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Public Act 100-1052


 

Public Act 1052 100TH GENERAL ASSEMBLY

  
  
  

 


 
Public Act 100-1052
 
HB4146 EnrolledLRB100 14115 SMS 28871 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Managed Care Reform and Patient Rights Act
is amended by changing Section 25 as follows:
 
    (215 ILCS 134/25)
    Sec. 25. Transition of services.
    (a) A health care plan shall provide for continuity of care
for its enrollees as follows:
        (1) If an enrollee's physician leaves the health care
    plan's network of health care providers for reasons other
    than termination of a contract in situations involving
    imminent harm to a patient or a final disciplinary action
    by a State licensing board and the physician remains within
    the health care plan's service area, the health care plan
    shall permit the enrollee to continue an ongoing course of
    treatment with that physician during a transitional
    period:
            (A) of 90 days from the date of the notice of
        physician's termination from the health care plan to
        the enrollee of the physician's disaffiliation from
        the health care plan if the enrollee has an ongoing
        course of treatment; or
            (B) if the enrollee has entered the third trimester
        of pregnancy at the time of the physician's
        disaffiliation, that includes the provision of
        post-partum care directly related to the delivery.
        (2) Notwithstanding the provisions in item (1) of this
    subsection, such care shall be authorized by the health
    care plan during the transitional period only if the
    physician agrees:
            (A) to continue to accept reimbursement from the
        health care plan at the rates applicable prior to the
        start of the transitional period;
            (B) to adhere to the health care plan's quality
        assurance requirements and to provide to the health
        care plan necessary medical information related to
        such care; and
            (C) to otherwise adhere to the health care plan's
        policies and procedures, including but not limited to
        procedures regarding referrals and obtaining
        preauthorizations for treatment.
        (3) During an enrollee's plan year, a health care plan
    shall not remove a drug from its formulary or negatively
    change its preferred or cost-tier sharing unless, at least
    60 days before making the formulary change, the health care
    plan:
            (A) provides general notification of the change in
        its formulary to current and prospective enrollees;
            (B) directly notifies enrollees currently
        receiving coverage for the drug, including information
        on the specific drugs involved and the steps they may
        take to request coverage determinations and
        exceptions, including a statement that a certification
        of medical necessity by the enrollee's prescribing
        provider will result in continuation of coverage at the
        existing level; and
            (C) directly notifies by first class mail and
        through an electronic transmission, if available, the
        prescribing provider of all health care plan enrollees
        currently prescribed the drug affected by the proposed
        change; the notice shall include a one-page form by
        which the prescribing provider can notify the health
        care plan by first class mail that coverage of the drug
        for the enrollee is medically necessary.
        The notification in paragraph (C) may direct the
    prescribing provider to an electronic portal through which
    the prescribing provider may electronically file a
    certification to the health care plan that coverage of the
    drug for the enrollee is medically necessary. The
    prescribing provider may make a secure electronic
    signature beside the words "certification of medical
    necessity", and this certification shall authorize
    continuation of coverage for the drug.
        If the prescribing provider certifies to the health
    care plan either in writing or electronically that the drug
    is medically necessary for the enrollee as provided in
    paragraph (C), a health care plan shall authorize coverage
    for the drug prescribed based solely on the prescribing
    provider's assertion that coverage is medically necessary,
    and the health care plan is prohibited from making
    modifications to the coverage related to the covered drug,
    including, but not limited to:
            (i) increasing the out-of-pocket costs for the
        covered drug;
            (ii) moving the covered drug to a more restrictive
        tier; or
            (iii) denying an enrollee coverage of the drug for
        which the enrollee has been previously approved for
        coverage by the health care plan.
        Nothing in this item (3) prevents a health care plan
    from removing a drug from its formulary or denying an
    enrollee coverage if the United States Food and Drug
    Administration has issued a statement about the drug that
    calls into question the clinical safety of the drug, the
    drug manufacturer has notified the United States Food and
    Drug Administration of a manufacturing discontinuance or
    potential discontinuance of the drug as required by Section
    506C of the Federal Food, Drug, and Cosmetic Act, as
    codified in 21 U.S.C. 356c, or the drug manufacturer has
    removed the drug from the market.
        Nothing in this item (3) prohibits a health care plan,
    by contract, written policy or procedure, or any other
    agreement or course of conduct, from requiring a pharmacist
    to effect substitutions of prescription drugs consistent
    with Section 19.5 of the Pharmacy Practice Act, under which
    a pharmacist may substitute an interchangeable biologic
    for a prescribed biologic product, and Section 25 of the
    Pharmacy Practice Act, under which a pharmacist may select
    a generic drug determined to be therapeutically equivalent
    by the United States Food and Drug Administration and in
    accordance with the Illinois Food, Drug and Cosmetic Act.
        This item (3) applies to a policy or contract that is
    amended, delivered, issued, or renewed on or after January
    1, 2019. This item (3) does not apply to a health plan as
    defined in the State Employees Group Insurance Act of 1971
    or medical assistance under Article V of the Illinois
    Public Aid Code.
    (b) A health care plan shall provide for continuity of care
for new enrollees as follows:
        (1) If a new enrollee whose physician is not a member
    of the health care plan's provider network, but is within
    the health care plan's service area, enrolls in the health
    care plan, the health care plan shall permit the enrollee
    to continue an ongoing course of treatment with the
    enrollee's current physician during a transitional period:
            (A) of 90 days from the effective date of
        enrollment if the enrollee has an ongoing course of
        treatment; or
            (B) if the enrollee has entered the third trimester
        of pregnancy at the effective date of enrollment, that
        includes the provision of post-partum care directly
        related to the delivery.
        (2) If an enrollee elects to continue to receive care
    from such physician pursuant to item (1) of this
    subsection, such care shall be authorized by the health
    care plan for the transitional period only if the physician
    agrees:
            (A) to accept reimbursement from the health care
        plan at rates established by the health care plan; such
        rates shall be the level of reimbursement applicable to
        similar physicians within the health care plan for such
        services;
            (B) to adhere to the health care plan's quality
        assurance requirements and to provide to the health
        care plan necessary medical information related to
        such care; and
            (C) to otherwise adhere to the health care plan's
        policies and procedures including, but not limited to
        procedures regarding referrals and obtaining
        preauthorization for treatment.
    (c) In no event shall this Section be construed to require
a health care plan to provide coverage for benefits not
otherwise covered or to diminish or impair preexisting
condition limitations contained in the enrollee's contract. In
no event shall this Section be construed to prohibit the
addition of prescription drugs to a health care plan's list of
covered drugs during the coverage year.
(Source: P.A. 91-617, eff. 7-1-00.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 8/24/2018