Illinois General Assembly

  Bills & Resolutions  
  Compiled Statutes  
  Public Acts  
  Legislative Reports  
  IL Constitution  
  Legislative Guide  
  Legislative Glossary  

 Search By Number
 (example: HB0001)
Search Tips

Search By Keyword

Public Act 098-1035


 

Public Act 1035 98TH GENERAL ASSEMBLY

  
  
  

 


 
Public Act 098-1035
 
HB3638 EnrolledLRB098 12067 KTG 45783 b

    AN ACT concerning public aid.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 1. Short title. This amendatory Act may be referred
to as the Health Insurance Consumer Protection Act of 2014.
 
    Section 3. Findings and purpose. The General Assembly
finds that the federal Patient Protection and Affordable Care
Act and the federal regulations implementing that Act give the
State and its Department of Insurance primary responsibility
for ensuring that all policies of health insurance and health
care plans that are offered for sale directly to consumers in
the State provide consumers with adequate information about the
coverage offered to enable them to meaningfully compare plans
and premiums and enroll in the appropriate policy or plan. The
purpose of this amendatory Act of the 98th General Assembly is
to build on the consumer protections provided in federal law
for policies or qualified health plans offered for sale
directly to consumers through the Health Insurance Marketplace
in Illinois.
 
    Section 5. The Illinois Insurance Code is amended by
changing Sections 155.36 and 355a as follows:
 
    (215 ILCS 5/155.36)
    Sec. 155.36. Managed Care Reform and Patient Rights Act.
Insurance companies that transact the kinds of insurance
authorized under Class 1(b) or Class 2(a) of Section 4 of this
Code shall comply with Sections 45, 45.1, 45.2, and 85 and the
definition of the term "emergency medical condition" in Section
10 of the Managed Care Reform and Patient Rights Act.
(Source: P.A. 96-857, eff. 7-1-10.)
 
    (215 ILCS 5/355a)  (from Ch. 73, par. 967a)
    Sec. 355a. Standardization of terms and coverage.
    (1) The purpose of this Section shall be (a) to provide
reasonable standardization and simplification of terms and
coverages of individual accident and health insurance policies
to facilitate public understanding and comparisons; (b) to
eliminate provisions contained in individual accident and
health insurance policies which may be misleading or
unreasonably confusing in connection either with the purchase
of such coverages or with the settlement of claims; and (c) to
provide for reasonable disclosure in the sale of accident and
health coverages.
    (2) Definitions applicable to this Section are as follows:
        (a) "Policy" means all or any part of the forms
    constituting the contract between the insurer and the
    insured, including the policy, certificate, subscriber
    contract, riders, endorsements, and the application if
    attached, which are subject to filing with and approval by
    the Director.
        (b) "Service corporations" means voluntary health and
    dental corporations organized and operating respectively
    under the Voluntary Health Services Plans Act and the
    Dental Service Plan Act.
        (c) "Accident and health insurance" means insurance
    written under Article XX of the Insurance Code, other than
    credit accident and health insurance, and coverages
    provided in subscriber contracts issued by service
    corporations. For purposes of this Section such service
    corporations shall be deemed to be insurers engaged in the
    business of insurance.
    (3) The Director shall issue such rules as he shall deem
necessary or desirable to establish specific standards,
including standards of full and fair disclosure that set forth
the form and content and required disclosure for sale, of
individual policies of accident and health insurance, which
rules and regulations shall be in addition to and in accordance
with the applicable laws of this State, and which may cover but
shall not be limited to: (a) terms of renewability; (b) initial
and subsequent conditions of eligibility; (c) non-duplication
of coverage provisions; (d) coverage of dependents; (e)
pre-existing conditions; (f) termination of insurance; (g)
probationary periods; (h) limitation, exceptions, and
reductions; (i) elimination periods; (j) requirements
regarding replacements; (k) recurrent conditions; and (l) the
definition of terms including but not limited to the following:
hospital, accident, sickness, injury, physician, accidental
means, total disability, partial disability, nervous disorder,
guaranteed renewable, and non-cancellable.
    The Director may issue rules that specify prohibited policy
provisions not otherwise specifically authorized by statute
which in the opinion of the Director are unjust, unfair or
unfairly discriminatory to the policyholder, any person
insured under the policy, or beneficiary.
    (4) The Director shall issue such rules as he shall deem
necessary or desirable to establish minimum standards for
benefits under each category of coverage in individual accident
and health policies, other than conversion policies issued
pursuant to a contractual conversion privilege under a group
policy, including but not limited to the following categories:
(a) basic hospital expense coverage; (b) basic
medical-surgical expense coverage; (c) hospital confinement
indemnity coverage; (d) major medical expense coverage; (e)
disability income protection coverage; (f) accident only
coverage; and (g) specified disease or specified accident
coverage.
    Nothing in this subsection (4) shall preclude the issuance
of any policy which combines two or more of the categories of
coverage enumerated in subparagraphs (a) through (f) of this
subsection.
    No policy shall be delivered or issued for delivery in this
State which does not meet the prescribed minimum standards for
the categories of coverage listed in this subsection unless the
Director finds that such policy is necessary to meet specific
needs of individuals or groups and such individuals or groups
will be adequately informed that such policy does not meet the
prescribed minimum standards, and such policy meets the
requirement that the benefits provided therein are reasonable
in relation to the premium charged. The standards and criteria
to be used by the Director in approving such policies shall be
included in the rules required under this Section with as much
specificity as practicable.
    The Director shall prescribe by rule the method of
identification of policies based upon coverages provided.
    (5) (a) In order to provide for full and fair disclosure in
the sale of individual accident and health insurance policies,
no such policy shall be delivered or issued for delivery in
this State unless the outline of coverage described in
paragraph (b) of this subsection either accompanies the policy,
or is delivered to the applicant at the time the application is
made, and an acknowledgment signed by the insured, of receipt
of delivery of such outline, is provided to the insurer. In the
event the policy is issued on a basis other than that applied
for, the outline of coverage properly describing the policy
must accompany the policy when it is delivered and such outline
shall clearly state that the policy differs, and to what
extent, from that for which application was originally made.
All policies, except single premium nonrenewal policies, shall
have a notice prominently printed on the first page of the
policy or attached thereto stating in substance, that the
policyholder shall have the right to return the policy within
10 days of its delivery and to have the premium refunded if
after examination of the policy the policyholder is not
satisfied for any reason.
    (b) The Director shall issue such rules as he shall deem
necessary or desirable to prescribe the format and content of
the outline of coverage required by paragraph (a) of this
subsection. "Format" means style, arrangement, and overall
appearance, including such items as the size, color, and
prominence of type and the arrangement of text and captions.
"Content" shall include without limitation thereto, statements
relating to the particular policy as to the applicable category
of coverage prescribed under subsection 4; principal benefits;
exceptions, reductions and limitations; and renewal
provisions, including any reservation by the insurer of a right
to change premiums. Such outline of coverage shall clearly
state that it constitutes a summary of the policy issued or
applied for and that the policy should be consulted to
determine governing contractual provisions.
    (c) Without limiting the generality of paragraph (b) of
this subsection (5), no qualified health plans shall be offered
for sale directly to consumers through the health insurance
marketplace operating in the State in accordance with Sections
1311 and 1321 of the federal Patient Protection and Affordable
Care Act of 2010 (Public Law 111-148), as amended by the
federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and any amendments thereto, or
regulations or guidance issued thereunder (collectively, "the
Federal Act"), unless the following information is made
available to the consumer at the time he or she is comparing
policies and their premiums:
        (i) With respect to prescription drug benefits, the
    most recently published formulary where a consumer can view
    in one location covered prescription drugs; information on
    tiering and the cost-sharing structure for each tier; and
    information about how a consumer can obtain specific
    copayment amounts or coinsurance percentages for a
    specific qualified health plan before enrolling in that
    plan. This information shall clearly identify the
    qualified health plan to which it applies.
        (ii) The most recently published provider directory
    where a consumer can view the provider network that applies
    to each qualified health plan and information about each
    provider, including location, contact information,
    specialty, medical group, if any, any institutional
    affiliation, and whether the provider is accepting new
    patients. The information shall clearly identify the
    qualified health plan to which it applies.
    (d) Each company that offers qualified health plans for
sale directly to consumers through the health insurance
marketplace operating in the State shall make the information
in paragraph (c) of this subsection (5), for each qualified
health plan that it offers, available and accessible to the
general public on the company's Internet website and through
other means for individuals without access to the Internet.
    (e) The Department shall ensure that State-operated
Internet websites, in addition to the Internet website for the
health insurance marketplace established in this State in
accordance with the Federal Act, prominently provide links to
Internet-based materials and tools to help consumers be
informed purchasers of health insurance.
    (f) Nothing in this Section shall be interpreted or
implemented in a manner not consistent with the Federal Act.
This Section shall apply to all qualified health plans offered
for sale directly to consumers through the health insurance
marketplace operating in this State for any coverage year
beginning on or after January 1, 2015.
    (6) Prior to the issuance of rules pursuant to this
Section, the Director shall afford the public, including the
companies affected thereby, reasonable opportunity for
comment. Such rulemaking is subject to the provisions of the
Illinois Administrative Procedure Act.
    (7) When a rule has been adopted, pursuant to this Section,
all policies of insurance or subscriber contracts which are not
in compliance with such rule shall, when so provided in such
rule, be deemed to be disapproved as of a date specified in
such rule not less than 120 days following its effective date,
without any further or additional notice other than the
adoption of the rule.
    (8) When a rule adopted pursuant to this Section so
provides, a policy of insurance or subscriber contract which
does not comply with the rule shall not less than 120 days from
the effective date of such rule, be construed, and the insurer
or service corporation shall be liable, as if the policy or
contract did comply with the rule.
    (9) Violation of any rule adopted pursuant to this Section
shall be a violation of the insurance law for purposes of
Sections 370 and 446 of the Insurance Code.
(Source: P.A. 90-177, eff. 7-23-97; 90-372, eff. 7-1-98;
90-655, eff. 7-30-98.)
 
    Section 10. The Managed Care Reform and Patient Rights Act
is amended by changing Section 15 and by adding Sections 45.1
and 45.2 as follows:
 
    (215 ILCS 134/15)
    Sec. 15. Provision of information.
    (a) A health care plan shall provide annually to enrollees
and prospective enrollees, upon request, a complete list of
participating health care providers in the health care plan's
service area and a description of the following terms of
coverage:
        (1) the service area;
        (2) the covered benefits and services with all
    exclusions, exceptions, and limitations;
        (3) the pre-certification and other utilization review
    procedures and requirements;
        (4) a description of the process for the selection of a
    primary care physician, any limitation on access to
    specialists, and the plan's standing referral policy;
        (5) the emergency coverage and benefits, including any
    restrictions on emergency care services;
        (6) the out-of-area coverage and benefits, if any;
        (7) the enrollee's financial responsibility for
    copayments, deductibles, premiums, and any other
    out-of-pocket expenses;
        (8) the provisions for continuity of treatment in the
    event a health care provider's participation terminates
    during the course of an enrollee's treatment by that
    provider;
        (9) the appeals process, forms, and time frames for
    health care services appeals, complaints, and external
    independent reviews, administrative complaints, and
    utilization review complaints, including a phone number to
    call to receive more information from the health care plan
    concerning the appeals process; and
        (10) a statement of all basic health care services and
    all specific benefits and services mandated to be provided
    to enrollees by any State law or administrative rule.
    (a-5) Without limiting the generality of subsection (a) of
this Section, no qualified health plans shall be offered for
sale directly to consumers through the health insurance
marketplace operating in the State in accordance with Sections
1311 and 1321 of the federal Patient Protection and Affordable
Care Act of 2010 (Public Law 111-148), as amended by the
federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and any amendments thereto, or
regulations or guidance issued thereunder (collectively, "the
Federal Act"), unless, in addition to the information required
under subsection (a) of this Section, the following information
is available to the consumer at the time he or she is comparing
health care plans and their premiums:
        (1) With respect to prescription drug benefits, the
    most recently published formulary where a consumer can view
    in one location covered prescription drugs; information on
    tiering and the cost-sharing structure for each tier; and
    information about how a consumer can obtain specific
    copayment amounts or coinsurance percentages for a
    specific qualified health plan before enrolling in that
    plan. This information shall clearly identify the
    qualified health plan to which it applies.
        (2) The most recently published provider directory
    where a consumer can view the provider network that applies
    to each qualified health plan and information about each
    provider, including location, contact information,
    specialty, medical group, if any, any institutional
    affiliation, and whether the provider is accepting new
    patients. The information shall clearly identify the
    qualified health plan to which it applies.
    In the event of an inconsistency between any separate
written disclosure statement and the enrollee contract or
certificate, the terms of the enrollee contract or certificate
shall control.
    (b) Upon written request, a health care plan shall provide
to enrollees a description of the financial relationships
between the health care plan and any health care provider and,
if requested, the percentage of copayments, deductibles, and
total premiums spent on healthcare related expenses and the
percentage of copayments, deductibles, and total premiums
spent on other expenses, including administrative expenses,
except that no health care plan shall be required to disclose
specific provider reimbursement.
    (c) A participating health care provider shall provide all
of the following, where applicable, to enrollees upon request:
        (1) Information related to the health care provider's
    educational background, experience, training, specialty,
    and board certification, if applicable.
        (2) The names of licensed facilities on the provider
    panel where the health care provider presently has
    privileges for the treatment, illness, or procedure that is
    the subject of the request.
        (3) Information regarding the health care provider's
    participation in continuing education programs and
    compliance with any licensure, certification, or
    registration requirements, if applicable.
    (d) A health care plan shall provide the information
required to be disclosed under this Act upon enrollment and
annually thereafter in a legible and understandable format. The
Department shall promulgate rules to establish the format
based, to the extent practical, on the standards developed for
supplemental insurance coverage under Title XVIII of the
federal Social Security Act as a guide, so that a person can
compare the attributes of the various health care plans.
    (e) The written disclosure requirements of this Section may
be met by disclosure to one enrollee in a household.
    (f) Each issuer of qualified health plans for sale directly
to consumers through the health insurance marketplace
operating in the State shall make the information described in
subsection (a) of this Section, for each qualified health plan
that it offers, available and accessible to the general public
on the company's Internet website and through other means for
individuals without access to the Internet.
    (g) The Department shall ensure that State-operated
Internet websites, in addition to the Internet website for the
health insurance marketplace established in this State in
accordance with the Federal Act and its implementing
regulations, prominently provide links to Internet-based
materials and tools to help consumers be informed purchasers of
health care plans.
    (h) Nothing in this Section shall be interpreted or
implemented in a manner not consistent with the Federal Act.
This Section shall apply to all qualified health plans offered
for sale directly to consumers through the health insurance
marketplace operating in this State for any coverage year
beginning on or after January 1, 2015.
(Source: P.A. 91-617, eff. 1-1-00.)
 
    (215 ILCS 134/45.1 new)
    Sec. 45.1. Medical exceptions procedures required.
    (a) Every health carrier that offers a qualified health
plan, as defined in the federal Patient Protection and
Affordable Care Act of 2010 (Public Law 111-148), as amended by
the federal Health Care and Education Reconciliation Act of
2010 (Public Law 111-152), and any amendments thereto, or
regulations or guidance issued under those Acts (collectively,
"the Federal Act"), directly to consumers in this State shall
establish and maintain a medical exceptions process that allows
covered persons or their authorized representatives to request
any clinically appropriate prescription drug when (1) the drug
is not covered based on the health benefit plan's formulary;
(2) the health benefit plan is discontinuing coverage of the
drug on the plan's formulary for reasons other than safety or
other than because the prescription drug has been withdrawn
from the market by the drug's manufacturer; (3) the
prescription drug alternatives required to be used in
accordance with a step therapy requirement (A) has been
ineffective in the treatment of the enrollee's disease or
medical condition or, based on both sound clinical evidence and
medical and scientific evidence, the known relevant physical or
mental characteristics of the enrollee, and the known
characteristics of the drug regimen, is likely to be
ineffective or adversely affect the drug's effectiveness or
patient compliance or (B) has caused or, based on sound medical
evidence, is likely to cause an adverse reaction or harm to the
enrollee; or (4) the number of doses available under a dose
restriction for the prescription drug (A) has been ineffective
in the treatment of the enrollee's disease or medical condition
or (B) based on both sound clinical evidence and medical and
scientific evidence, the known relevant physical and mental
characteristics of the enrollee, and known characteristics of
the drug regimen, is likely to be ineffective or adversely
affect the drug's effective or patient compliance.
    (b) The health carrier's established medical exceptions
procedures must require, at a minimum, the following:
        (1) Any request for approval of coverage made verbally
    or in writing (regardless of whether made using a paper or
    electronic form or some other writing) at any time shall be
    reviewed by appropriate health care professionals.
        (2) The health carrier must, within 72 hours after
    receipt of a request made under subsection (a) of this
    Section, either approve or deny the request. In the case of
    a denial, the health carrier shall provide the covered
    person or the covered person's authorized representative
    and the covered person's prescribing provider with the
    reason for the denial, an alternative covered medication,
    if applicable, and information regarding the procedure for
    submitting an appeal to the denial.
        (3) In the case of an expedited coverage determination,
    the health carrier must either approve or deny the request
    within 24 hours after receipt of the request. In the case
    of a denial, the health carrier shall provide the covered
    person or the covered person's authorized representative
    and the covered person's prescribing provider with the
    reason for the denial, an alternative covered medication,
    if applicable, and information regarding the procedure for
    submitting an appeal to the denial.
    (c) Notwithstanding any other provision of this Section,
nothing in this Section shall be interpreted or implemented in
a manner not consistent with the Federal Act.
 
    (215 ILCS 134/45.2 new)
    Sec. 45.2. Prior authorization form; prescription
benefits.
    (a) Notwithstanding any other provision of law, on and
after January 1, 2015, a health insurer that provides
prescription drug benefits must, within 72 hours after receipt
of a paper or electronic prior authorization form from a
prescribing provider or pharmacist, either approve or deny the
prior authorization. In the case of a denial, the insurer shall
provide the prescriber with the reason for the denial, an
alternative covered medication, if applicable, and information
regarding the denial.
    In the case of an expedited coverage determination, the
health insurer must either approve or deny the prior
authorization within 24 hours after receipt of the paper or
electronic prior authorization form. In the case of a denial,
the health insurer shall provide the prescriber with the reason
for the denial, an alternative covered medication, if
applicable, and information regarding the procedure for
submitting an appeal to the denial.
    (b) This Section does not apply to plans for beneficiaries
of Medicare or Medicaid.
    (c) For the purposes of this Section:
    "Pharmacist" has the same meaning as set forth in the
Pharmacy Practice Act.
    "Prescribing provider" includes a provider authorized to
write a prescription, as described in subsection (e) of Section
3 of the Pharmacy Practice Act, to treat a medical condition of
an insured.
 
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 8/25/2014