HB 5395

Abstract

Amends the Network Adequacy and Transparency Act. Adds definitions. Provides that the minimum ratio for each provider type shall be no less than any such ratio established for qualified health plans in Federally-Facilitated Exchanges by federal law or by the federal Centers for Medicare and Medicaid Services. Provides that the maximum travel time and distance standards and appointment wait time standards shall be no greater than any such standards established for qualified health plans in Federally-Facilitated Exchanges by federal law or by the federal Centers for Medicare and Medicaid Services. Makes changes to provisions concerning network adequacy, notice of nonrenewal or termination, transition of services, network transparency, administration and enforcement, provider requirements, and provider directory information. Amends the Managed Care Reform and Patient Rights Act. Makes changes to provisions concerning notice of nonrenewal or termination and transition of services. Amends the Illinois Administrative Procedure Act to authorize the Department of Insurance to adopt emergency rules implementing federal standards for provider ratios, time and distance, or appointment wait times when such standards apply to health insurance coverage regulated by the Department of Insurance and are more stringent than the State standards extant at the time the final federal standards are published. Amends the Illinois Administrative Procedure Act to make a conforming change. Effective immediately. House Committee Amendment No. 1 Adds reference to: 215 ILCS 5/355 from Ch. 73, par. 967 215 ILCS 125/4-12 from Ch. 111 1/2, par. 1409.5 215 ILCS 130/3006 from Ch. 73, par. 1503-6 215 ILCS 5/121-2.05 from Ch. 73, par. 733-2.05 215 ILCS 5/352c new 215 ILCS 5/356z.18 215 ILCS 5/367.3 from Ch. 73, par. 979.3 215 ILCS 5/367a from Ch. 73, par. 979a 215 ILCS 5/368f 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 130/4003 from Ch. 73, par. 1504-3 215 ILCS 190/Act rep. 215 ILCS 5/155.36 215 ILCS 5/155.37 215 ILCS 5/356z.40 215 ILCS 5/370c from Ch. 73, par. 982c 215 ILCS 134/10 215 ILCS 134/45.1 215 ILCS 134/85 215 ILCS 134/87 new 215 ILCS 180/10 215 ILCS 200/20 Replaces everything after the enacting clause. Reinserts the provisions of the introduced bill with the following changes. Provides that the amendatory Act may be referred to as the Health Care Consumer Access and Protection Act. Amends the Illinois Insurance Code. Provides that, unless prohibited under federal law, for plan year 2026 and thereafter, for each insurer proposing to offer a qualified health plan issued in the individual market through the Illinois Health Benefits Exchange, the insurer's rate filing must apply a cost-sharing reduction defunding adjustment factor within a range that is uniform across all insurers; is consistent with the total adjustment expected to be needed to cover actual cost-sharing reduction costs across all silver plans on the Illinois Health Benefits Exchange statewide; and makes certain assumptions. Provides that the rate filing must apply an induced demand factor based on a specified formula. Provides that certain provisions concerning filing of premium rates for group accident and health insurance for approval by the Department of Insurance do not apply to group policies issued to large employers. Removes language providing that certain provisions do not apply to the large group market. Provides that for large employer group policies issued, delivered, amended, or renewed on or after January 1, 2026, the premium rates and risk classifications must be filed with the Department annually for approval. Amends the Limited Health Service Organization Act to provide that pharmaceutical policies are subject to the provisions of the amendatory Act. Sets forth provisions concerning short-term, limited-duration insurance. Provides that no company shall issue, deliver, amend, or renew short-term, limited-duration insurance. Provides that the Department may adopt rules as deemed necessary that prescribe specific standards for or restrictions on policy provisions, benefit design, disclosures, and sales and marketing practices for excepted benefits. Provides that the Director of Insurance's authority under specified provisions is extended to group and blanket excepted benefits. Makes conforming changes in the Health Maintenance Organization Act. Repeals the Short-Term, Limited-Duration Health Insurance Coverage Act. Provides that no later than July 1, 2025, insurance companies that use a drug formulary shall post the formulary on their websites. Makes changes concerning utilization reviews and step therapy requirements. Provides that beginning January 1, 2026, coverage for inpatient mental health treatment at participating hospitals or other licensed facilities shall comply with specified requirements concerning prior authorization, coverage, and concurrent review. Makes other changes. Further amends the Managed Care Reform and Patient Rights Act. Removes provisions concerning step therapy. Provides that only a clinical peer may make an adverse determination. Sets forth certain requirements for utilization review programs. Provides that no utilization review program or any policy, contract, certificate, evidence of coverage, or formulary shall impose step therapy requirements for any health care service, including prescription drugs. Amends the Health Carrier External Review Act. Requires a health insurance issuer to publish on its public website a list of services for which prior authorization is required. Effective January 1, 2025. Balanced Budget Note (Office of Management and Budget) Please be advised that the Balanced Budget Note Act does not apply to House Bill 5395, as amended by House Amendment 1, as it is not a supplemental appropriation that increases or decreases appropriations. Under the Act, a balanced budget note must be prepared only for bills that change a general funds appropriation for the fiscal year in which the new bill is enacted. Fiscal Note (Dept. of Healthcare & Family Services) Expected expenditures for the Illinois Department of Healthcare and Family Services, based on the provisions in HB 5395, are estimated at approximately $30 million per year, beginning January 1, 2026 (the anticipated effective date of the provisions regarding prior approval for inpatient treatment). This estimate assumes a static number of inpatient mental health admissions and does not account for any fluctuations in admissions that may result from changes in provider behavior or from the implementation of other, less-intensive interventions. House Floor Amendment No. 4 Adds reference to: 215 ILCS 124/55 new 215 ILCS 122/5-5 215 ILCS 200/15 305 ILCS 5/5-16.12 Replaces everything after the enacting clause. Reinserts the provisions of the bill, as amended by House Amendment No. 1, with changes that include the following. Provides that the amendatory Act may be referred to as the Health Care Protection Act. In the Network Adequacy and Transparency Act, provides that the Department of Insurance shall enforce certain network adequacy and transparency standards for stand-alone dental plans for plans amended, delivered, issued, or renewed on or after January 1, 2025. Provides that for the Department to enforce any new or modified federal standard before the Department adopts the standard by rule, the Department must, no later than May 15 before the start of the plan year, give public notice to the affected health insurance issuers through a bulletin. Further amends the Illinois Insurance Code, makes changes concerning provider directories. Creates the Uniform Electronic Provider Directory Information Form Task Force. Requires the Department of Insurance, with input from the Uniform Electronic Provider Directory Information Form Task Force, to develop and publish a uniform electronic provider directory information form that issuers shall make available to providers to notify the issuer of the provider's currently accurate provider directory information. Provides that certain provisions concerning prosthetic and customized orthotic devices do not apply to certain other fixed indemnities. Requires the Department to create a template for drug formularies by March 31, 2025. With regard to a prohibition on certain step therapy requirements, removes an exception for the Department of Healthcare and Family services. Makes changes concerning the calculation of a cost-sharing reduction defunding adjustment factor; retrospective review of coverage for inpatient mental health treatment at participating hospitals; the definition of "step therapy requirement"; concurrent review; and standards for utilization review criteria. Makes other changes. Amends the Illinois Health Benefits Exchange Law. Provides that beginning for plan year 2026, if a health insurance issuer offers a product as defined under federal regulations at the gold or silver level through the Illinois Health Benefits Exchange, the issuer must offer that product at both the gold and silver levels. Provides that no later than October 1, 2025 (rather than July 1, 2025), insurance companies that use a drug formulary shall post the formulary on their websites. Amends the Managed Care Reform and Patient Rights Act. Makes changes concerning definitions and utilization review programs. Further amends the Prior Authorization Reform Act. Changes the definition of "medically necessary". Amends the Illinois Public Aid Code. Makes changes concerning the applicability of the Managed Care Reform and Patient Rights Act to the Code. Effective January 1, 2025. Senate Committee Amendment No. 2 Deletes reference to: 215 ILCS 5/121-2.05 215 ILCS 5/352c new 215 ILCS 5/356z.18 215 ILCS 5/367.3 215 ILCS 5/367a 215 ILCS 5/368f 215 ILCS 125/5-3 215 ILCS 130/4003 215 ILCS 190/Act rep. Adds reference to: 215 ILCS 124/36 new Replaces everything after the enacting clause. Reinserts the provisions of the engrossed bill with changes that include the following. Requires the issuer of a network plan to submit a self-audit of its provider directory and a summary to the Department of Insurance, which the Department shall make publicly available. Makes changes to the information that must be provided in a network plan directory. Sets forth required actions if an issuer or the Department identifies a provider incorrectly listed in the provider directory. Removes provisions repealing the Short-Term, Limited-Duration Health Insurance Coverage Act and the related changes. Makes changes to provisions concerning confidentiality; transition of services; unreasonable and inadequate rates; the definitions of "excepted benefits" and "step therapy requirement"; off-formulary exception requests; algorithmic automated review processes; utilization review criteria; and adverse determinations. Makes other changes. Effective January 1, 2025, except that certain changes to the Managed Care Reform and Patient Rights Act take effect January 1, 2026. Senate Floor Amendment No. 3 Provides that specified provisions do not apply to group policies issued in the large group market as defined in the Illinois Health Insurance Portability and Accountability Act. Defines "administrator" and "plan sponsor". Makes other and conforming changes.