly related to the emergency medical condition following
10stabilization.
11    "Stabilization" means, with respect to an emergency
12medical condition, to provide such medical treatment of the
13condition as may be necessary to assure, within reasonable
14medical probability, that no material deterioration of the
15condition is likely to result.
16    "Utilization review" means the evaluation, including any
17evaluation based on an algorithmic automated process, of the
18medical necessity, appropriateness, and efficiency of the use
19of health care services, procedures, and facilities.
20    "Utilization review program" means a program established
21by a person to perform utilization review.
22(Source: P.A. 102-409, eff. 1-1-22; 103-426, eff. 8-4-23.)
 
23    (215 ILCS 134/45)
24    Sec. 45. Health care services appeals, complaints, and
25external independent reviews.

 

 

HB2472 Enrolled- 30 -LRB103 28761 BMS 55144 b

1    (a) A health care plan shall establish and maintain an
2appeals procedure as outlined in this Act. Compliance with
3this Act's appeals procedures shall satisfy a health care
4plan's obligation to provide appeal procedures under any other
5State law or rules. All appeals of a health care plan's
6administrative determinations and complaints regarding its
7administrative decisions shall be handled as required under
8Section 50.
9    (b) When an appeal concerns a decision or action by a
10health care plan, its employees, or its subcontractors that
11relates to (i) health care services, including, but not
12limited to, procedures or treatments, for an enrollee with an
13ongoing course of treatment ordered by a health care provider,
14the denial of which could significantly increase the risk to
15an enrollee's health, or (ii) a treatment referral, service,
16procedure, or other health care service, the denial of which
17could significantly increase the risk to an enrollee's health,
18the health care plan must allow for the filing of an appeal
19either orally or in writing. Upon submission of the appeal, a
20health care plan must notify the party filing the appeal, as
21soon as possible, but in no event more than 24 hours after the
22submission of the appeal, of all information that the plan
23requires to evaluate the appeal. The health care plan shall
24render a decision on the appeal within 24 hours after receipt
25of the required information. The health care plan shall notify
26the party filing the appeal and the enrollee, enrollee's

 

 

HB2472 Enrolled- 31 -LRB103 28761 BMS 55144 b

1primary care physician, and any health care provider who
2recommended the health care service involved in the appeal of
3its decision orally followed-up by a written notice of the
4determination.
5    (c) For all appeals related to health care services
6including, but not limited to, procedures or treatments for an
7enrollee and not covered by subsection (b) above, the health
8care plan shall establish a procedure for the filing of such
9appeals. Upon submission of an appeal under this subsection, a
10health care plan must notify the party filing an appeal,
11within 3 business days, of all information that the plan
12requires to evaluate the appeal. The health care plan shall
13render a decision on the appeal within 15 business days after
14receipt of the required information. The health care plan
15shall notify the party filing the appeal, the enrollee, the
16enrollee's primary care physician, and any health care
17provider who recommended the health care service involved in
18the appeal orally of its decision followed-up by a written
19notice of the determination.
20    (d) An appeal under subsection (b) or (c) may be filed by
21the enrollee, the enrollee's designee or guardian, the
22enrollee's primary care physician, or the enrollee's health
23care provider. A health care plan shall designate a clinical
24peer to review appeals, because these appeals pertain to
25medical or clinical matters and such an appeal must be
26reviewed by an appropriate health care professional. No one

 

 

HB2472 Enrolled- 32 -LRB103 28761 BMS 55144 b

1reviewing an appeal may have had any involvement in the
2initial determination that is the subject of the appeal. The
3written notice of determination required under subsections (b)
4and (c) shall include (i) clear and detailed reasons for the
5determination, (ii) the medical or clinical criteria for the
6determination, which shall be based upon sound clinical
7evidence and reviewed on a periodic basis, and (iii) in the
8case of an adverse determination, the procedures for
9requesting an external independent review as provided by the
10Illinois Health Carrier External Review Act.
11    (e) If an appeal filed under subsection (b) or (c) is
12denied for a reason including, but not limited to, the
13service, procedure, or treatment is not viewed as medically
14necessary, denial of specific tests or procedures, denial of
15referral to specialist physicians or denial of hospitalization
16requests or length of stay requests, any involved party may
17request an external independent review as provided by the
18Illinois Health Carrier External Review Act.
19    (f) Until July 1, 2013, if an external independent review
20decision made pursuant to the Illinois Health Carrier External
21Review Act upholds a determination adverse to the covered
22person, the covered person has the right to appeal the final
23decision to the Department; if the external review decision is
24found by the Director to have been arbitrary and capricious,
25then the Director, with consultation from a licensed medical
26professional, may overturn the external review decision and

 

 

HB2472 Enrolled- 33 -LRB103 28761 BMS 55144 b

1require the health carrier to pay for the health care service
2or treatment; such decision, if any, shall be made solely on
3the legal or medical merits of the claim. If an external review
4decision is overturned by the Director pursuant to this
5Section and the health carrier so requests, then the Director
6shall assign a new independent review organization to
7reconsider the overturned decision. The new independent review
8organization shall follow subsection (d) of Section 40 of the
9Health Carrier External Review Act in rendering a decision.
10    (g) Future contractual or employment action by the health
11care plan regarding the patient's physician or other health
12care provider shall not be based solely on the physician's or
13other health care provider's participation in health care
14services appeals, complaints, or external independent reviews
15under the Illinois Health Carrier External Review Act.
16    (h) Nothing in this Section shall be construed to require
17a health care plan to pay for a health care service not covered
18under the enrollee's certificate of coverage or policy.
19    (i) Even if a health care plan or other utilization review
20program uses an algorithmic automated process in the course of
21utilization review for medical necessity, the health care plan
22or other utilization review program shall ensure that only a
23clinical peer makes any adverse determination based on medical
24necessity and that any subsequent appeal is processed as
25required by this Section, including the restriction that only
26a clinical peer may review an appeal. A health care plan or

 

 

HB2472 Enrolled- 34 -LRB103 28761 BMS 55144 b

1other utilization review program using an automated process
2shall have the accreditation and the policies and procedures
3required by subsection (b-10) of Section 85 of this Act.
4(Source: P.A. 96-857, eff. 7-1-10.)
 
5    (215 ILCS 134/85)
6    Sec. 85. Utilization review program registration.
7    (a) No person may conduct a utilization review program in
8this State unless once every 2 years the person registers the
9utilization review program with the Department and provides
10proof of current accreditation for itself and its
11subcontractors certifies compliance with the Health
12Utilization Management Standards of the Utilization Review
13Accreditation Commission, the National Committee for Quality
14Assurance, or another accreditation entity authorized under
15this Section Health Utilization Management Standards of the
16American Accreditation Healthcare Commission (URAC) sufficient
17to achieve American Accreditation Healthcare Commission (URAC)
18accreditation or submits evidence of accreditation by the
19American Accreditation Healthcare Commission (URAC) for its
20Health Utilization Management Standards. Nothing in this Act
21shall be construed to require a health care plan or its
22subcontractors to become American Accreditation Healthcare
23Commission (URAC) accredited.
24    (b) In addition, the Director of the Department, in
25consultation with the Director of the Department of Public

 

 

HB2472 Enrolled- 35 -LRB103 28761 BMS 55144 b

1Health, may certify alternative utilization review standards
2of national accreditation organizations or entities in order
3for plans to comply with this Section. Any alternative
4utilization review standards shall meet or exceed those
5standards required under subsection (a).
6    (b-5) The Department shall recognize the Accreditation
7Association for Ambulatory Health Care among the list of
8accreditors from which utilization organizations may receive
9accreditation and qualify for reduced registration and renewal
10fees.
11    (b-10) Utilization review programs that use algorithmic
12automated processes to decide whether to render adverse
13determinations based on medical necessity in the course of
14utilization review shall use objective, evidence-based
15criteria compliant with the accreditation requirements of the
16Health Utilization Management Standards of the Utilization
17Review Accreditation Commission or the National Committee for
18Quality Assurance (NCQA) and shall provide proof of such
19compliance to the Department with the registration required
20under subsection (a), including any renewal registrations.
21Nothing in this subsection supersedes paragraph (2) of
22subsection (e). The utilization review program shall include,
23with its registration materials, attachments that contain
24policies and procedures:
25        (1) to ensure that licensed physicians with relevant
26    board certifications establish all criteria that the

 

 

HB2472 Enrolled- 36 -LRB103 28761 BMS 55144 b

1    algorithmic automated process uses for utilization review;
2    and
3        (2) for a program integrity system that, both before
4    new or revised criteria are used for utilization review
5    and when implementation errors in the algorithmic
6    automated process are identified after new or revised
7    criteria go into effect, requires licensed physicians with
8    relevant board certifications to verify that the
9    algorithmic automated process and corrections to it yield
10    results consistent with the criteria for their certified
11    field.
12    (c) The provisions of this Section do not apply to:
13        (1) persons providing utilization review program
14    services only to the federal government;
15        (2) self-insured health plans under the federal
16    Employee Retirement Income Security Act of 1974, however,
17    this Section does apply to persons conducting a
18    utilization review program on behalf of these health
19    plans;
20        (3) hospitals and medical groups performing
21    utilization review activities for internal purposes unless
22    the utilization review program is conducted for another
23    person.
24    Nothing in this Act prohibits a health care plan or other
25entity from contractually requiring an entity designated in
26item (3) of this subsection to adhere to the utilization

 

 

HB2472 Enrolled- 37 -LRB103 28761 BMS 55144 b

1review program requirements of this Act.
2    (d) This registration shall include submission of all of
3the following information regarding utilization review program
4activities:
5        (1) The name, address, and telephone number of the
6    utilization review programs.
7        (2) The organization and governing structure of the
8    utilization review programs.
9        (3) The number of lives for which utilization review
10    is conducted by each utilization review program.
11        (4) Hours of operation of each utilization review
12    program.
13        (5) Description of the grievance process for each
14    utilization review program.
15        (6) Number of covered lives for which utilization
16    review was conducted for the previous calendar year for
17    each utilization review program.
18        (7) Written policies and procedures for protecting
19    confidential information according to applicable State and
20    federal laws for each utilization review program.
21    (e) (1) A utilization review program shall have written
22procedures for assuring that patient-specific information
23obtained during the process of utilization review will be:
24        (A) kept confidential in accordance with applicable
25    State and federal laws; and
26        (B) shared only with the enrollee, the enrollee's

 

 

HB2472 Enrolled- 38 -LRB103 28761 BMS 55144 b

1    designee, the enrollee's health care provider, and those
2    who are authorized by law to receive the information.
3    Summary data shall not be considered confidential if it
4does not provide information to allow identification of
5individual patients or health care providers.
6        (2) Only a clinical peer health care professional may
7    make adverse determinations regarding the medical
8    necessity of health care services during the course of
9    utilization review. Either a health care professional or
10    an accredited algorithmic automated process, or both in
11    combination, may certify the medical necessity of a health
12    care service in accordance with accreditation standards.
13    Nothing in this subsection prohibits an accredited
14    algorithmic automated process from being used to refer a
15    case to a clinical peer for a potential adverse
16    determination.
17        (3) When making retrospective reviews, utilization
18    review programs shall base reviews solely on the medical
19    information available to the attending physician or
20    ordering provider at the time the health care services
21    were provided. This paragraph includes billing records and
22    diagnosis or procedure codes that substantively contain
23    the same medical information to an equal or lesser degree
24    of specificity as the records the attending physician or
25    ordering provider directly consulted at the time health
26    care services were provided.

 

 

HB2472 Enrolled- 39 -LRB103 28761 BMS 55144 b

1        (4) When making prospective, concurrent, and
2    retrospective determinations, utilization review programs
3    shall collect only information that is necessary to make
4    the determination and shall not routinely require health
5    care providers to numerically code diagnoses or procedures
6    to be considered for certification, unless required under
7    State or federal Medicare or Medicaid rules or
8    regulations, but may request such code if available, or
9    routinely request copies of medical records of all
10    enrollees reviewed. During prospective or concurrent
11    review, copies of medical records shall only be required
12    when necessary to verify that the health care services
13    subject to review are medically necessary. In these cases,
14    only the necessary or relevant sections of the medical
15    record shall be required.
16    (f) If the Department finds that a utilization review
17program is not in compliance with this Section, the Department
18shall issue a corrective action plan and allow a reasonable
19amount of time for compliance with the plan. If the
20utilization review program does not come into compliance, the
21Department may issue a cease and desist order. Before issuing
22a cease and desist order under this Section, the Department
23shall provide the utilization review program with a written
24notice of the reasons for the order and allow a reasonable
25amount of time to supply additional information demonstrating
26compliance with requirements of this Section and to request a

 

 

HB2472 Enrolled- 40 -LRB103 28761 BMS 55144 b

1hearing. The hearing notice shall be sent by certified mail,
2return receipt requested, and the hearing shall be conducted
3in accordance with the Illinois Administrative Procedure Act.
4    (g) A utilization review program subject to a corrective
5action may continue to conduct business until a final decision
6has been issued by the Department.
7    (h) Any adverse determination made by a health care plan
8or its subcontractors may be appealed in accordance with
9subsection (f) of Section 45.
10    (i) The Director may by rule establish a registration fee
11for each person conducting a utilization review program. All
12fees paid to and collected by the Director under this Section
13shall be deposited into the Insurance Producer Administration
14Fund.
15(Source: P.A. 99-111, eff. 1-1-16.)
 
16    Section 35. The Voluntary Health Services Plans Act is
17amended by changing Section 10 as follows:
 
18    (215 ILCS 165/10)  (from Ch. 32, par. 604)
19    Sec. 10. Application of Insurance Code provisions. Health
20services plan corporations and all persons interested therein
21or dealing therewith shall be subject to the provisions of
22Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
23143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3,
24355b, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v,

 

 

HB2472 Enrolled- 41 -LRB103 28761 BMS 55144 b

1356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a,
2356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
3356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22,
4356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32,
5356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
6356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62,
7356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401,
8401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
9and (15) of Section 367 of the Illinois Insurance Code.
10    Rulemaking authority to implement Public Act 95-1045, if
11any, is conditioned on the rules being adopted in accordance
12with all provisions of the Illinois Administrative Procedure
13Act and all rules and procedures of the Joint Committee on
14Administrative Rules; any purported rule not so adopted, for
15whatever reason, is unauthorized.
16(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
17102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
1810-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,
19eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
20102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff.
211-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
22eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
23103-551, eff. 8-11-23; revised 8-29-23.)
 
24    Section 40. The Health Carrier External Review Act is
25amended by changing Section 10 as follows:
 

 

 

HB2472 Enrolled- 42 -LRB103 28761 BMS 55144 b

1    (215 ILCS 180/10)
2    Sec. 10. Definitions. For the purposes of this Act:
3    "Adverse determination" means:
4        (1) a determination by a health carrier or its
5    designee utilization review organization that, based upon
6    the health information provided for a covered person, a
7    request for a benefit, including any quantity, frequency,
8    duration, or other measurement of a benefit, under the
9    health carrier's health benefit plan upon application of
10    any utilization review technique does not meet the health
11    carrier's requirements for medical necessity,
12    appropriateness, health care setting, level of care, or
13    effectiveness or is determined to be experimental or
14    investigational and the requested benefit is therefore
15    denied, reduced, or terminated or payment is not provided
16    or made, in whole or in part, for the benefit;
17        (2) the denial, reduction, or termination of or
18    failure to provide or make payment, in whole or in part,
19    for a benefit based on a determination by a health carrier
20    or its designee utilization review organization that a
21    preexisting condition was present before the effective
22    date of coverage; or
23        (3) a rescission of coverage determination, which does
24    not include a cancellation or discontinuance of coverage
25    that is attributable to a failure to timely pay required

 

 

HB2472 Enrolled- 43 -LRB103 28761 BMS 55144 b

1    premiums or contributions towards the cost of coverage.
2    "Adverse determination" includes unilateral
3determinations that replace the requested health care service
4with an approval of an alternative health care service without
5the agreement of the covered person or the covered person's
6attending provider for the requested health care service, or
7that condition approval of the requested service on first
8trying an alternative health care service, either if the
9request was made under a medical exceptions procedure, or if
10all of the following are true: (1) the requested service was
11not excluded by name, description, or service category under
12the written terms of coverage, (2) the alternative health care
13service poses no greater risk to the patient based on
14generally accepted standards of care, and (3) the alternative
15health care service is at least as likely to produce the same
16or better effect on the covered person's health as the
17requested service based on generally accepted standards of
18care. "Adverse determination" includes determinations made
19based on any source of health information pertaining to the
20covered person that is used to deny, reduce, replace,
21condition, or terminate the benefit or payment. "Adverse
22determination" includes determinations made in response to a
23request for authorization when the request was submitted by
24the health care provider regardless of whether the provider
25gave notice to or obtained the consent of the covered person or
26authorized representative to file the request. "Adverse

 

 

HB2472 Enrolled- 44 -LRB103 28761 BMS 55144 b

1determination" does not include substitutions performed under
2Section 19.5 or 25 of the Pharmacy Practice Act.
3    "Authorized representative" means:
4        (1) a person to whom a covered person has given
5    express written consent to represent the covered person
6    for purposes of this Law;
7        (2) a person authorized by law to provide substituted
8    consent for a covered person;
9        (3) a family member of the covered person or the
10    covered person's treating health care professional when
11    the covered person is unable to provide consent;
12        (4) a health care provider when the covered person's
13    health benefit plan requires that a request for a benefit
14    under the plan be initiated by the health care provider;
15    or
16        (5) in the case of an urgent care request, a health
17    care provider with knowledge of the covered person's
18    medical condition.
19    "Best evidence" means evidence based on:
20        (1) randomized clinical trials;
21        (2) if randomized clinical trials are not available,
22    then cohort studies or case-control studies;
23        (3) if items (1) and (2) are not available, then
24    case-series; or
25        (4) if items (1), (2), and (3) are not available, then
26    expert opinion.

 

 

HB2472 Enrolled- 45 -LRB103 28761 BMS 55144 b

1    "Case-series" means an evaluation of a series of patients
2with a particular outcome, without the use of a control group.
3    "Clinical review criteria" means the written screening
4procedures, decision abstracts, clinical protocols, and
5practice guidelines used by a health carrier to determine the
6necessity and appropriateness of health care services.
7    "Cohort study" means a prospective evaluation of 2 groups
8of patients with only one group of patients receiving specific
9intervention.
10    "Concurrent review" means a review conducted during a
11patient's stay or course of treatment in a facility, the
12office of a health care professional, or other inpatient or
13outpatient health care setting.
14    "Covered benefits" or "benefits" means those health care
15services to which a covered person is entitled under the terms
16of a health benefit plan.
17    "Covered person" means a policyholder, subscriber,
18enrollee, or other individual participating in a health
19benefit plan.
20    "Director" means the Director of the Department of
21Insurance.
22    "Emergency medical condition" means a medical condition
23manifesting itself by acute symptoms of sufficient severity,
24including, but not limited to, severe pain, such that a
25prudent layperson who possesses an average knowledge of health
26and medicine could reasonably expect the absence of immediate

 

 

HB2472 Enrolled- 46 -LRB103 28761 BMS 55144 b

1medical attention to result in:
2        (1) placing the health of the individual or, with
3    respect to a pregnant woman, the health of the woman or her
4    unborn child, in serious jeopardy;
5        (2) serious impairment to bodily functions; or
6        (3) serious dysfunction of any bodily organ or part.
7    "Emergency services" means health care items and services
8furnished or required to evaluate and treat an emergency
9medical condition.
10    "Evidence-based standard" means the conscientious,
11explicit, and judicious use of the current best evidence based
12on an overall systematic review of the research in making
13decisions about the care of individual patients.
14    "Expert opinion" means a belief or an interpretation by
15specialists with experience in a specific area about the
16scientific evidence pertaining to a particular service,
17intervention, or therapy.
18    "Facility" means an institution providing health care
19services or a health care setting.
20    "Final adverse determination" means an adverse
21determination involving a covered benefit that has been upheld
22by a health carrier, or its designee utilization review
23organization, at the completion of the health carrier's
24internal grievance process procedures as set forth by the
25Managed Care Reform and Patient Rights Act or as set forth for
26any additional authorization or internal appeal process

 

 

HB2472 Enrolled- 47 -LRB103 28761 BMS 55144 b

1provided by contract between the health carrier and the
2provider. "Final adverse determination" includes
3determinations made in an appeal of a denial of prior
4authorization when the appeal was submitted by the health care
5provider regardless of whether the provider gave notice to or
6obtained the consent of the covered person or authorized
7representative to file an internal appeal.
8    "Health benefit plan" means a policy, contract,
9certificate, plan, or agreement offered or issued by a health
10carrier to provide, deliver, arrange for, pay for, or
11reimburse any of the costs of health care services.
12    "Health care provider" or "provider" means a physician,
13hospital facility, or other health care practitioner licensed,
14accredited, or certified to perform specified health care
15services consistent with State law, responsible for
16recommending health care services on behalf of a covered
17person.
18    "Health care services" means services for the diagnosis,
19prevention, treatment, cure, or relief of a health condition,
20illness, injury, or disease.
21    "Health carrier" means an entity subject to the insurance
22laws and regulations of this State, or subject to the
23jurisdiction of the Director, that contracts or offers to
24contract to provide, deliver, arrange for, pay for, or
25reimburse any of the costs of health care services, including
26a sickness and accident insurance company, a health

 

 

HB2472 Enrolled- 48 -LRB103 28761 BMS 55144 b

1maintenance organization, or any other entity providing a plan
2of health insurance, health benefits, or health care services.
3"Health carrier" also means Limited Health Service
4Organizations (LHSO) and Voluntary Health Service Plans.
5    "Health information" means information or data, whether
6oral or recorded in any form or medium, and personal facts or
7information about events or relationships that relate to:
8        (1) the past, present, or future physical, mental, or
9    behavioral health or condition of an individual or a
10    member of the individual's family;
11        (2) the provision of health care services to an
12    individual; or
13        (3) payment for the provision of health care services
14    to an individual.
15    "Independent review organization" means an entity that
16conducts independent external reviews of adverse
17determinations and final adverse determinations.
18    "Medical or scientific evidence" means evidence found in
19the following sources:
20        (1) peer-reviewed scientific studies published in or
21    accepted for publication by medical journals that meet
22    nationally recognized requirements for scientific
23    manuscripts and that submit most of their published
24    articles for review by experts who are not part of the
25    editorial staff;
26        (2) peer-reviewed medical literature, including

 

 

HB2472 Enrolled- 49 -LRB103 28761 BMS 55144 b

1    literature relating to therapies reviewed and approved by
2    a qualified institutional review board, biomedical
3    compendia, and other medical literature that meet the
4    criteria of the National Institutes of Health's Library of
5    Medicine for indexing in Index Medicus (Medline) and
6    Elsevier Science Ltd. for indexing in Excerpta Medicus
7    (EMBASE);
8        (3) medical journals recognized by the Secretary of
9    Health and Human Services under Section 1861(t)(2) of the
10    federal Social Security Act;
11        (4) the following standard reference compendia:
12            (a) The American Hospital Formulary Service-Drug
13        Information;
14            (b) Drug Facts and Comparisons;
15            (c) The American Dental Association Accepted
16        Dental Therapeutics; and
17            (d) The United States Pharmacopoeia-Drug
18        Information;
19        (5) findings, studies, or research conducted by or
20    under the auspices of federal government agencies and
21    nationally recognized federal research institutes,
22    including:
23            (a) the federal Agency for Healthcare Research and
24        Quality;
25            (b) the National Institutes of Health;
26            (c) the National Cancer Institute;

 

 

HB2472 Enrolled- 50 -LRB103 28761 BMS 55144 b

1            (d) the National Academy of Sciences;
2            (e) the Centers for Medicare & Medicaid Services;
3            (f) the federal Food and Drug Administration; and
4            (g) any national board recognized by the National
5        Institutes of Health for the purpose of evaluating the
6        medical value of health care services; or
7        (6) any other medical or scientific evidence that is
8    comparable to the sources listed in items (1) through (5).
9    "Person" means an individual, a corporation, a
10partnership, an association, a joint venture, a joint stock
11company, a trust, an unincorporated organization, any similar
12entity, or any combination of the foregoing.
13    "Prospective review" means a review conducted prior to an
14admission or the provision of a health care service or a course
15of treatment in accordance with a health carrier's requirement
16that the health care service or course of treatment, in whole
17or in part, be approved prior to its provision.
18    "Protected health information" means health information
19(i) that identifies an individual who is the subject of the
20information; or (ii) with respect to which there is a
21reasonable basis to believe that the information could be used
22to identify an individual.
23    "Randomized clinical trial" means a controlled prospective
24study of patients that have been randomized into an
25experimental group and a control group at the beginning of the
26study with only the experimental group of patients receiving a

 

 

HB2472 Enrolled- 51 -LRB103 28761 BMS 55144 b

1specific intervention, which includes study of the groups for
2variables and anticipated outcomes over time.
3    "Retrospective review" means any review of a request for a
4benefit that is not a concurrent or prospective review
5request. "Retrospective review" does not include the review of
6a claim that is limited to veracity of documentation or
7accuracy of coding.
8    "Utilization review" has the meaning provided by the
9Managed Care Reform and Patient Rights Act.
10    "Utilization review organization" means a utilization
11review program as defined in the Managed Care Reform and
12Patient Rights Act.
13(Source: P.A. 97-574, eff. 8-26-11; 97-813, eff. 7-13-12;
1498-756, eff. 7-16-14.)
 
15    Section 45. The Prior Authorization Reform Act is amended
16by changing Section 55 as follows:
 
17    (215 ILCS 200/55)
18    Sec. 55. Denial or penalty.
19    (a) The health insurance issuer or its contracted
20utilization review organization may not revoke or further
21limit, condition, or restrict a previously issued prior
22authorization approval while it remains valid under this Act.
23    (b) Notwithstanding any other provision of law, if a claim
24is properly coded and submitted timely to a health insurance

 

 

HB2472 Enrolled- 52 -LRB103 28761 BMS 55144 b

1issuer, the health insurance issuer shall make payment
2according to the terms of coverage on claims for health care
3services for which prior authorization was required and
4approval received before the rendering of health care
5services, unless one of the following occurs:
6        (1) it is timely determined that the enrollee's health
7    care professional or health care provider knowingly
8    provided health care services that required prior
9    authorization from the health insurance issuer or its
10    contracted utilization review organization without first
11    obtaining prior authorization for those health care
12    services;
13        (2) it is timely determined that the health care
14    services claimed were not performed;
15        (3) it is timely determined that the health care
16    services rendered were contrary to the instructions of the
17    health insurance issuer or its contracted utilization
18    review organization or delegated reviewer if contact was
19    made between those parties before the service being
20    rendered;
21        (4) it is timely determined that the enrollee
22    receiving such health care services was not an enrollee of
23    the health care plan; or
24        (5) the approval was based upon a material
25    misrepresentation by the enrollee, health care
26    professional, or health care provider; as used in this

 

 

HB2472 Enrolled- 53 -LRB103 28761 BMS 55144 b

1    paragraph (5), "material" means a fact or situation that
2    is not merely technical in nature and results or could
3    result in a substantial change in the situation.
4    (c) Nothing in this Section shall preclude a utilization
5review organization or a health insurance issuer from
6performing post-service reviews of health care claims for
7purposes of payment integrity or for the prevention of fraud,
8waste, or abuse.
9    (d) If a health insurance issuer imposes a monetary
10penalty on the enrollee for the enrollee's, health care
11professional's, or health care provider's failure to obtain
12any form of prior authorization for a health care service, the
13penalty may not exceed the lesser of:
14        (1) the actual cost of the health care service; or
15        (2) $1,000 per occurrence in addition to the plan
16    cost-sharing provisions.
17    (e) A health insurance issuer may not require both the
18enrollee and the health care professional or health care
19provider to obtain any form of prior authorization for the
20same instance of a health care service, nor otherwise require
21more than one prior authorization for the same instance of a
22health care service.
23(Source: P.A. 102-409, eff. 1-1-22.)
 
24    Section 99. Effective date. This Act takes effect January
251, 2025.