Illinois General Assembly - Full Text of SB0177
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Full Text of SB0177  102nd General Assembly

SB0177 102ND GENERAL ASSEMBLY

  
  

 


 
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB0177

 

Introduced 2/9/2021, by Sen. Linda Holmes

 

SYNOPSIS AS INTRODUCED:
 
New Act
215 ILCS 5/370g  from Ch. 73, par. 982g
215 ILCS 134/10
215 ILCS 134/65
305 ILCS 5/5-5.12d new

    Creates the Prior Authorization Reform Act. Provides requirements concerning disclosure and review of prior authorization requirements, denial of claims or coverage by a utilization review organization, and the implementation of prior authorization requirements or restrictions. Provides requirements concerning a utilization review organization's obligations with respect to prior authorizations in nonurgent circumstances, urgent health care services, and emergency health care services. Provides that a utilization review organization shall not require prior authorization under specified circumstances. Provides requirements concerning the length of prior authorizations. Provides that health care services are automatically deemed authorized if a utilization review organization fails to comply with the requirements of the Act. Provides that the Director of Insurance may impose an administrative fine not to exceed $250,000 for violations of the Act. Defines terms. Amends the Illinois Insurance Code to change the definition of "emergency medical condition". Amends the Managed Care Reform and Patient Rights Act to provide that companies that transact accident and health insurance shall comply with specified requirements of the Managed Care Reform and Patient Rights Act. Amends the Illinois Public Aid Code to provide that all managed care organizations shall comply with the requirements of the Prior Authorization Reform Act. Makes other changes. Effective January 1, 2022.


LRB102 14906 BMS 20261 b

 

 

A BILL FOR

 

SB0177LRB102 14906 BMS 20261 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 1. Short title. This Act may be cited as the Prior
5Authorization Reform Act.
 
6    Section 5. Purpose. The General Assembly hereby finds and
7declares that:
8        (1) the health care professional-patient relationship
9    is paramount and should not be subject to third-party
10    intrusion;
11        (2) prior authorization programs shall be subject to
12    member coverage agreements and medical policies but shall
13    not hinder the independent medical judgment of a physician
14    or health care provider; and
15        (3) prior authorization programs must be transparent
16    to ensure a fair and consistent process for health care
17    providers and patients.
 
18    Section 10. Applicability; scope. This Act applies to
19health insurance coverage as defined in the Illinois Health
20Insurance Portability and Accountability Act, and policies
21issued or delivered in this State to the Department of
22Healthcare and Family Services and providing coverage to

 

 

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1persons who are enrolled under Article V of the Illinois
2Public Aid Code or under the Children's Health Insurance
3Program Act, amended, delivered, issued, or renewed on or
4after the effective date of this Act, with the exception of
5employee or employer self-insured health benefit plans under
6the federal Employee Retirement Income Security Act of 1974,
7health care provided pursuant to the Workers' Compensation Act
8or the Workers' Occupational Diseases Act, and State employee
9health plans. This Act does not diminish a health care plan's
10duties and responsibilities under other federal or State law
11or rules promulgated thereunder.
 
12    Section 15. Definitions. As used in this Act:
13    "Adverse determination" has the meaning given to that term
14in Section 10 of the Health Carrier External Review Act.
15    "Appeal" means a formal request, either orally or in
16writing, to reconsider an adverse determination.
17    "Approval" means a determination by a utilization review
18organization that a health care service has been reviewed and,
19based on the information provided, satisfies the utilization
20review organization's requirements for medical necessity and
21appropriateness.
22    "Clinical review criteria" has the meaning given to that
23term in Section 10 of the Health Carrier External Review Act.
24    "Department" means the Department of Insurance.
25    "Emergency medical condition" has the meaning given to

 

 

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1that term in Section 10 of the Managed Care Reform and Patient
2Rights Act.
3    "Emergency services" has the meaning given to that term in
4federal health insurance reform requirements for the group and
5individual health insurance markets, 45 CFR 147.138.
6    "Enrollee" has the meaning given to that term in Section
710 of the Managed Care Reform and Patient Rights Act.
8    "Health care professional" has the meaning given to that
9term in Section 10 of the Managed Care Reform and Patient
10Rights Act.
11    "Health care provider" has the meaning given to that term
12in Section 10 of the Managed Care Reform and Patient Rights
13Act.
14    "Health care service" means any services or level of
15services included in the furnishing to an individual of
16medical care or the hospitalization incident to the furnishing
17of such care, as well as the furnishing to any person of any
18other services for the purpose of preventing, alleviating,
19curing, or healing human illness or injury, including
20behavioral health, mental health, home health, and
21pharmaceutical services and products.
22    "Health insurance issuer" has the meaning given to that
23term in Section 5 of the Illinois Health Insurance Portability
24and Accountability Act.
25    "Medically necessary" means a health care professional
26exercising prudent clinical judgment would provide care to a

 

 

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1patient for the purpose of preventing, diagnosing, or treating
2an illness, injury, disease, or its symptoms and that are: (i)
3in accordance with generally accepted standards of medical
4practice; (ii) clinically appropriate in terms of type,
5frequency, extent, site, and duration and are considered
6effective for the patient's illness, injury, or disease; and
7(iii) not primarily for the convenience of the patient,
8treating physician, other health care professional, caregiver,
9family member, or other interested party.
10    "Physician" means a person licensed under the Medical
11Practice Act of 1987 to practice medicine in all its branches.
12    "Prior authorization" means the process by which
13utilization review organizations determine the medical
14necessity and medical appropriateness of otherwise covered
15health care services before the rendering of such health care
16services. "Prior authorization" includes any utilization
17review organization's requirement that an enrollee, health
18care professional, or health care provider notify the
19utilization review organization before, at the time of, or
20concurrent to providing a health care service.
21    "Urgent health care service" means a health care service
22with respect to which the application of the time periods for
23making a non-expedited prior authorization that in the opinion
24of a health care professional with knowledge of the enrollee's
25medical condition:
26        (1) could seriously jeopardize the life or health of

 

 

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1    the enrollee or the ability of the enrollee to regain
2    maximum function; or
3        (2) could subject the enrollee to severe pain that
4    cannot be adequately managed without the care or treatment
5    that is the subject of the utilization review.
6    "Urgent health care service" does not include emergency
7services.
8    "Utilization review organization" has the meaning given to
9that term in 50 Ill. Adm. Code 4520.30.
 
10    Section 20. Disclosure and review of prior authorization
11requirements.
12    (a) A utilization review organization shall maintain a
13complete list of services for which prior authorization is
14required, including for all services where prior authorization
15is performed by an entity under contract with the utilization
16review organization.
17    (b) A utilization review organization shall make any
18current prior authorization requirements and restrictions,
19including the written clinical review criteria, readily
20accessible and conspicuously posted on its website to
21enrollees, health care professionals, and health care
22providers. Content published by a thirty party and licensed
23for use by a utilization review organization may be made
24available through the utilization review organization's
25secure, password-protected website so long as the access

 

 

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1requirements of the website do not unreasonably restrict
2access. Requirements shall be described in detail, written in
3easily understandable language, and readily available to the
4health care professional and health care provider at the point
5of care. The website shall indicate for each service subject
6to prior authorization:
7        (1) when prior authorization became required for
8    policies issued or delivered in Illinois, including the
9    effective date or dates and the termination date or dates,
10    if applicable, in Illinois;
11        (2) the date the Illinois-specific requirement was
12    listed on the utilization review organization's website;
13    and
14        (3) where applicable, the date that prior
15    authorization was removed for Illinois.
16    (c) The clinical review criteria must:
17        (1) be based on nationally recognized standards except
18    where State law provides its own standard;
19        (2) be developed in accordance with the current
20    standards of national medical accreditation entities;
21        (3) ensure quality of care and access to needed health
22    care services;
23        (4) be evidence-based;
24        (5) be sufficiently flexible to allow deviations from
25    norms when justified on a case-by-case basis;
26        (6) be evaluated and updated, if necessary, at least

 

 

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1    annually; and
2        (7) before establishing or substantially or materially
3    altering written clinical review criteria, obtain input
4    from actively practicing physicians representing major
5    areas of the specialty. The utilization review
6    organization shall seek input from physicians who are not
7    employees of the utilization review organization or
8    consultants to the utilization review organization.
9    (d) A utilization review organization shall not deny a
10claim for failure to obtain prior authorization if the prior
11authorization requirement was not in effect on the date of
12service on the claim.
13    (e) A utilization review organization shall not deny prior
14authorization of a health care service solely based on the
15grounds that the health care service does not meet an
16evidence-based standard where:
17        (1) no independently developed, evidence-based
18    standards can be derived from reliable scientific evidence
19    or documents published by professional societies;
20        (2) evidence-based standards conflict;
21        (3) evidence-based standards from expert consensus
22    panels do not exist; or
23        (4) a health care professional or health care provider
24    judges a service, product, or procedure is medically
25    appropriate for his or her patient even if it has not been
26    formally approved for the specific condition being

 

 

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1    treated.
2    (f) A utilization review organization shall not deem as
3incidental or deny supplies or health care services that are
4routinely used as part of a health care service when:
5        (1) an associated health care service has received
6    prior authorization; or
7        (2) prior authorization for the health care service is
8    not required.
9    (g) If a utilization review organization intends to
10implement a new prior authorization requirement or restriction
11or amend an existing requirement or restriction, the
12utilization review organization shall provide enrollees,
13contracted health care professionals, and contracted health
14care providers of enrollees written notice of the new or
15amended requirement or amendment no less than 60 days before
16the requirement or restriction is implemented. The written
17notice may be provided in an electronic format, including
18email or facsimile, if the enrollee, health care professional,
19or health care provider has agreed in advance to receive
20notices electronically. The utilization review organization
21shall ensure that the new or amended requirement is not
22implemented unless the utilization review organization's
23website has been updated to reflect the new or amended
24requirement or restriction.
25    (h) Entities utilizing prior authorization shall make
26statistics available regarding prior authorization approvals

 

 

SB0177- 9 -LRB102 14906 BMS 20261 b

1and denials on their website in a readily accessible format.
2The categories must be updated quarterly and include all of
3the following information:
4        (1) a list of all health care services, including
5    medications, that are subject to prior authorization;
6        (2) the total number of prior authorization requests
7    received;
8        (3) the physician specialty;
9        (4) the number of prior authorization requests
10    approved during the previous plan year by the utilization
11    review organization with respect to each service described
12    in paragraph (1);
13        (5) the number of prior authorization requests
14    approved during the previous plan year by the utilization
15    review organization after the receipt of additional
16    information from the enrollee, the enrollee's health care
17    professional, or the enrollee's health care provider;
18        (6) the number of prior authorization requests denied
19    during the previous plan year by the health insurance
20    issuer with respect to each service described in paragraph
21    (1) and the top 5 reasons for denial, which must include
22    related evidence-based criteria, if applicable;
23        (7) the number of requests described in paragraph (6)
24    that were appealed, the number of the appealed requests
25    that upheld the adverse determination, and the number of
26    appealed requests that reversed the adverse determination;

 

 

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1        (8) the time between submission and response;
2        (9) the average length of time for resolution; and
3        (10) any other information as the Director determines
4    appropriate after consultation with and comment from
5    stakeholders.
 
6    Section 25. Utilization review organization's obligations
7with respect to prior authorizations in nonurgent
8circumstances. If a utilization review organization requires
9prior authorization of a health care service, the utilization
10review organization must make a prior authorization or adverse
11determination and notify the enrollee, the enrollee's health
12care professional, and the enrollee's health care provider of
13the prior authorization or adverse determination within 72
14hours after obtaining all necessary information to make the
15prior authorization or adverse determination. As used in this
16Section, "necessary information" includes the results of any
17face-to-face clinical evaluation or second opinion that may be
18required.
 
19    Section 30. Utilization review organization's obligations
20with respect to prior authorizations concerning urgent health
21care services.
22    (a) A utilization review organization must render a prior
23authorization or adverse determination concerning urgent care
24services and notify the enrollee, the enrollee's health care

 

 

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1professional, and the enrollee's health care provider of that
2prior authorization or adverse determination not later than 24
3hours after receiving all information needed to complete the
4review of the requested health care services.
5    (b) To facilitate the rendering of a prior authorization
6in conformance with this Section, a utilization review
7organization must establish and provide access to a hotline
8that is staffed 24 hours per day, 7 days per week by
9appropriately trained and licensed clinical personnel who have
10access to physicians for consultation that are designated by
11the plan to make such determinations for prior authorization
12concerning urgent care services.
 
13    Section 35. Utilization review organization's obligations
14with respect to prior authorization concerning emergency
15health care services.
16    (a) A utilization review organization shall cover
17emergency health care services necessary to screen and
18stabilize an enrollee. If a health care professional or health
19care provider certifies in writing to a utilization review
20organization within 72 hours after an enrollee's admission
21that the enrollee's condition required emergency health care
22services, that certification creates a presumption that the
23emergency health care services were medically necessary and
24such presumption may be rebutted only if the utilization
25review organization can establish, with clear and convincing

 

 

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1evidence, that the emergency health care services were not
2medically necessary.
3    (b) If an enrollee receives an emergency health care
4service that requires immediate post-evaluation or
5post-stabilization services, a utilization review organization
6shall make a prior authorization determination within 60
7minutes after receiving a request; if the prior authorization
8determination is not made within 60 minutes, the services
9shall be deemed approved.
 
10    Section 40. Personnel qualified to make adverse
11determinations of a prior authorization request. A utilization
12review organization must ensure that all adverse
13determinations are made by a physician. The physician must:
14        (1) possess a current and valid nonrestricted license
15    to practice medicine in all its branches in Illinois or in
16    another United States jurisdiction;
17        (2) practice in the same or similar specialty as the
18    physician who typically manages the medical condition or
19    disease or provides the health care service involved in
20    the request; and
21        (3) have experience treating patients with the medical
22    condition or disease for which the health care service is
23    being requested.
 
24    Section 45. Consultation before issuing an adverse

 

 

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1determination of a prior authorization. If a utilization
2review organization is questioning the medical necessity of a
3health care service, the utilization review organization must
4notify the enrollee's health care professional and health care
5provider that medical necessity is being questioned. Before
6issuing an adverse determination, the enrollee's health care
7professional and health care provider must have the
8opportunity to discuss the medical necessity of the health
9care service on the telephone or by other agreeable method
10with the physician who will be responsible for issuing the
11prior authorization of the health care service under review.
 
12    Section 50. Requirements applicable to the physician who
13can review consultations and appeals. A utilization program
14must ensure that all appeals are reviewed by a physician. The
15physician must:
16        (1) possess a current and valid nonrestricted license
17    to practice medicine in Illinois or in another United
18    States jurisdiction;
19        (2) be currently in active practice in the same or
20    similar specialty as physician who typically manages the
21    medical condition or disease for at least 5 consecutive
22    years;
23        (3) be knowledgeable of, and have experience
24    providing, the health care services under appeal;
25        (4) not be employed by a utilization review

 

 

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1    organization, be under contract with the utilization
2    review organization other than to participate in one or
3    more of the utilization review organization's health care
4    professional networks or to perform reviews of appeals, or
5    otherwise have any financial interest in the outcome of
6    the appeal;
7        (5) not have been directly involved in making the
8    adverse determination; and
9        (6) consider all known clinical aspects of the health
10    care service under review, including, but not limited to,
11    a review of all pertinent medical records provided to the
12    utilization review organization by the enrollee's health
13    care professional or health care provider and any medical
14    literature provided to the utilization review organization
15    by the health care professional or health care provider.
 
16    Section 55. Limitation on prior authorization. A
17utilization review organization shall not require prior
18authorization:
19        (1) where a medication or procedure prescribed for a
20    patient is customary and properly indicated or is a
21    treatment for the clinical indication as supported by
22    peer-reviewed medical publications;
23        (2) for a patient currently managed with an
24    established treatment regimen; or
25        (3) for the provision of medication-assisted treatment

 

 

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1    for the treatment of a substance use disorder as those
2    terms are defined in the Substance Use Disorder Act.
 
3    Section 60. Denial.
4    (a) A utilization review organization may not revoke,
5limit, condition, or restrict a prior authorization.
6    (b) Notwithstanding any other provision of law, a
7utilization review organization shall approve and payment
8shall be made by the patient's health insurance issuer on
9claims for health care services for which prior authorization
10was required and approval received before the rendering of
11health care services, unless one of the following occurs:
12        (1) it is timely determined that the enrollee's health
13    care professional or health care provider knowingly
14    provided health care services that required prior
15    authorization from the utilization review organization
16    without first obtaining prior authorization for those
17    health care services;
18        (2) it is timely determined that the health care
19    services claimed were not performed;
20        (3) it is timely determined that the health care
21    services rendered were contrary to the instructions of the
22    utilization review organization or its delegated physician
23    reviewer if contact was made between those parties before
24    the service being rendered;
25        (4) it is timely determined that the enrollee

 

 

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1    receiving such health care services was not an enrollee of
2    the health care plan; or
3        (5) the approval was based upon a material
4    misrepresentation by the enrollee or health care provider;
5    as used in this paragraph (5), "material" means a fact or
6    situation that is not merely technical in nature and
7    results or could result in a substantial change in the
8    situation.
 
9    Section 65. Length of prior authorization approval. A
10prior authorization approval shall be valid for 12 months
11after the date the health care professional or health care
12provider receives the prior authorization approval and the
13approval period shall be effective regardless of any changes,
14including any changes in dosage for a prescription drug
15prescribed by the health care professional. Except to the
16extent required by medical exceptions processes for
17prescription drugs, nothing in this Section shall require a
18policy to cover any care, treatment, or services for any
19health condition that the terms of coverage otherwise
20completely exclude from the policy's covered benefits without
21regard for whether the care, treatment, or services are
22medically necessary.
 
23    Section 70. Length of prior authorization for treatment
24for chronic or long-term care conditions. If a utilization

 

 

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1review organization requires a prior authorization for a
2health care service or medication for the treatment of a
3chronic or long-term care condition, the prior authorization
4shall remain valid for the length of the treatment as
5determined by the patient's health care professional.
 
6    Section 75. Continuity of care for enrollees.
7    (a) On receipt of information documenting a prior
8authorization from the enrollee or from the enrollee's health
9care professional or health care provider, a utilization
10review organization shall honor a prior authorization granted
11to an enrollee from a previous utilization review organization
12for at least the initial 90 days of an enrollee's coverage
13under a new health plan.
14    (b) During the time period described in subsection (a), a
15utilization review organization may perform its own review to
16grant a prior authorization subject to the terms of the
17member's coverage agreement.
18    (c) If there is a change in coverage of or approval
19criteria for a previously authorized health care service, the
20change in coverage or approval criteria does not affect an
21enrollee who received prior authorization before the effective
22date of the change for the remainder of the enrollee's plan
23year.
24    (d) Except to the extent required by medical exceptions
25processes for prescription drugs, nothing in this Section

 

 

SB0177- 18 -LRB102 14906 BMS 20261 b

1shall require a policy to cover any care, treatment, or
2services for any health condition that the terms of coverage
3otherwise completely exclude from the policy's covered
4benefits without regard for whether the care, treatment, or
5services are medically necessary.
 
6    Section 80. Health care services deemed authorized if a
7utilization review organization fails to comply with the
8requirements of this Act. A failure by a utilization review
9organization to comply with the deadlines and other
10requirements specified in this Act shall result in any health
11care services subject to review to be automatically deemed
12authorized by the utilization review organization.
 
13    Section 85. Severability. If any provision of this Act or
14its application to any person or circumstance is held invalid,
15the invalidity does not affect other provisions or
16applications of this Act that can be given effect without the
17invalid provision or application, and to this end the
18provisions of this Act are declared to be severable.
 
19    Section 90. Administration and enforcement.
20    (a) The Department shall enforce the provisions of this
21Act pursuant to the enforcement powers granted to it by law. To
22enforce the provisions of this Act, the Director is hereby
23granted specific authority to issue a cease and desist order

 

 

SB0177- 19 -LRB102 14906 BMS 20261 b

1or require a utilization review organization or health
2insurance issuer to submit a plan of correction for violations
3of this Act, or both, in accordance with the requirements and
4authority set forth in Section 85 of the Managed Care Reform
5and Patient Rights Act. Subject to the provisions of the
6Illinois Administrative Procedure Act, the Director may,
7pursuant to Section 403A of the Illinois Insurance Code,
8impose upon a utilization review organization or health
9insurance issuer an administrative fine not to exceed $250,000
10for failure to submit a requested plan of correction, failure
11to comply with its plan of correction, or repeated violations
12of this Act.
13    (b) Any person who believes that his or her utilization
14review organization or health insurance issuer is in violation
15of the provisions of this Act may file a complaint with the
16Department. The Department shall review all complaints
17received and investigate all complaints that it deems to state
18a potential violation. The Department shall fairly,
19efficiently, and timely review and investigate complaints.
20Utilization review organizations found to be in violation of
21this Act shall be penalized in accordance with this Section.
22    (c) The Department of Healthcare and Family Services shall
23enforce the provisions of this Act as it applies to persons
24enrolled under Article V of the Illinois Public Aid Code or
25under the Children's Health Insurance Program Act.
 

 

 

SB0177- 20 -LRB102 14906 BMS 20261 b

1    Section 900. The Illinois Insurance Code is amended by
2changing Section 370g as follows:
 
3    (215 ILCS 5/370g)  (from Ch. 73, par. 982g)
4    Sec. 370g. Definitions. As used in this Article, the
5following definitions apply:
6    (a) "Health care services" means health care services or
7products rendered or sold by a provider within the scope of the
8provider's license or legal authorization. The term includes,
9but is not limited to, hospital, medical, surgical, dental,
10vision and pharmaceutical services or products.
11    (b) "Insurer" means an insurance company or a health
12service corporation authorized in this State to issue policies
13or subscriber contracts which reimburse for expenses of health
14care services.
15    (c) "Insured" means an individual entitled to
16reimbursement for expenses of health care services under a
17policy or subscriber contract issued or administered by an
18insurer.
19    (d) "Provider" means an individual or entity duly licensed
20or legally authorized to provide health care services.
21    (e) "Noninstitutional provider" means any person licensed
22under the Medical Practice Act of 1987, as now or hereafter
23amended.
24    (f) "Beneficiary" means an individual entitled to
25reimbursement for expenses of or the discount of provider fees

 

 

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1for health care services under a program where the beneficiary
2has an incentive to utilize the services of a provider which
3has entered into an agreement or arrangement with an
4administrator.
5    (g) "Administrator" means any person, partnership or
6corporation, other than an insurer or health maintenance
7organization holding a certificate of authority under the
8"Health Maintenance Organization Act", as now or hereafter
9amended, that arranges, contracts with, or administers
10contracts with a provider whereby beneficiaries are provided
11an incentive to use the services of such provider.
12    (h) "Emergency medical condition" has the meaning given to
13that term in Section 10 of the Managed Care Reform and Patient
14Rights Act. means a medical condition manifesting itself by
15acute symptoms of sufficient severity (including severe pain)
16such that a prudent layperson, who possesses an average
17knowledge of health and medicine, could reasonably expect the
18absence of immediate medical attention to result in:
19        (1) placing the health of the individual (or, with
20    respect to a pregnant woman, the health of the woman or her
21    unborn child) in serious jeopardy;
22        (2) serious impairment to bodily functions; or
23        (3) serious dysfunction of any bodily organ or part.
24(Source: P.A. 91-617, eff. 1-1-00.)
 
25    Section 905. The Managed Care Reform and Patient Rights

 

 

SB0177- 22 -LRB102 14906 BMS 20261 b

1Act is amended by changing Sections 10 and 65 as follows:
 
2    (215 ILCS 134/10)
3    Sec. 10. Definitions.
4    "Adverse determination" means a determination by a health
5care plan under Section 45 or by a utilization review program
6under Section 85 that a health care service is not medically
7necessary.
8    "Clinical peer" means a health care professional who is in
9the same profession and the same or similar specialty as the
10health care provider who typically manages the medical
11condition, procedures, or treatment under review.
12    "Department" means the Department of Insurance.
13    "Emergency medical condition" means a medical condition
14manifesting itself by acute symptoms of sufficient severity,
15regardless of the final diagnosis given, such that a prudent
16layperson, who possesses an average knowledge of health and
17medicine, could reasonably expect the absence of immediate
18medical attention to result in:
19        (1) placing the health of the individual (or, with
20    respect to a pregnant woman, the health of the woman or her
21    unborn child) in serious jeopardy;
22        (2) serious impairment to bodily functions;
23        (3) serious dysfunction of any bodily organ or part;
24        (4) inadequately controlled pain; or
25        (5) with respect to a pregnant woman who is having

 

 

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1    contractions:
2            (A) inadequate time to complete a safe transfer to
3        another hospital before delivery; or
4            (B) a transfer to another hospital may pose a
5        threat to the health or safety of the woman or unborn
6        child.
7    "Emergency medical screening examination" means a medical
8screening examination and evaluation by a physician licensed
9to practice medicine in all its branches, or to the extent
10permitted by applicable laws, by other appropriately licensed
11personnel under the supervision of or in collaboration with a
12physician licensed to practice medicine in all its branches to
13determine whether the need for emergency services exists.
14    "Emergency services" means, with respect to an enrollee of
15a health care plan, transportation services, including but not
16limited to ambulance services, and covered inpatient and
17outpatient hospital services furnished by a provider qualified
18to furnish those services that are needed to evaluate or
19stabilize an emergency medical condition. "Emergency services"
20does not refer to post-stabilization medical services.
21    "Enrollee" means any person and his or her dependents
22enrolled in or covered by a health care plan.
23    "Health care plan" means a plan, including, but not
24limited to, a health maintenance organization, a managed care
25community network as defined in the Illinois Public Aid Code,
26or an accountable care entity as defined in the Illinois

 

 

SB0177- 24 -LRB102 14906 BMS 20261 b

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

 

 

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1    Act; and
2        (6) not-for-profit voluntary health services plans
3    with health maintenance organization authority in
4    existence as of January 1, 1999 that are affiliated with a
5    union and that only extend coverage to union members and
6    their dependents.
7    "Health care professional" means a physician, a registered
8professional nurse, or other individual appropriately licensed
9or registered to provide health care services.
10    "Health care provider" means any physician, hospital
11facility, facility licensed under the Nursing Home Care Act,
12long-term care facility as defined in Section 1-113 of the
13Nursing Home Care Act, or other person that is licensed or
14otherwise authorized to deliver health care services. Nothing
15in this Act shall be construed to define Independent Practice
16Associations or Physician-Hospital Organizations as health
17care providers.
18    "Health care services" means any services included in the
19furnishing to any individual of medical care, or the
20hospitalization incident to the furnishing of such care, as
21well as the furnishing to any person of any and all other
22services for the purpose of preventing, alleviating, curing,
23or healing human illness or injury including behavioral
24health, mental health, home health, and pharmaceutical
25services and products.
26    "Medical director" means a physician licensed in any state

 

 

SB0177- 26 -LRB102 14906 BMS 20261 b

1to practice medicine in all its branches appointed by a health
2care plan.
3    "Person" means a corporation, association, partnership,
4limited liability company, sole proprietorship, or any other
5legal entity.
6    "Physician" means a person licensed under the Medical
7Practice Act of 1987.
8    "Post-stabilization medical services" means health care
9services provided to an enrollee that are furnished in a
10licensed hospital by a provider that is qualified to furnish
11such services, and determined to be medically necessary and
12directly related to the emergency medical condition following
13stabilization.
14    "Stabilization" means, with respect to an emergency
15medical condition, to provide such medical treatment of the
16condition as may be necessary to assure, within reasonable
17medical probability, that no material deterioration of the
18condition is likely to result.
19    "Utilization review" means the evaluation of the medical
20necessity, appropriateness, and efficiency of the use of
21health care services, procedures, and facilities.
22    "Utilization review program" means a program established
23by a person to perform utilization review.
24(Source: P.A. 101-452, eff. 1-1-20.)
 
25    (215 ILCS 134/65)

 

 

SB0177- 27 -LRB102 14906 BMS 20261 b

1    Sec. 65. Emergency services prior to stabilization.
2    (a) A health care plan that provides or that is required by
3law to provide coverage for emergency services shall provide
4coverage such that payment under this coverage is not
5dependent upon whether the services are performed by a plan or
6non-plan health care provider and without regard to prior
7authorization. This coverage shall be at the same benefit
8level as if the services or treatment had been rendered by the
9health care plan physician licensed to practice medicine in
10all its branches or health care provider.
11    (b) Prior authorization or approval by the plan shall not
12be required for emergency services.
13    (c) Coverage and payment shall only be retrospectively
14denied under the following circumstances:
15        (1) upon reasonable determination that the emergency
16    services claimed were never performed;
17        (2) upon timely determination that the emergency
18    evaluation and treatment were rendered to an enrollee who
19    sought emergency services and whose circumstance did not
20    meet the definition of emergency medical condition;
21        (3) upon determination that the patient receiving such
22    services was not an enrollee of the health care plan; or
23        (4) upon material misrepresentation by the enrollee or
24    health care provider; "material" means a fact or situation
25    that is not merely technical in nature and results or
26    could result in a substantial change in the situation.

 

 

SB0177- 28 -LRB102 14906 BMS 20261 b

1    (d) When an enrollee presents to a hospital seeking
2emergency services, the determination as to whether the need
3for those services exists shall be made for purposes of
4treatment by a physician licensed to practice medicine in all
5its branches or, to the extent permitted by applicable law, by
6other appropriately licensed personnel under the supervision
7of or in collaboration with a physician licensed to practice
8medicine in all its branches. The physician or other
9appropriate personnel shall indicate in the patient's chart
10the results of the emergency medical screening examination.
11    (e) The appropriate use of the 911 emergency telephone
12system or its local equivalent shall not be discouraged or
13penalized by the health care plan when an emergency medical
14condition exists. This provision shall not imply that the use
15of 911 or its local equivalent is a factor in determining the
16existence of an emergency medical condition.
17    (f) The medical director's or his or her designee's
18determination of whether the enrollee meets the standard of an
19emergency medical condition shall be based solely upon the
20presenting symptoms documented in the medical record at the
21time care was sought. Only a clinical peer may make an adverse
22determination.
23    (g) Nothing in this Section shall prohibit the imposition
24of deductibles, copayments, and co-insurance. Nothing in this
25Section alters the prohibition on billing enrollees contained
26in the Health Maintenance Organization Act.

 

 

SB0177- 29 -LRB102 14906 BMS 20261 b

1    (h) This Section shall apply to the types of companies
2subject to Section 155.36 of the Illinois Insurance Code.
3(Source: P.A. 91-617, eff. 1-1-00.)
 
4    Section 910. The Illinois Public Aid Code is amended by
5adding Section 5-5.12d as follows:
 
6    (305 ILCS 5/5-5.12d new)
7    Sec. 5-5.12d. Managed care organization prior
8authorization of health care services.
9    (a) As used in this Section, "health care service" has the
10meaning given to that term in the Prior Authorization Reform
11Act.
12    (b) Notwithstanding any other provision of law to the
13contrary, all managed care organizations shall comply with the
14requirements of the Prior Authorization Reform Act.
 
15    Section 999. Effective date. This Act takes effect January
161, 2022.