Illinois General Assembly - Bill Status for HB3638

Amends the Illinois Public Aid Code and the Illinois Insurance Code. Requires the Department of Healthcare and Family Services and the Department of Insurance to jointly develop a uniform prior authorization form for prescription drug benefits on or before July 1, 2014. Provides that on and after January 1, 2015, or 6 months after the form is developed, whichever is later, every prescribing provider may use that uniform prior authorization form to request prior authorization for coverage of prescription drug benefits and every health care service plan shall accept that form as sufficient to request prior authorization for prescription drug benefits. Provides that on and after January 1, 2015, a health insurer that provides prescription drug benefits shall utilize and accept the prior authorization form when requiring prior authorization for prescription drug benefits; and that if a health care service plan fails to utilize or accept the prior authorization form, or fails to respond within 2 business days upon receipt of a completed prior authorization request from a prescribing provider, the prior authorization request shall be deemed to have been granted. Exempts certain providers. Sets forth certain criteria for the prior authorization form. Provides that "prescribing provider" includes a provider authorized to write a prescription as described in the Pharmacy Practice Act. Effective January 1, 2014.

Replaces everything after the enacting clause. Amends the Illinois Insurance Code. Provides that on and after January 1, 2015, a health insurer that provides prescription drug benefits must, within 72 hours after receipt of a prior authorization form from a prescribing provider or pharmacist, either approve or deny the prior authorization; and 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 prior authorization form. In the case of a denial, requires the health insurer to 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. Requires health insurers to provide confirmation of receipt of a prior authorization form within one hour after receipt of the prior authorization form. Provides that the provision concerning prior authorization forms and prescription benefits do not apply to plans for beneficiaries of Medicare or Medicaid. Effective immediately.

Replaces everything after the enacting clause. Provides that the Act may be referred to as the Health Insurance Consumer Protection Act of 2014 and sets forth findings and a purpose. Amends the Illinois Insurance Code. Provides that no policy shall be offered for sale directly to consumers in the State as a qualified health plan, as defined in the federal Patient Protection and Affordable Care Act, unless certain information is made available to the consumer at the time he or she is comparing policies and their premiums. Sets forth provisions concerning providing information and applicability. Amends the Managed Care Reform and Patient Rights Act. Provides that no health care plan shall be offered for sale directly to consumers in the State as a qualified health plan, as defined in the federal Patient Protection and Affordable Care Act, unless certain information is made available to the consumer at the time he or she is comparing policies and their premiums. Sets forth provisions concerning providing information and applicability. Provides that every health carrier that offers a qualified health plan, as defined in the federal Patient Protection and Affordable Care Act, directly to consumers in the 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 certain conditions exist. Inserts provisions similar to the provisions of the engrossed bill (that amended the Illinois Insurance Code) with the following changes. Replaces references to "prior authorization form" with "paper or electronic prior authorization form". Provides that in the case of a denial, the health insurer shall provide the prescriber with information regarding the denial (rather than information regarding the procedure for submitting an appeal to the denial). Deletes a requirement that health insurers must provide confirmation of receipt of a prior authorization form within one hour after receipt of the prior authorization form. Effective immediately.

Further amends the Illinois Insurance Code to provide that certain insurers must comply with the medical exceptions procedures and prior authorization form requirements established under the Managed Care Reform and Patient Rights Act. Provides that no qualified health plans shall be offered for sale directly to consumers through the health insurance marketplace operating in the State (rather than no policy shall be offered for sale directly to consumers in this State as a qualified health plan), unless specified information is made available to the consumer a the time he or she is comparing policies and premiums, and makes conforming changes throughout the language. Changes references from "up-to-date formulary" to "most recently published formulary". Makes other changes.

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