Full Text of HB0711 102nd General Assembly
HB0711ham001 102ND GENERAL ASSEMBLY | Rep. Greg Harris Filed: 4/7/2021
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| 1 | | AMENDMENT TO HOUSE BILL 711
| 2 | | AMENDMENT NO. ______. Amend House Bill 711 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. Short title. This Act may be cited as the Prior | 5 | | Authorization Reform Act. | 6 | | Section 5. Purpose. The General Assembly hereby finds and | 7 | | declares 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 |
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| 1 | | providers and patients.
| 2 | | Section 10. Applicability; scope. This Act applies to | 3 | | health insurance coverage as defined in the Illinois Health | 4 | | Insurance Portability and Accountability Act, and policies | 5 | | issued or delivered in this State to the Department of | 6 | | Healthcare and Family Services and providing coverage to | 7 | | persons who are enrolled under Article V of the Illinois | 8 | | Public Aid Code or under the Children's Health Insurance | 9 | | Program Act, amended, delivered, issued, or renewed on or | 10 | | after the effective date of this Act, with the exception of | 11 | | employee or employer self-insured health benefit plans under | 12 | | the federal Employee Retirement Income Security Act of 1974, | 13 | | health care provided pursuant to the Workers' Compensation Act | 14 | | or the Workers' Occupational Diseases Act, and State employee | 15 | | health plans. This Act does not diminish a health care plan's | 16 | | duties and responsibilities under other federal or State law | 17 | | or rules promulgated thereunder. | 18 | | Section 15. Definitions. As used in this Act:
| 19 | | "Adverse determination" has the meaning given to that term | 20 | | in Section 10 of the Health Carrier External Review Act.
| 21 | | "Appeal" means a formal request, either orally or in | 22 | | writing, to reconsider an adverse determination.
| 23 | | "Approval" means a determination by a utilization review | 24 | | organization that a health care service has been reviewed and, |
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| 1 | | based on the information provided, satisfies the utilization | 2 | | review organization's requirements for medical necessity and | 3 | | appropriateness.
| 4 | | "Clinical review criteria" has the meaning given to that | 5 | | term in Section 10 of the Health Carrier External Review Act.
| 6 | | "Department" means the Department of Insurance.
| 7 | | "Emergency medical condition" has the meaning given to | 8 | | that term in Section 10 of the Managed Care Reform and Patient | 9 | | Rights Act.
| 10 | | "Emergency services" has the meaning given to that term in | 11 | | federal health insurance reform requirements for the group and | 12 | | individual health insurance markets, 45 CFR 147.138.
| 13 | | "Enrollee" has the meaning given to that term in Section | 14 | | 10 of the Managed Care Reform and Patient Rights Act.
| 15 | | "Health care professional" has the meaning given to that | 16 | | term in Section 10 of the Managed Care Reform and Patient | 17 | | Rights Act.
| 18 | | "Health care provider" has the meaning given to that term | 19 | | in Section 10 of the Managed Care Reform and Patient Rights | 20 | | Act.
| 21 | | "Health care service" means any services or level of | 22 | | services included in the furnishing to an individual of | 23 | | medical care or the hospitalization incident to the furnishing | 24 | | of such care, as well as the furnishing to any person of any | 25 | | other services for the purpose of preventing, alleviating, | 26 | | curing, or healing human illness or injury, including |
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| 1 | | behavioral health, mental health, home health, and | 2 | | pharmaceutical services and products.
| 3 | | "Health insurance issuer" has the meaning given to that | 4 | | term in Section 5 of the Illinois Health Insurance Portability | 5 | | and Accountability Act.
| 6 | | "Medically necessary" means a health care professional | 7 | | exercising prudent clinical judgment would provide care to a | 8 | | patient for the purpose of preventing, diagnosing, or treating | 9 | | an illness, injury, disease, or its symptoms and that are: (i) | 10 | | in accordance with generally accepted standards of medical | 11 | | practice; (ii) clinically appropriate in terms of type, | 12 | | frequency, extent, site, and duration and are considered | 13 | | effective for the patient's illness, injury, or disease; and | 14 | | (iii) not primarily for the convenience of the patient, | 15 | | treating physician, other health care professional, caregiver, | 16 | | family member, or other interested party, but focused on what | 17 | | is best for the patient's health outcome.
| 18 | | "Physician" means a person licensed under the Medical | 19 | | Practice Act of 1987 to practice medicine in all its branches.
| 20 | | "Prior authorization" means the process by which | 21 | | utilization review organizations determine the medical | 22 | | necessity and medical appropriateness of otherwise covered | 23 | | health care services before the rendering of such health care | 24 | | services. "Prior authorization" includes any utilization | 25 | | review organization's requirement that an enrollee, health | 26 | | care professional, or health care provider notify the |
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| 1 | | utilization review organization before, at the time of, or | 2 | | concurrent to providing a health care service.
| 3 | | "Urgent health care service" means a health care service | 4 | | with respect to which the application of the time periods for | 5 | | making a non-expedited prior authorization that in the opinion | 6 | | of a health care professional with knowledge of the enrollee's | 7 | | medical condition:
| 8 | | (1) could seriously jeopardize the life or health of | 9 | | the enrollee or the ability of the enrollee to regain | 10 | | maximum function; or
| 11 | | (2) could subject the enrollee to severe pain that | 12 | | cannot be adequately managed without the care or treatment | 13 | | that is the subject of the utilization review.
| 14 | | "Urgent health care service" does not include emergency | 15 | | services.
| 16 | | "Utilization review organization" has the meaning given to | 17 | | that term in 50 Ill. Adm. Code 4520.30.
| 18 | | Section 20. Disclosure and review of prior authorization | 19 | | requirements.
| 20 | | (a) A health insurance issuer shall maintain a complete | 21 | | list of services for which prior authorization is required, | 22 | | including for all services where prior authorization is | 23 | | performed by an entity under contract with the health | 24 | | insurance issuer.
| 25 | | (b) A health insurance issuer shall make any current prior |
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| 1 | | authorization requirements and restrictions, including the | 2 | | written clinical review criteria, readily accessible and | 3 | | conspicuously posted on its website to enrollees, health care | 4 | | professionals, and health care providers. Content published by | 5 | | a third party and licensed for use by a health insurance issuer | 6 | | or its contracted utilization review organization may be made | 7 | | available through the health insurance issuer's or its | 8 | | contracted utilization review organization's secure, | 9 | | password-protected website so long as the access requirements | 10 | | of the website do not unreasonably restrict access. | 11 | | Requirements shall be described in detail, written in easily | 12 | | understandable language, and readily available to the health | 13 | | care professional and health care provider at the point of | 14 | | care. The website shall indicate for each service subject to | 15 | | prior authorization:
| 16 | | (1) when prior authorization became required for | 17 | | policies issued or delivered in Illinois, including the | 18 | | effective date or dates and the termination date or dates, | 19 | | if applicable, in Illinois;
| 20 | | (2) the date the Illinois-specific requirement was | 21 | | listed on the health insurance issuer's or its contracted | 22 | | utilization review organization's website; and
| 23 | | (3) where applicable, the date that prior | 24 | | authorization was removed for Illinois.
| 25 | | (c) The clinical review criteria must:
| 26 | | (1) be based on nationally recognized, generally |
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| 1 | | accepted standards except where State law provides its own | 2 | | standard;
| 3 | | (2) be developed in accordance with the current | 4 | | standards of a national medical accreditation entity;
| 5 | | (3) ensure quality of care and access to needed health | 6 | | care services;
| 7 | | (4) be evidence-based;
| 8 | | (5) be sufficiently flexible to allow deviations from | 9 | | norms when justified on a case-by-case basis;
and | 10 | | (6) be evaluated and updated, if necessary, at least | 11 | | annually. | 12 | | (d) A health insurance issuer shall not deny a claim for | 13 | | failure to obtain prior authorization if the prior | 14 | | authorization requirement was not in effect on the date of | 15 | | service on the claim.
| 16 | | (e) Neither a health insurance issuer nor a contracted | 17 | | utilization review organization shall deny prior authorization | 18 | | of a health care service solely based on the grounds that:
| 19 | | (1) no independently developed, evidence-based | 20 | | standards can be derived from reliable scientific evidence | 21 | | or documents published by professional societies;
| 22 | | (2) evidence-based standards conflict;
or | 23 | | (3) evidence-based standards from expert consensus | 24 | | panels do not exist.
| 25 | | (f) A health insurance issuer or its contracted | 26 | | utilization review organization shall not deem as incidental |
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| 1 | | or deny supplies or health care services that are routinely | 2 | | used as part of a health care service when:
| 3 | | (1) an associated health care service has received | 4 | | prior authorization; or
| 5 | | (2) prior authorization for the health care service is | 6 | | not required.
| 7 | | (g) If a health insurance issuer intends either to | 8 | | implement a new prior authorization requirement or restriction | 9 | | or amend an existing requirement or restriction, the health | 10 | | insurance issuer shall provide enrollees, contracted health | 11 | | care professionals, and contracted health care providers of | 12 | | enrollees written notice of the new or amended requirement or | 13 | | amendment no less than 60 days before the requirement or | 14 | | restriction is implemented. The written notice may be provided | 15 | | in an electronic format, including email or facsimile, if the | 16 | | enrollee, health care professional, or health care provider | 17 | | has agreed in advance to receive notices electronically. The | 18 | | health insurance issuer shall ensure that the new or amended | 19 | | requirement is not implemented unless the health insurance | 20 | | issuer's or its contracted utilization review organization's | 21 | | website has been updated to reflect the new or amended | 22 | | requirement or restriction.
| 23 | | (h) Entities utilizing prior authorization shall make | 24 | | statistics available regarding prior authorization approvals | 25 | | and denials on their website in a readily accessible format. | 26 | | The categories must be updated quarterly and include all of |
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| 1 | | the following information:
| 2 | | (1) a list of all health care services, including | 3 | | medications, that are subject to prior authorization;
| 4 | | (2) the total number of prior authorization requests | 5 | | received;
| 6 | | (3) the number of prior authorization requests denied | 7 | | during the previous plan year by the health insurance | 8 | | issuer or its contracted utilization review organization | 9 | | with respect to each service described in paragraph (1) | 10 | | and the top 5 reasons for denial;
| 11 | | (4) the number of requests described in paragraph (3) | 12 | | that were appealed, the number of the appealed requests | 13 | | that upheld the adverse determination, and the number of | 14 | | appealed requests that reversed the adverse determination;
| 15 | | (5) the average time between submission and response;
| 16 | | and | 17 | | (6) any other information as the Director determines | 18 | | appropriate.
| 19 | | Section 25. Health insurance issuer's and its contracted | 20 | | utilization review organization's obligations with respect to | 21 | | prior authorizations in nonurgent circumstances. If a health | 22 | | insurance issuer requires prior authorization of a health care | 23 | | service, the health insurance issuer or its contracted | 24 | | utilization review organization must make an approval or | 25 | | adverse determination and notify the enrollee, the enrollee's |
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| 1 | | health care professional, and the enrollee's health care | 2 | | provider of the approval or adverse determination as required | 3 | | by applicable law, but no later than 72 hours after obtaining | 4 | | all necessary information to make the approval or adverse | 5 | | determination. As used in this Section, "necessary | 6 | | information" includes the results of any face-to-face clinical | 7 | | evaluation or second opinion that may be required. | 8 | | Section 30. Health insurance issuer's and its contracted | 9 | | utilization review organization's obligations with respect to | 10 | | prior authorizations concerning urgent health care services.
| 11 | | (a) A health insurance issuer or its contracted | 12 | | utilization review organization must render an approval or | 13 | | adverse determination concerning urgent care services and any | 14 | | services for any current or prospective resident of a skilled | 15 | | nursing facility and notify the enrollee, the enrollee's | 16 | | health care professional, and the enrollee's health care | 17 | | provider of that approval or adverse determination not later | 18 | | than 24 hours after receiving all information needed to | 19 | | complete the review of the requested health care services.
| 20 | | (b) To facilitate the rendering of a prior authorization | 21 | | determination in conformance with this Section, a health | 22 | | insurance issuer or its contracted utilization review | 23 | | organization must establish and provide access to a hotline | 24 | | that is staffed 24 hours per day, 7 days per week by | 25 | | appropriately trained and licensed clinical personnel who have |
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| 1 | | access to physicians for consultation, designated by the plan | 2 | | to make such determinations for prior authorization concerning | 3 | | urgent care services.
| 4 | | Section 35. Health insurance issuer's and its contracted | 5 | | utilization review organization's obligations with respect to | 6 | | prior authorization concerning emergency health care services.
| 7 | | (a) A health insurance issuer shall cover emergency health | 8 | | care services necessary to screen and stabilize an enrollee. | 9 | | If a health care professional or health care provider | 10 | | certifies in writing to a health insurance issuer within 72 | 11 | | hours after an enrollee's admission that the enrollee's | 12 | | condition required emergency health care services, that | 13 | | certification shall create a presumption that the emergency | 14 | | health care services were medically necessary and such | 15 | | presumption may be rebutted only if the health insurance | 16 | | issuer or its contracted utilization review organization can | 17 | | establish, with clear and convincing evidence, that the | 18 | | emergency health care services were not medically necessary.
| 19 | | (b) If an enrollee receives an emergency health care | 20 | | service that requires immediate post-evaluation or | 21 | | post-stabilization services, a health insurance issuer or its | 22 | | contracted utilization review organization shall make a prior | 23 | | authorization determination within 60 minutes after receiving | 24 | | a request; if the prior authorization determination is not | 25 | | made within 60 minutes, the services shall be deemed approved.
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| 1 | | Section 40. Personnel qualified to make adverse | 2 | | determinations of a prior authorization request. A health | 3 | | insurance issuer or its contracted utilization review | 4 | | organization must ensure that all adverse determinations are | 5 | | made by a physician when the request is by a physician or a | 6 | | representative of a physician. The physician must:
| 7 | | (1) possess a current and valid nonrestricted license | 8 | | to practice medicine in all its branches in any United | 9 | | States jurisdiction;
| 10 | | (2) practice in the same or similar specialty as the | 11 | | physician who typically manages the medical condition or | 12 | | disease or provides the health care service involved in | 13 | | the request; and
| 14 | | (3) have experience treating patients with the medical | 15 | | condition or disease for which the health care service is | 16 | | being requested.
| 17 | | Notwithstanding the foregoing, a licensed health care | 18 | | professional who satisfies the requirements of this Section | 19 | | may make an adverse determination of a prior authorization | 20 | | request submitted by a health care professional licensed in | 21 | | the same profession. | 22 | | Section 45. Consultation before issuing an adverse | 23 | | determination of a prior authorization. If a health insurance | 24 | | issuer or its contracted utilization review organization is |
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| 1 | | questioning the medical necessity of a health care service, | 2 | | the health insurance issuer or its contracted utilization | 3 | | review organization must notify the enrollee's health care | 4 | | professional and health care provider that medical necessity | 5 | | is being questioned. Before issuing an adverse determination, | 6 | | the enrollee's health care professional and health care | 7 | | provider must have the opportunity to discuss the medical | 8 | | necessity of the health care service on the telephone or by | 9 | | other agreeable method with the health care professional who | 10 | | will be responsible for issuing the prior authorization | 11 | | determination of the health care service under review. | 12 | | Section 50. Requirements applicable to the physician who | 13 | | can review consultations and appeals. A health insurance | 14 | | issuer or its contracted utilization review organization must | 15 | | ensure that all appeals are reviewed by a physician. The | 16 | | physician must:
| 17 | | (1) possess a current and valid nonrestricted license | 18 | | to practice medicine in any United States jurisdiction;
| 19 | | (2) be currently in active practice in the same or | 20 | | similar specialty as a physician who typically manages the | 21 | | medical condition or disease;
| 22 | | (3) be knowledgeable of, and have experience | 23 | | providing, the health care services under appeal;
| 24 | | (4) not have been directly involved in making the | 25 | | adverse determination; and
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| 1 | | (5) consider all known clinical aspects of the health | 2 | | care service under review, including, but not limited to, | 3 | | a review of all pertinent medical records provided to the | 4 | | health insurance issuer or its contracted utilization | 5 | | review organization by the enrollee's health care | 6 | | professional or health care provider and any medical | 7 | | literature provided to the health insurance issuer or its | 8 | | contracted utilization review organization by the health | 9 | | care professional or health care provider.
| 10 | | Section 55. Review of prior authorization requirements. A | 11 | | health insurance issuer shall periodically review its prior | 12 | | authorization requirements and consider removal of prior | 13 | | authorization requirements:
| 14 | | (1) where a medication or procedure prescribed is | 15 | | customary and properly indicated or is a treatment for the | 16 | | clinical indication as supported by peer-reviewed medical | 17 | | publications;
or | 18 | | (2) for patients currently managed with an established | 19 | | treatment regimen. | 20 | | Section 60. Denial.
| 21 | | (a) The health insurance issuer or its contracted | 22 | | utilization review organization may not revoke, limit, | 23 | | condition, or restrict a previously issued prior authorization | 24 | | approval.
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| 1 | | (b) Notwithstanding any other provision of law, if a claim | 2 | | is properly coded and submitted timely to a health insurance | 3 | | issuer, the health insurance issuer shall make payment on | 4 | | claims for health care services for which prior authorization | 5 | | was required and approval received before the rendering of | 6 | | health care services, unless one of the following occurs:
| 7 | | (1) it is timely determined that the enrollee's health | 8 | | care professional or health care provider knowingly | 9 | | provided health care services that required prior | 10 | | authorization from the health insurance issuer or its | 11 | | contracted utilization review organization without first | 12 | | obtaining prior authorization for those health care | 13 | | services;
| 14 | | (2) it is timely determined that the health care | 15 | | services claimed were not performed;
| 16 | | (3) it is timely determined that the health care | 17 | | services rendered were contrary to the instructions of the | 18 | | health insurance issuer or its contracted utilization | 19 | | review organization or delegated physician reviewer if | 20 | | contact was made between those parties before the service | 21 | | being rendered;
| 22 | | (4) it is timely determined that the enrollee | 23 | | receiving such health care services was not an enrollee of | 24 | | the health care plan; or
| 25 | | (5) the approval was based upon a material | 26 | | misrepresentation by the enrollee or health care provider; |
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| 1 | | as used in this paragraph (5), "material" means a fact or | 2 | | situation that is not merely technical in nature and | 3 | | results or could result in a substantial change in the | 4 | | situation.
| 5 | | Section 65. Length of prior authorization approval. A | 6 | | prior authorization approval shall be valid for the lesser of | 7 | | 12 months after the date the health care professional or | 8 | | health care provider receives the prior authorization approval | 9 | | or the length of treatment as determined by the patient's | 10 | | health care professional, and the approval period shall be | 11 | | effective regardless of any changes, including any changes in | 12 | | dosage for a prescription drug prescribed by the health care | 13 | | professional. This Section shall not apply to the prescription | 14 | | of benzodiazepines or Schedule II narcotic drugs, such as | 15 | | opioids. Except to the extent required by medical exceptions | 16 | | processes for prescription drugs, nothing in this Section | 17 | | shall require a policy to cover any care, treatment, or | 18 | | services for any health condition that the terms of coverage | 19 | | otherwise completely exclude from the policy's covered | 20 | | benefits without regard for whether the care, treatment, or | 21 | | services are medically necessary. | 22 | | Section 70. Length of prior authorization approval for | 23 | | treatment for chronic or long-term conditions. If a health | 24 | | insurance issuer requires a prior authorization for a |
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| 1 | | recurring health care service or maintenance medication for | 2 | | the treatment of a chronic or long-term condition, the | 3 | | approval shall remain valid for the lesser of 12 months from | 4 | | the date the health care professional or health care provider | 5 | | receives the prior authorization approval or the length of the | 6 | | treatment as determined by the patient's health care | 7 | | professional. Except to the extent required by medical | 8 | | exceptions processes for prescription drugs, nothing in this | 9 | | Section shall require a policy to cover any care, treatment, | 10 | | or services for any health condition that the terms of | 11 | | coverage otherwise completely exclude from the policy's | 12 | | covered benefits without regard for whether the care, | 13 | | treatment, or services are medically necessary. | 14 | | Section 75. Continuity of care for enrollees.
| 15 | | (a) On receipt of information documenting a prior | 16 | | authorization approval from the enrollee or from the | 17 | | enrollee's health care professional or health care provider, a | 18 | | health insurance issuer shall honor a prior authorization | 19 | | granted to an enrollee from a previous health insurance issuer | 20 | | or its contracted utilization review organization for at least | 21 | | the initial 90 days of an enrollee's coverage under a new | 22 | | health plan.
| 23 | | (b) During the time period described in subsection (a), a | 24 | | health insurance issuer or its contracted utilization review | 25 | | organization may perform its own review to grant a prior |
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| 1 | | authorization approval subject to the terms of the member's | 2 | | coverage agreement.
| 3 | | (c) If there is a change in coverage of or approval | 4 | | criteria for a previously authorized health care service, the | 5 | | change in coverage or approval criteria does not affect an | 6 | | enrollee who received prior authorization approval before the | 7 | | effective date of the change for the remainder of the | 8 | | enrollee's plan year.
| 9 | | (d) Except to the extent required by medical exceptions | 10 | | processes for prescription drugs, nothing in this Section | 11 | | shall require a policy to cover any care, treatment, or | 12 | | services for any health condition that the terms of coverage | 13 | | otherwise completely exclude from the policy's covered | 14 | | benefits without regard for whether the care, treatment, or | 15 | | services are medically necessary.
| 16 | | Section 80. Health care services deemed authorized if a | 17 | | health insurance issuer or its contracted utilization review | 18 | | organization fails to comply with the requirements of this | 19 | | Act. A failure by a health insurance issuer or its contracted | 20 | | utilization review organization to comply with the deadlines | 21 | | and other requirements specified in this Act shall result in | 22 | | any health care services subject to review to be automatically | 23 | | deemed authorized by the health insurance issuer or its | 24 | | contracted utilization review organization. |
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| 1 | | Section 85. Severability. If any provision of this Act or | 2 | | its application to any person or circumstance is held invalid, | 3 | | the invalidity does not affect other provisions or | 4 | | applications of this Act that can be given effect without the | 5 | | invalid provision or application, and to this end the | 6 | | provisions of this Act are declared to be severable. | 7 | | Section 90. Administration and enforcement.
| 8 | | (a) The Department shall enforce the provisions of this | 9 | | Act pursuant to the enforcement powers granted to it by law. To | 10 | | enforce the provisions of this Act, the Director is hereby | 11 | | granted specific authority to issue a cease and desist order | 12 | | or require a utilization review organization or health | 13 | | insurance issuer to submit a plan of correction for violations | 14 | | of this Act, or both, in accordance with the requirements and | 15 | | authority set forth in Section 85 of the Managed Care Reform | 16 | | and Patient Rights Act. Subject to the provisions of the | 17 | | Illinois Administrative Procedure Act, the Director may, | 18 | | pursuant to Section 403A of the Illinois Insurance Code, | 19 | | impose upon a utilization review organization or health | 20 | | insurance issuer an administrative fine not to exceed $250,000 | 21 | | for failure to submit a requested plan of correction, failure | 22 | | to comply with its plan of correction, or repeated violations | 23 | | of this Act.
| 24 | | (b) Any person who believes that his or her utilization | 25 | | review organization or health insurance issuer is in violation |
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| 1 | | of the provisions of this Act may file a complaint with the | 2 | | Department. The Department shall review all complaints | 3 | | received and investigate all complaints that it deems to state | 4 | | a potential violation. The Department shall fairly, | 5 | | efficiently, and timely review and investigate complaints. | 6 | | Utilization review organizations found to be in violation of | 7 | | this Act shall be penalized in accordance with this Section.
| 8 | | (c) The Department of Healthcare and Family Services shall | 9 | | enforce the provisions of this Act as it applies to persons | 10 | | enrolled under Article V of the Illinois Public Aid Code or | 11 | | under the Children's Health Insurance Program Act.
| 12 | | Section 900. The Illinois Insurance Code is amended by | 13 | | changing Section 370g as follows:
| 14 | | (215 ILCS 5/370g) (from Ch. 73, par. 982g)
| 15 | | Sec. 370g. Definitions. As used in this Article, the | 16 | | following definitions
apply:
| 17 | | (a) "Health care services" means health care services or | 18 | | products
rendered or sold by a provider within the scope of the | 19 | | provider's license
or legal authorization. The term includes, | 20 | | but is not limited to, hospital,
medical, surgical, dental, | 21 | | vision and pharmaceutical services or products.
| 22 | | (b) "Insurer" means an insurance company or a health | 23 | | service corporation
authorized in this State to issue policies | 24 | | or subscriber contracts which
reimburse for expenses of health |
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| 1 | | care services.
| 2 | | (c) "Insured" means an individual entitled to | 3 | | reimbursement for expenses
of health care services under a | 4 | | policy or subscriber contract issued or
administered by an | 5 | | insurer.
| 6 | | (d) "Provider" means an individual or entity duly licensed | 7 | | or legally
authorized to provide health care services.
| 8 | | (e) "Noninstitutional provider" means any person licensed | 9 | | under the Medical
Practice Act of 1987, as now or hereafter | 10 | | amended.
| 11 | | (f) "Beneficiary" means an individual entitled to | 12 | | reimbursement for
expenses of or the discount of provider fees | 13 | | for health care services under
a program where the beneficiary | 14 | | has an incentive to utilize the services of a
provider which | 15 | | has entered into an agreement or arrangement with an
| 16 | | administrator.
| 17 | | (g) "Administrator" means any person, partnership or | 18 | | corporation, other
than an insurer or health maintenance | 19 | | organization holding a certificate of
authority under the | 20 | | "Health Maintenance Organization Act", as now or hereafter
| 21 | | amended, that arranges, contracts with, or administers | 22 | | contracts with a
provider whereby beneficiaries are provided | 23 | | an incentive to use the services of
such provider.
| 24 | | (h) "Emergency medical condition" has the meaning given to | 25 | | that term in Section 10 of the Managed Care Reform and Patient | 26 | | Rights Act. means a medical condition manifesting
itself
by
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| 1 | | acute symptoms of sufficient severity (including severe
pain) | 2 | | such that a prudent
layperson, who possesses an average | 3 | | knowledge of health and medicine, could
reasonably expect the | 4 | | absence of immediate medical attention to result in:
| 5 | | (1) placing the health of the individual (or, with | 6 | | respect to a pregnant
woman, the
health of the woman or her | 7 | | unborn child) in serious jeopardy;
| 8 | | (2) serious
impairment to bodily functions; or
| 9 | | (3) serious dysfunction of any bodily organ
or part.
| 10 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 11 | | Section 905. The Managed Care Reform and Patient Rights | 12 | | Act is amended by changing Sections 10 and 65 as follows:
| 13 | | (215 ILCS 134/10)
| 14 | | Sec. 10. Definitions.
| 15 | | "Adverse determination" means a determination by a health | 16 | | care plan under
Section 45 or by a utilization review program | 17 | | under Section
85 that
a health care service is not medically | 18 | | necessary.
| 19 | | "Clinical peer" means a health care professional who is in | 20 | | the same
profession and the same or similar specialty as the | 21 | | health care provider who
typically manages the medical | 22 | | condition, procedures, or treatment under
review.
| 23 | | "Department" means the Department of Insurance.
| 24 | | "Emergency medical condition" means a medical condition |
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| 1 | | manifesting itself by
acute symptoms of sufficient severity, | 2 | | regardless of the final diagnosis given, such that a prudent
| 3 | | layperson, who possesses an average knowledge of health and | 4 | | medicine, could
reasonably expect the absence of immediate | 5 | | medical attention to result in:
| 6 | | (1) placing the health of the individual (or, with | 7 | | respect to a pregnant
woman, the
health of the woman or her | 8 | | unborn child) in serious jeopardy;
| 9 | | (2) serious
impairment to bodily functions;
| 10 | | (3) serious dysfunction of any bodily organ
or part;
| 11 | | (4) inadequately controlled pain; or | 12 | | (5) with respect to a pregnant woman who is having | 13 | | contractions: | 14 | | (A) inadequate time to complete a safe transfer to | 15 | | another hospital before delivery; or | 16 | | (B) a transfer to another hospital may pose a | 17 | | threat to the health or safety of the woman or unborn | 18 | | child. | 19 | | "Emergency medical screening examination" means a medical | 20 | | screening
examination and
evaluation by a physician licensed | 21 | | to practice medicine in all its branches, or
to the extent | 22 | | permitted
by applicable laws, by other appropriately licensed | 23 | | personnel under the
supervision of or in
collaboration with a | 24 | | physician licensed to practice medicine in all its
branches to | 25 | | determine whether
the need for emergency services exists.
| 26 | | "Emergency services" means, with respect to an enrollee of |
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| 1 | | a health care
plan,
transportation services, including but not | 2 | | limited to ambulance services, and
covered inpatient and | 3 | | outpatient hospital services
furnished by a provider
qualified | 4 | | to furnish those services that are needed to evaluate or | 5 | | stabilize an
emergency medical condition. "Emergency services" | 6 | | does not
refer to post-stabilization medical services.
| 7 | | "Enrollee" means any person and his or her dependents | 8 | | enrolled in or covered
by a health care plan.
| 9 | | "Health care plan" means a plan, including, but not | 10 | | limited to, a health maintenance organization, a managed care | 11 | | community network as defined in the Illinois Public Aid Code, | 12 | | or an accountable care entity as defined in the Illinois | 13 | | Public Aid Code that receives capitated payments to cover | 14 | | medical services from the Department of Healthcare and Family | 15 | | Services, that establishes, operates, or maintains a
network | 16 | | of health care providers that has entered into an agreement | 17 | | with the
plan to provide health care services to enrollees to | 18 | | whom the plan has the
ultimate obligation to arrange for the | 19 | | provision of or payment for services
through organizational | 20 | | arrangements for ongoing quality assurance,
utilization review | 21 | | programs, or dispute resolution.
Nothing in this definition | 22 | | shall be construed to mean that an independent
practice | 23 | | association or a physician hospital organization that | 24 | | subcontracts
with
a health care plan is, for purposes of that | 25 | | subcontract, a health care plan.
| 26 | | For purposes of this definition, "health care plan" shall |
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| 1 | | not include the
following:
| 2 | | (1) indemnity health insurance policies including | 3 | | those using a contracted
provider network;
| 4 | | (2) health care plans that offer only dental or only | 5 | | vision coverage;
| 6 | | (3) preferred provider administrators, as defined in | 7 | | Section 370g(g) of
the
Illinois Insurance Code;
| 8 | | (4) employee or employer self-insured health benefit | 9 | | plans under the
federal Employee Retirement Income | 10 | | Security Act of 1974;
| 11 | | (5) health care provided pursuant to the Workers' | 12 | | Compensation Act or the
Workers' Occupational Diseases | 13 | | Act; and
| 14 | | (6) not-for-profit voluntary health services plans | 15 | | with health maintenance
organization
authority in | 16 | | existence as of January 1, 1999 that are affiliated with a | 17 | | union
and that
only extend coverage to union members and | 18 | | their dependents.
| 19 | | "Health care professional" means a physician, a registered | 20 | | professional
nurse,
or other individual appropriately licensed | 21 | | or registered
to provide health care services.
| 22 | | "Health care provider" means any physician, hospital | 23 | | facility, facility licensed under the Nursing Home Care Act, | 24 | | long-term care facility as defined in Section 1-113 of the | 25 | | Nursing Home Care Act, or other
person that is licensed or | 26 | | otherwise authorized to deliver health care
services. Nothing |
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| 1 | | in this
Act shall be construed to define Independent Practice | 2 | | Associations or
Physician-Hospital Organizations as health | 3 | | care providers.
| 4 | | "Health care services" means any services included in the | 5 | | furnishing to any
individual of medical care, or the
| 6 | | hospitalization incident to the furnishing of such care, as | 7 | | well as the
furnishing to any person of
any and all other | 8 | | services for the purpose of preventing,
alleviating, curing, | 9 | | or healing human illness or injury including behavioral | 10 | | health, mental health, home health ,
and pharmaceutical | 11 | | services and products.
| 12 | | "Medical director" means a physician licensed in any state | 13 | | to practice
medicine in all its
branches appointed by a health | 14 | | care plan.
| 15 | | "Person" means a corporation, association, partnership,
| 16 | | limited liability company, sole proprietorship, or any other | 17 | | legal entity.
| 18 | | "Physician" means a person licensed under the Medical
| 19 | | Practice Act of 1987.
| 20 | | "Post-stabilization medical services" means health care | 21 | | services
provided to an enrollee that are furnished in a | 22 | | licensed hospital by a provider
that is qualified to furnish | 23 | | such services, and determined to be medically
necessary and | 24 | | directly related to the emergency medical condition following
| 25 | | stabilization.
| 26 | | "Stabilization" means, with respect to an emergency |
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| 1 | | medical condition, to
provide such medical treatment of the | 2 | | condition as may be necessary to assure,
within reasonable | 3 | | medical probability, that no material deterioration
of the | 4 | | condition is likely to result.
| 5 | | "Utilization review" means the evaluation of the medical | 6 | | necessity,
appropriateness, and efficiency of the use of | 7 | | health care services, procedures,
and facilities.
| 8 | | "Utilization review program" means a program established | 9 | | by a person to
perform utilization review.
| 10 | | (Source: P.A. 101-452, eff. 1-1-20 .)
| 11 | | (215 ILCS 134/65)
| 12 | | Sec. 65. Emergency services prior to stabilization.
| 13 | | (a) A health care plan
that provides or that is required by | 14 | | law to provide coverage for emergency
services shall provide | 15 | | coverage such that payment under this coverage is not
| 16 | | dependent upon whether the services are performed by a plan or | 17 | | non-plan health
care provider and without regard to prior | 18 | | authorization. This coverage shall be
at the same benefit | 19 | | level as if the services or treatment had been rendered by
the | 20 | | health care plan physician licensed to practice medicine in | 21 | | all
its branches or health care provider.
| 22 | | (b) Prior authorization or approval by the plan shall not | 23 | | be required for
emergency services.
| 24 | | (c) Coverage and payment shall only be retrospectively | 25 | | denied under the
following circumstances:
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| 1 | | (1) upon reasonable determination that the emergency | 2 | | services claimed were
never performed;
| 3 | | (2) upon timely determination that the emergency | 4 | | evaluation and treatment
were
rendered to an enrollee who | 5 | | sought emergency services and whose circumstance
did not | 6 | | meet the definition of emergency medical condition;
| 7 | | (3) upon determination that the patient receiving such | 8 | | services was not an
enrollee of the health care plan; or
| 9 | | (4) upon material misrepresentation by the enrollee or | 10 | | health care
provider; "material" means a fact or situation | 11 | | that is not merely technical in
nature and results or | 12 | | could result in a substantial change in the situation.
| 13 | | (d) When an enrollee presents to a hospital seeking | 14 | | emergency services,
the determination as to whether the need | 15 | | for those
services exists shall be made for purposes of | 16 | | treatment by a
physician licensed to practice medicine in all | 17 | | its branches or, to the extent
permitted by applicable law, by | 18 | | other appropriately licensed
personnel under the supervision | 19 | | of
or in collaboration with a physician licensed to practice | 20 | | medicine in all its
branches.
The physician or other
| 21 | | appropriate personnel shall indicate in the patient's chart | 22 | | the results of the
emergency medical screening examination.
| 23 | | (e) The appropriate use of the 911 emergency telephone | 24 | | system or its local
equivalent shall not be discouraged or | 25 | | penalized by the health care plan when
an emergency medical | 26 | | condition exists.
This provision shall not imply that the use |
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| 1 | | of 911 or its local equivalent is a
factor in determining the | 2 | | existence of an emergency medical condition.
| 3 | | (f) The medical director's or his or her designee's
| 4 | | determination of whether the enrollee meets the standard of an | 5 | | emergency
medical condition shall be based solely upon the | 6 | | presenting symptoms documented
in the medical record at the | 7 | | time care was
sought.
Only a clinical peer may make an adverse | 8 | | determination.
| 9 | | (g) Nothing in this Section shall prohibit the imposition | 10 | | of deductibles,
copayments, and co-insurance.
Nothing in this | 11 | | Section alters the prohibition on billing enrollees contained
| 12 | | in the Health Maintenance Organization Act.
| 13 | | (h) This Section shall apply to the types of companies | 14 | | subject to Section 155.36 of the Illinois Insurance Code. | 15 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 16 | | Section 910. The Illinois Public Aid Code is amended by | 17 | | adding Section 5-5.12d as follows: | 18 | | (305 ILCS 5/5-5.12d new) | 19 | | Sec. 5-5.12d. Managed care organization prior | 20 | | authorization of health care services. | 21 | | (a) As used in this Section, "health care service" has the | 22 | | meaning given to that term in the Prior Authorization Reform | 23 | | Act. | 24 | | (b) Notwithstanding any other provision of law to the |
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| 1 | | contrary, all managed care organizations shall comply with the | 2 | | requirements of the Prior Authorization Reform Act.
| 3 | | Section 999. Effective date. This Act takes effect January | 4 | | 1, 2022.".
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