Public Act 100-1052
 
HB4146 EnrolledLRB100 14115 SMS 28871 b


  
    AN ACT concerning regulation.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  



 
 
    Section 5. The Managed Care Reform and Patient Rights Act 
is amended  by changing Section 25 as follows:
 



    (215 ILCS 134/25)



    Sec. 25. Transition of services. 

    (a) A health care plan shall provide for continuity of care 
for its
enrollees as follows:


        (1) If an enrollee's physician leaves the health care 
    plan's network
of
health care providers for reasons other 
    than termination of a contract in
situations
involving 
    imminent harm to a patient
or a final disciplinary action 
    by a State
licensing board
and the physician
remains within 
    the health care plan's service area, the health care plan

    shall
permit the enrollee to continue an ongoing course of 
    treatment with that
physician during a transitional 
    period:


            (A) of 90 days from the date of the notice of 
        physician's
termination
from the health care plan to 
        the enrollee of the physician's
disaffiliation from 
        the health care plan if the enrollee has an ongoing 
        course
of treatment; or


            (B) if the enrollee has entered the third trimester 
        of pregnancy at the
time
of the physician's 
        disaffiliation, that includes the
provision of 
        post-partum care directly related to the delivery.


        (2) Notwithstanding the provisions in item (1) of this 
    subsection, such
care shall be
authorized by the health 
    care plan during the transitional period only if
the

    physician agrees:


            (A) to continue to accept reimbursement from the 
        health care plan
at the
rates applicable prior to the 
        start of the transitional period;


            (B) to adhere to the health care plan's quality 
        assurance
requirements
and
to provide to the health 
        care plan necessary medical information related
to

        such care; and


            (C) to otherwise adhere to the health care plan's 
        policies and
procedures,
including but not limited to 
        procedures regarding referrals and obtaining

        preauthorizations for treatment.

        (3) During an enrollee's plan year, a health care plan 
    shall not remove a drug from its formulary or negatively 
    change its preferred or cost-tier sharing unless, at least 
    60 days before making the formulary change, the health care 
    plan:
            (A) provides general notification of the change in 
        its formulary to current and prospective enrollees;
            (B) directly notifies enrollees currently 
        receiving coverage for the drug, including information 
        on the specific drugs involved and the steps they may 
        take to request coverage determinations and 
        exceptions, including a statement that a certification 
        of medical necessity by the enrollee's prescribing 
        provider will result in continuation of coverage at the 
        existing level; and
            (C) directly notifies by first class mail and 
        through an electronic transmission, if available, the 
        prescribing provider of all health care plan enrollees 
        currently prescribed the drug affected by the proposed 
        change; the notice shall include a one-page form by 
        which the prescribing provider can notify the health 
        care plan by first class mail that coverage of the drug 
        for the enrollee is medically necessary.
        The notification in paragraph (C) may direct the 
    prescribing provider to an electronic portal through which 
    the prescribing provider may electronically file a 
    certification to the health care plan that coverage of the 
    drug for the enrollee is medically necessary.  The 
    prescribing provider may make a secure electronic 
    signature beside the words "certification of medical 
    necessity", and this certification shall authorize 
    continuation of coverage for the drug.
        If the prescribing provider certifies to the health 
    care plan either in writing or electronically that the drug 
    is medically necessary for the enrollee as provided in 
    paragraph (C), a health care plan shall authorize coverage 
    for the drug prescribed based solely on the prescribing 
    provider's assertion that coverage is medically necessary, 
    and the health care plan is prohibited from making 
    modifications to the coverage related to the covered drug, 
    including, but not limited to: 
            (i) increasing the out-of-pocket costs for the 
        covered drug;
            (ii) moving the covered drug to a more restrictive 
        tier; or 
            (iii) denying an enrollee coverage of the drug for 
        which the enrollee has been previously approved for 
        coverage by the health care plan. 
        Nothing in this item (3) prevents a health care plan 
    from removing a drug from its formulary or denying an 
    enrollee coverage if the United States Food and Drug 
    Administration has issued a statement about the drug that 
    calls into question the clinical safety of the drug, the 
    drug manufacturer has notified the United States Food and 
    Drug Administration of a manufacturing discontinuance or 
    potential discontinuance of the drug as required by Section 
    506C of the Federal Food, Drug, and Cosmetic Act, as 
    codified in 21 U.S.C. 356c, or the drug manufacturer has 
    removed the drug from the market. 
        Nothing in this item (3) prohibits a health care plan, 
    by contract, written policy or procedure, or any other 
    agreement or course of conduct, from requiring a pharmacist 
    to effect substitutions of prescription drugs consistent 
    with Section 19.5 of the Pharmacy Practice Act, under which 
    a pharmacist may substitute an interchangeable biologic 
    for a prescribed biologic product, and Section 25 of the 
    Pharmacy Practice Act, under which a pharmacist may select 
    a generic drug determined to be therapeutically equivalent 
    by the United States Food and Drug Administration and in 
    accordance with the Illinois Food, Drug and Cosmetic Act. 
        This item (3) applies to a policy or contract that is 
    amended, delivered, issued, or renewed on or after January 
    1, 2019. This item (3) does not apply to a health plan as 
    defined in the State Employees Group Insurance Act of 1971 
    or medical assistance under Article V of the Illinois 
    Public Aid Code. 
    (b) A health care plan shall provide for continuity of care 
for new
enrollees as follows:


        (1) If a new enrollee whose physician is not a member 
    of the health care
plan's provider network, but is within 
    the health care plan's service
area,
enrolls in the health 
    care plan, the health care plan shall permit
the enrollee

    to continue an ongoing course of treatment with the 
    enrollee's current
physician during a transitional period:


            (A) of 90 days from the
effective
date of 
        enrollment if
the enrollee has an ongoing course of 
        treatment;
or


            (B) if the enrollee has entered the third trimester 
        of pregnancy at the
effective date of enrollment, that

        includes the provision of post-partum care directly 
        related to the delivery.  


        (2) If an enrollee elects to continue to receive care 
    from such physician
pursuant to item (1) of this 
    subsection, such care shall be authorized by the
health 
    care plan for the transitional period only if the physician 
    agrees:


            (A) to accept reimbursement from the health care 
        plan at rates
established
by the health care plan; such 
        rates shall be
the level of reimbursement applicable to 
        similar physicians within the health
care plan for such 
        services;


            (B) to adhere to the health care plan's quality 
        assurance
requirements
and to provide to the health 
        care plan necessary medical information
related to 
        such care; and


            (C) to otherwise adhere to the health care plan's 
        policies and
procedures
including, but not limited to 
        procedures regarding referrals and obtaining

        preauthorization for treatment.

    (c) In no event shall this Section be construed to require 
a health care
plan
to
provide coverage for benefits not 
otherwise covered or to diminish or
impair preexisting 
condition limitations contained in the enrollee's
contract. In 
no event shall this Section be construed to prohibit the 
addition of prescription drugs to a health care plan's list of 
covered drugs during the coverage year. 

(Source: P.A. 91-617, eff. 7-1-00.)

 
 
    Section 99. Effective date. This Act takes effect upon 
becoming law.