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Public Act 102-0409


 

Public Act 0409 102ND GENERAL ASSEMBLY

  
  
  

 


 
Public Act 102-0409
 
HB0711 EnrolledLRB102 10190 BMS 20259 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 1. Short title. This Act may be cited as the Prior
Authorization Reform Act.
 
    Section 5. Purpose. The General Assembly hereby finds and
declares that:
        (1) the health care professional-patient relationship
    is paramount and should not be subject to third-party
    intrusion;
        (2) prior authorization programs shall be subject to
    member coverage agreements and medical policies but shall
    not hinder the independent medical judgment of a physician
    or health care provider; and
        (3) prior authorization programs must be transparent
    to ensure a fair and consistent process for health care
    providers and patients.
 
    Section 10. Applicability; scope. This Act applies to
health insurance coverage as defined in the Illinois Health
Insurance Portability and Accountability Act, and policies
issued or delivered in this State to the Department of
Healthcare and Family Services and providing coverage to
persons who are enrolled under Article V of the Illinois
Public Aid Code or under the Children's Health Insurance
Program Act, amended, delivered, issued, or renewed on or
after the effective date of this Act, with the exception of
employee or employer self-insured health benefit plans under
the federal Employee Retirement Income Security Act of 1974,
health care provided pursuant to the Workers' Compensation Act
or the Workers' Occupational Diseases Act, and State,
employee, unit of local government, or school district health
plans. This Act does not diminish a health care plan's duties
and responsibilities under other federal or State law or rules
promulgated thereunder. This Act is not intended to alter or
impede the provisions of any consent decree or judicial order
to which the State or any of its agencies is a party.
 
    Section 15. Definitions. As used in this Act:
    "Adverse determination" has the meaning given to that term
in Section 10 of the Health Carrier External Review Act.
    "Appeal" means a formal request, either orally or in
writing, to reconsider an adverse determination.
    "Approval" means a determination by a health insurance
issuer or its contracted utilization review organization that
a health care service has been reviewed and, based on the
information provided, satisfies the health insurance issuer's
or its contracted utilization review organization's
requirements for medical necessity and appropriateness.
    "Clinical review criteria" has the meaning given to that
term in Section 10 of the Health Carrier External Review Act.
    "Department" means the Department of Insurance.
    "Emergency medical condition" has the meaning given to
that term in Section 10 of the Managed Care Reform and Patient
Rights Act.
    "Emergency services" has the meaning given to that term in
federal health insurance reform requirements for the group and
individual health insurance markets, 45 CFR 147.138.
    "Enrollee" has the meaning given to that term in Section
10 of the Managed Care Reform and Patient Rights Act.
    "Health care professional" has the meaning given to that
term in Section 10 of the Managed Care Reform and Patient
Rights Act.
    "Health care provider" has the meaning given to that term
in Section 10 of the Managed Care Reform and Patient Rights
Act, except that facilities licensed under the Nursing Home
Care Act and long-term care facilities as defined in Section
1-113 of the Nursing Home Care Act are excluded from this Act.
    "Health care service" means any services or level of
services included in the furnishing to an individual of
medical care or the hospitalization incident to the furnishing
of such care, as well as the furnishing to any person of any
other services for the purpose of preventing, alleviating,
curing, or healing human illness or injury, including
behavioral health, mental health, home health, and
pharmaceutical services and products.
    "Health insurance issuer" has the meaning given to that
term in Section 5 of the Illinois Health Insurance Portability
and Accountability Act.
    "Medically necessary" means a health care professional
exercising prudent clinical judgment would provide care to a
patient for the purpose of preventing, diagnosing, or treating
an illness, injury, disease, or its symptoms and that are: (i)
in accordance with generally accepted standards of medical
practice; (ii) clinically appropriate in terms of type,
frequency, extent, site, and duration and are considered
effective for the patient's illness, injury, or disease; and
(iii) not primarily for the convenience of the patient,
treating physician, other health care professional, caregiver,
family member, or other interested party, but focused on what
is best for the patient's health outcome.
    "Physician" means a person licensed under the Medical
Practice Act of 1987 or licensed under the laws of another
state to practice medicine in all its branches.
    "Prior authorization" means the process by which health
insurance issuers or their contracted utilization review
organizations determine the medical necessity and medical
appropriateness of otherwise covered health care services
before the rendering of such health care services. "Prior
authorization" includes any health insurance issuer's or its
contracted utilization review organization's requirement that
an enrollee, health care professional, or health care provider
notify the health insurance issuer or its contracted
utilization review organization before, at the time of, or
concurrent to providing a health care service.
    "Urgent health care service" means a health care service
with respect to which the application of the time periods for
making a non-expedited prior authorization that in the opinion
of a health care professional with knowledge of the enrollee's
medical condition:
        (1) could seriously jeopardize the life or health of
    the enrollee or the ability of the enrollee to regain
    maximum function; or
        (2) could subject the enrollee to severe pain that
    cannot be adequately managed without the care or treatment
    that is the subject of the utilization review.
    "Urgent health care service" does not include emergency
services.
    "Utilization review organization" has the meaning given to
that term in 50 Ill. Adm. Code 4520.30.
 
    Section 20. Disclosure and review of prior authorization
requirements.
    (a) A health insurance issuer shall maintain a complete
list of services for which prior authorization is required,
including for all services where prior authorization is
performed by an entity under contract with the health
insurance issuer.
    (b) A health insurance issuer shall make any current prior
authorization requirements and restrictions, including the
written clinical review criteria, readily accessible and
conspicuously posted on its website to enrollees, health care
professionals, and health care providers. Content published by
a third party and licensed for use by a health insurance issuer
or its contracted utilization review organization may be made
available through the health insurance issuer's or its
contracted utilization review organization's secure,
password-protected website so long as the access requirements
of the website do not unreasonably restrict access.
Requirements shall be described in detail, written in easily
understandable language, and readily available to the health
care professional and health care provider at the point of
care. The website shall indicate for each service subject to
prior authorization:
        (1) when prior authorization became required for
    policies issued or delivered in Illinois, including the
    effective date or dates and the termination date or dates,
    if applicable, in Illinois;
        (2) the date the Illinois-specific requirement was
    listed on the health insurance issuer's or its contracted
    utilization review organization's website;
        (3) where applicable, the date that prior
    authorization was removed for Illinois; and
        (4) where applicable, access to a standardized
    electronic prior authorization request transaction
    process.
    (c) The clinical review criteria must:
        (1) be based on nationally recognized, generally
    accepted standards except where State law provides its own
    standard;
        (2) be developed in accordance with the current
    standards of a national medical accreditation entity;
        (3) ensure quality of care and access to needed health
    care services;
        (4) be evidence-based;
        (5) be sufficiently flexible to allow deviations from
    norms when justified on a case-by-case basis; and
        (6) be evaluated and updated, if necessary, at least
    annually.
    (d) A health insurance issuer shall not deny a claim for
failure to obtain prior authorization if the prior
authorization requirement was not in effect on the date of
service on the claim.
    (e) A health insurance issuer or its contracted
utilization review organization shall not deem as incidental
or deny supplies or health care services that are routinely
used as part of a health care service when:
        (1) an associated health care service has received
    prior authorization; or
        (2) prior authorization for the health care service is
    not required.
    (f) If a health insurance issuer intends either to
implement a new prior authorization requirement or restriction
or amend an existing requirement or restriction, the health
insurance issuer shall provide contracted health care
professionals and contracted health care providers of
enrollees written notice of the new or amended requirement or
amendment no less than 60 days before the requirement or
restriction is implemented. The written notice may be provided
in an electronic format, including email or facsimile, if the
health care professional or health care provider has agreed in
advance to receive notices electronically. The health
insurance issuer shall ensure that the new or amended
requirement is not implemented unless the health insurance
issuer's or its contracted utilization review organization's
website has been updated to reflect the new or amended
requirement or restriction.
    (g) Entities using prior authorization shall make
statistics available regarding prior authorization approvals
and denials on their website in a readily accessible format.
The statistics must be updated annually and include all of the
following information:
        (1) a list of all health care services, including
    medications, that are subject to prior authorization;
        (2) the total number of prior authorization requests
    received;
        (3) the number of prior authorization requests denied
    during the previous plan year by the health insurance
    issuer or its contracted utilization review organization
    with respect to each service described in paragraph (1)
    and the top 5 reasons for denial;
        (4) the number of requests described in paragraph (3)
    that were appealed, the number of the appealed requests
    that upheld the adverse determination, and the number of
    appealed requests that reversed the adverse determination;
        (5) the average time between submission and response;
    and
        (6) any other information as the Director determines
    appropriate.
 
    Section 25. Health insurance issuer's and its contracted
utilization review organization's obligations with respect to
prior authorizations in nonurgent circumstances.
Notwithstanding any other provision of law, if a health
insurance issuer requires prior authorization of a health care
service, the health insurance issuer or its contracted
utilization review organization must make an approval or
adverse determination and notify the enrollee, the enrollee's
health care professional, and the enrollee's health care
provider of the approval or adverse determination as required
by applicable law, but no later than 5 calendar days after
obtaining all necessary information to make the approval or
adverse determination. As used in this Section, "necessary
information" includes the results of any face-to-face clinical
evaluation, second opinion, or other clinical information that
is directly applicable to the requested service that may be
required.
 
    Section 30. Health insurance issuer's and its contracted
utilization review organization's obligations with respect to
prior authorizations concerning urgent health care services.
    (a) Notwithstanding any other provision of law, a health
insurance issuer or its contracted utilization review
organization must render an approval or adverse determination
concerning urgent care services and notify the enrollee, the
enrollee's health care professional, and the enrollee's health
care provider of that approval or adverse determination as
required by law, but not later than 48 hours after receiving
all information needed to complete the review of the requested
health care services.
    (b) To facilitate the rendering of a prior authorization
determination in conformance with this Section, a health
insurance issuer or its contracted utilization review
organization must establish a mechanism to ensure health care
professionals have access to appropriately trained and
licensed clinical personnel who have access to physicians for
consultation, designated by the plan to make such
determinations for prior authorization concerning urgent care
services.
 
    Section 35. Personnel qualified to make adverse
determinations of a prior authorization request. A health
insurance issuer or its contracted utilization review
organization must ensure that all adverse determinations are
made by a physician when the request is by a physician or a
representative of a physician. The physician must:
        (1) possess a current and valid nonrestricted license
    in any United States jurisdiction; and
        (2) have experience treating and managing patients
    with the medical condition or disease for which the health
    care service is being requested.
    Notwithstanding the foregoing, a licensed health care
professional who satisfies the requirements of this Section
may make an adverse determination of a prior authorization
request submitted by a health care professional licensed in
the same profession.
 
    Section 40. Requirements for adverse determination. If a
health insurance issuer or its contracted utilization review
organization makes an adverse determination, the health
insurance issuer or its contracted utilization review
organization shall include the following in the notification
to the enrollee, the enrollee's health care professional, and
the enrollee's health care provider:
        (1) the reasons for the adverse determination and
    related evidence-based criteria, including a description
    of any missing or insufficient documentation;
        (2) the right to appeal the adverse determination;
        (3) instructions on how to file the appeal; and
        (4) additional documentation necessary to support the
    appeal.
 
    Section 45. Requirements applicable to the personnel who
can review appeals. A health insurance issuer or its
contracted utilization review organization must ensure that
all appeals are reviewed by a physician when the request is by
a physician or a representative of a physician. The physician
must:
        (1) possess a current and valid nonrestricted license
    to practice medicine in any United States jurisdiction;
        (2) be in the same or similar specialty as a physician
    who typically manages the medical condition or disease;
        (3) be knowledgeable of, and have experience
    providing, the health care services under appeal;
        (4) not have been directly involved in making the
    adverse determination; and
        (5) consider all known clinical aspects of the health
    care service under review, including, but not limited to,
    a review of all pertinent medical records provided to the
    health insurance issuer or its contracted utilization
    review organization by the enrollee's health care
    professional or health care provider and any medical
    literature provided to the health insurance issuer or its
    contracted utilization review organization by the health
    care professional or health care provider.
    Notwithstanding the foregoing, a licensed health care
professional who satisfies the requirements in this Section
may review appeal requests submitted by a health care
professional licensed in the same profession.
 
    Section 50. Review of prior authorization requirements. A
health insurance issuer shall periodically review its prior
authorization requirements and consider removal of prior
authorization requirements:
        (1) where a medication or procedure prescribed is
    customary and properly indicated or is a treatment for the
    clinical indication as supported by peer-reviewed medical
    publications; or
        (2) for patients currently managed with an established
    treatment regimen.
 
    Section 55. Denial.
    (a) The health insurance issuer or its contracted
utilization review organization may not revoke or further
limit, condition, or restrict a previously issued prior
authorization approval while it remains valid under this Act.
    (b) Notwithstanding any other provision of law, if a claim
is properly coded and submitted timely to a health insurance
issuer, the health insurance issuer shall make payment
according to the terms of coverage on claims for health care
services for which prior authorization was required and
approval received before the rendering of health care
services, unless one of the following occurs:
        (1) it is timely determined that the enrollee's health
    care professional or health care provider knowingly
    provided health care services that required prior
    authorization from the health insurance issuer or its
    contracted utilization review organization without first
    obtaining prior authorization for those health care
    services;
        (2) it is timely determined that the health care
    services claimed were not performed;
        (3) it is timely determined that the health care
    services rendered were contrary to the instructions of the
    health insurance issuer or its contracted utilization
    review organization or delegated reviewer if contact was
    made between those parties before the service being
    rendered;
        (4) it is timely determined that the enrollee
    receiving such health care services was not an enrollee of
    the health care plan; or
        (5) the approval was based upon a material
    misrepresentation by the enrollee, health care
    professional, or health care provider; as used in this
    paragraph (5), "material" means a fact or situation that
    is not merely technical in nature and results or could
    result in a substantial change in the situation.
    (c) Nothing in this Section shall preclude a utilization
review organization or a health insurance issuer from
performing post-service reviews of health care claims for
purposes of payment integrity or for the prevention of fraud,
waste, or abuse.
 
    Section 60. Length of prior authorization approval. A
prior authorization approval shall be valid for the lesser of
6 months after the date the health care professional or health
care provider receives the prior authorization approval or the
length of treatment as determined by the patient's health care
professional or the renewal of the plan, and the approval
period shall be effective regardless of any changes, including
any changes in dosage for a prescription drug prescribed by
the health care professional. All dosage increases must be
based on established evidentiary standards and nothing in this
Section shall prohibit a health insurance issuer from having
safety edits in place. This Section shall not apply to the
prescription of benzodiazepines or Schedule II narcotic drugs,
such as opioids. Except to the extent required by medical
exceptions processes for prescription drugs set forth in
Section 45.1 of the Managed Care Reform and Patient Rights
Act, nothing in this Section shall require a policy to cover
any care, treatment, or services for any health condition that
the terms of coverage otherwise completely exclude from the
policy's covered benefits without regard for whether the care,
treatment, or services are medically necessary.
 
    Section 65. Length of prior authorization approval for
treatment for chronic or long-term conditions. If a health
insurance issuer requires a prior authorization for a
recurring health care service or maintenance medication for
the treatment of a chronic or long-term condition, the
approval shall remain valid for the lesser of 12 months from
the date the health care professional or health care provider
receives the prior authorization approval or the length of the
treatment as determined by the patient's health care
professional. This Section shall not apply to the prescription
of benzodiazepines or Schedule II narcotic drugs, such as
opioids. Except to the extent required by medical exceptions
processes for prescription drugs set forth in Section 45.1 of
the Managed Care Reform and Patient Rights Act, nothing in
this Section shall require a policy to cover any care,
treatment, or services for any health condition that the terms
of coverage otherwise completely exclude from the policy's
covered benefits without regard for whether the care,
treatment, or services are medically necessary.
 
    Section 70. Continuity of care for enrollees.
    (a) On receipt of information documenting a prior
authorization approval from the enrollee or from the
enrollee's health care professional or health care provider, a
health insurance issuer shall honor a prior authorization
granted to an enrollee from a previous health insurance issuer
or its contracted utilization review organization for at least
the initial 90 days of an enrollee's coverage under a new
health plan, subject to the terms of the member's coverage
agreement.
    (b) During the time period described in subsection (a), a
health insurance issuer or its contracted utilization review
organization may perform its own review to grant a prior
authorization approval subject to the terms of the member's
coverage agreement.
    (c) If there is a change in coverage of or approval
criteria for a previously authorized health care service, the
change in coverage or approval criteria does not affect an
enrollee who received prior authorization approval before the
effective date of the change for the remainder of the
enrollee's plan year.
    (d) Except to the extent required by medical exceptions
processes for prescription drugs, nothing in this Section
shall require a policy to cover any care, treatment, or
services for any health condition that the terms of coverage
otherwise completely exclude from the policy's covered
benefits without regard for whether the care, treatment, or
services are medically necessary.
 
    Section 75. Health care services deemed authorized if a
health insurance issuer or its contracted utilization review
organization fails to comply with the requirements of this
Act. A failure by a health insurance issuer or its contracted
utilization review organization to comply with the deadlines
and other requirements specified in this Act shall result in
any health care services subject to review to be automatically
deemed authorized by the health insurance issuer or its
contracted utilization review organization.
 
    Section 80. Severability. If any provision of this Act or
its application to any person or circumstance is held invalid,
the invalidity does not affect other provisions or
applications of this Act that can be given effect without the
invalid provision or application, and to this end the
provisions of this Act are declared to be severable.
 
    Section 85. Administration and enforcement.
    (a) The Department shall enforce the provisions of this
Act pursuant to the enforcement powers granted to it by law. To
enforce the provisions of this Act, the Director is hereby
granted specific authority to issue a cease and desist order
or require a utilization review organization or health
insurance issuer to submit a plan of correction for violations
of this Act, or both, in accordance with the requirements and
authority set forth in Section 85 of the Managed Care Reform
and Patient Rights Act. Subject to the provisions of the
Illinois Administrative Procedure Act, the Director may,
pursuant to Section 403A of the Illinois Insurance Code,
impose upon a utilization review organization or health
insurance issuer an administrative fine not to exceed $250,000
for failure to submit a requested plan of correction, failure
to comply with its plan of correction, or repeated violations
of this Act.
    (b) Any person who believes that his or her utilization
review organization or health insurance issuer is in violation
of the provisions of this Act may file a complaint with the
Department. The Department shall review all complaints
received and investigate all complaints that it deems to state
a potential violation. The Department shall fairly,
efficiently, and timely review and investigate complaints.
Health insurance issuers and utilization review organizations
found to be in violation of this Act shall be penalized in
accordance with this Section.
    (c) The Department of Healthcare and Family Services shall
enforce the provisions of this Act as it applies to persons
enrolled under Article V of the Illinois Public Aid Code or
under the Children's Health Insurance Program Act.
 
    Section 900. The Illinois Insurance Code is amended by
changing Sections 155.36 and 370g as follows:
 
    (215 ILCS 5/155.36)
    Sec. 155.36. Managed Care Reform and Patient Rights Act.
Insurance companies that transact the kinds of insurance
authorized under Class 1(b) or Class 2(a) of Section 4 of this
Code shall comply with Sections 45, 45.1, 45.2, 65, 70, and 85,
subsection (d) of Section 30, and the definition of the term
"emergency medical condition" in Section 10 of the Managed
Care Reform and Patient Rights Act.
(Source: P.A. 101-608, eff. 1-1-20.)
 
    (215 ILCS 5/370g)  (from Ch. 73, par. 982g)
    Sec. 370g. Definitions. As used in this Article, the
following definitions apply:
    (a) "Health care services" means health care services or
products rendered or sold by a provider within the scope of the
provider's license or legal authorization. The term includes,
but is not limited to, hospital, medical, surgical, dental,
vision and pharmaceutical services or products.
    (b) "Insurer" means an insurance company or a health
service corporation authorized in this State to issue policies
or subscriber contracts which reimburse for expenses of health
care services.
    (c) "Insured" means an individual entitled to
reimbursement for expenses of health care services under a
policy or subscriber contract issued or administered by an
insurer.
    (d) "Provider" means an individual or entity duly licensed
or legally authorized to provide health care services.
    (e) "Noninstitutional provider" means any person licensed
under the Medical Practice Act of 1987, as now or hereafter
amended.
    (f) "Beneficiary" means an individual entitled to
reimbursement for expenses of or the discount of provider fees
for health care services under a program where the beneficiary
has an incentive to utilize the services of a provider which
has entered into an agreement or arrangement with an
administrator.
    (g) "Administrator" means any person, partnership or
corporation, other than an insurer or health maintenance
organization holding a certificate of authority under the
"Health Maintenance Organization Act", as now or hereafter
amended, that arranges, contracts with, or administers
contracts with a provider whereby beneficiaries are provided
an incentive to use the services of such provider.
    (h) "Emergency medical condition" has the meaning given to
that term in Section 10 of the Managed Care Reform and Patient
Rights Act. means a medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain)
such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in:
        (1) placing the health of the individual (or, with
    respect to a pregnant woman, the health of the woman or her
    unborn child) in serious jeopardy;
        (2) serious impairment to bodily functions; or
        (3) serious dysfunction of any bodily organ or part.
(Source: P.A. 91-617, eff. 1-1-00.)
 
    Section 905. The Managed Care Reform and Patient Rights
Act is amended by changing Section 10 as follows:
 
    (215 ILCS 134/10)
    Sec. 10. Definitions.
    "Adverse determination" means a determination by a health
care plan under Section 45 or by a utilization review program
under Section 85 that a health care service is not medically
necessary.
    "Clinical peer" means a health care professional who is in
the same profession and the same or similar specialty as the
health care provider who typically manages the medical
condition, procedures, or treatment under review.
    "Department" means the Department of Insurance.
    "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
regardless of the final diagnosis given, such that a prudent
layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate
medical attention to result in:
        (1) placing the health of the individual (or, with
    respect to a pregnant woman, the health of the woman or her
    unborn child) in serious jeopardy;
        (2) serious impairment to bodily functions;
        (3) serious dysfunction of any bodily organ or part;
        (4) inadequately controlled pain; or
        (5) with respect to a pregnant woman who is having
    contractions:
            (A) inadequate time to complete a safe transfer to
        another hospital before delivery; or
            (B) a transfer to another hospital may pose a
        threat to the health or safety of the woman or unborn
        child.
    "Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed
to practice medicine in all its branches, or to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
    "Emergency services" means, with respect to an enrollee of
a health care plan, transportation services, including but not
limited to ambulance services, and covered inpatient and
outpatient hospital services furnished by a provider qualified
to furnish those services that are needed to evaluate or
stabilize an emergency medical condition. "Emergency services"
does not refer to post-stabilization medical services.
    "Enrollee" means any person and his or her dependents
enrolled in or covered by a health care plan.
    "Health care plan" means a plan, including, but not
limited to, a health maintenance organization, a managed care
community network as defined in the Illinois Public Aid Code,
or an accountable care entity as defined in the Illinois
Public Aid Code that receives capitated payments to cover
medical services from the Department of Healthcare and Family
Services, that establishes, operates, or maintains a network
of health care providers that has entered into an agreement
with the plan to provide health care services to enrollees to
whom the plan has the ultimate obligation to arrange for the
provision of or payment for services through organizational
arrangements for ongoing quality assurance, utilization review
programs, or dispute resolution. Nothing in this definition
shall be construed to mean that an independent practice
association or a physician hospital organization that
subcontracts with a health care plan is, for purposes of that
subcontract, a health care plan.
    For purposes of this definition, "health care plan" shall
not include the following:
        (1) indemnity health insurance policies including
    those using a contracted provider network;
        (2) health care plans that offer only dental or only
    vision coverage;
        (3) preferred provider administrators, as defined in
    Section 370g(g) of the Illinois Insurance Code;
        (4) employee or employer self-insured health benefit
    plans under the federal Employee Retirement Income
    Security Act of 1974;
        (5) health care provided pursuant to the Workers'
    Compensation Act or the Workers' Occupational Diseases
    Act; and
        (6) not-for-profit voluntary health services plans
    with health maintenance organization authority in
    existence as of January 1, 1999 that are affiliated with a
    union and that only extend coverage to union members and
    their dependents.
    "Health care professional" means a physician, a registered
professional nurse, or other individual appropriately licensed
or registered to provide health care services.
    "Health care provider" means any physician, hospital
facility, facility licensed under the Nursing Home Care Act,
long-term care facility as defined in Section 1-113 of the
Nursing Home Care Act, or other person that is licensed or
otherwise authorized to deliver health care services. Nothing
in this Act shall be construed to define Independent Practice
Associations or Physician-Hospital Organizations as health
care providers.
    "Health care services" means any services included in the
furnishing to any individual of medical care, or the
hospitalization incident to the furnishing of such care, as
well as the furnishing to any person of any and all other
services for the purpose of preventing, alleviating, curing,
or healing human illness or injury including behavioral
health, mental health, home health, and pharmaceutical
services and products.
    "Medical director" means a physician licensed in any state
to practice medicine in all its branches appointed by a health
care plan.
    "Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
    "Physician" means a person licensed under the Medical
Practice Act of 1987.
    "Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
licensed hospital by a provider that is qualified to furnish
such services, and determined to be medically necessary and
directly related to the emergency medical condition following
stabilization.
    "Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to assure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
    "Utilization review" means the evaluation of the medical
necessity, appropriateness, and efficiency of the use of
health care services, procedures, and facilities.
    "Utilization review program" means a program established
by a person to perform utilization review.
(Source: P.A. 101-452, eff. 1-1-20.)
 
    Section 910. The Illinois Public Aid Code is amended by
adding Section 5-5.12d as follows:
 
    (305 ILCS 5/5-5.12d new)
    Sec. 5-5.12d. Managed care organization prior
authorization of health care services.
    (a) As used in this Section, "health care service" has the
meaning given to that term in the Prior Authorization Reform
Act.
    (b) Notwithstanding any other provision of law to the
contrary, all managed care organizations shall comply with the
requirements of the Prior Authorization Reform Act.
 
    Section 999. Effective date. This Act takes effect January
1, 2022.

Effective Date: 1/1/2022