HB 5395

  • Illinois House Bill
  • 103rd Regular Session
  • Introduced in House May 24, 2024
  • Passed House Apr 18, 2024
  • Passed Senate May 23, 2024
  • Signed by Governor Jul 10, 2024

Network Adequacy-Standards

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.

Bill Sponsors (83)

Votes


Actions


Jul 10, 2024

House

Governor Approved

House

Public Act . . . . . . . . . 103-0650

House

Effective Date January 1, 2025

Jun 21, 2024

House

Sent to the Governor

May 30, 2024

Senate

Added as Alternate Co-Sponsor Sen. Meg Loughran Cappel

May 26, 2024

Senate

Added as Alternate Co-Sponsor Sen. Doris Turner

Senate

Added as Alternate Co-Sponsor Sen. Laura M. Murphy

May 25, 2024

House

Senate Floor Amendment No. 3 House Concurs 083-023-001

House

Passed Both Houses

House

House Concurs

House

Senate Committee Amendment No. 2 House Concurs 083-023-001

May 24, 2024

House

Placed on Calendar Order of Concurrence Senate Amendment(s) 2, 3

House

Senate Floor Amendment No. 3 Motion to Concur Recommends Be Adopted Human Services Committee; 009-000-000

House

Senate Committee Amendment No. 2 Motion to Concur Recommends Be Adopted Human Services Committee; 009-000-000

Senate

Added as Alternate Co-Sponsor Sen. Napoleon Harris, III

House

Senate Floor Amendment No. 3 Motion to Concur Rules Referred to Human Services Committee

House

Senate Committee Amendment No. 2 Motion to Concur Rules Referred to Human Services Committee

House

Senate Floor Amendment No. 3 Motion to Concur Referred to Rules Committee

House

Senate Committee Amendment No. 2 Motion to Concur Referred to Rules Committee

House

Senate Floor Amendment No. 3 Motion Filed Concur Rep. Anna Moeller

House

Senate Committee Amendment No. 2 Motion Filed Concur Rep. Anna Moeller

House

Arrived in House

May 23, 2024

Senate

Recalled to Second Reading

Senate

Senate Committee Amendment No. 1 Tabled Pursuant to Rule 5-4(a)

Senate

Third Reading - Passed; 045-014-000

Senate

Placed on Calendar Order of 3rd Reading

Senate

Senate Floor Amendment No. 3 Adopted; Peters

Senate

Senate Floor Amendment No. 3 Be Approved for Consideration Assignments

May 22, 2024

Senate

Placed on Calendar Order of 3rd Reading May 23, 2024

Senate

Senate Floor Amendment No. 3 Referred to Assignments

Senate

Senate Floor Amendment No. 3 Filed with Secretary by Sen. Robert Peters

Senate

Second Reading

May 21, 2024

Senate

Do Pass as Amended Insurance; 007-004-000

Senate

Rule 2-10 Third Reading/Passage Deadline Established As May 24, 2024

Senate

Placed on Calendar Order of 2nd Reading May 21, 2024

Senate

Senate Committee Amendment No. 2 Adopted

Senate

Added as Alternate Co-Sponsor Sen. Mattie Hunter

Senate

Senate Committee Amendment No. 2 Assignments Refers to Insurance

Senate

Added as Alternate Co-Sponsor Sen. Natalie Toro

May 20, 2024

Senate

Senate Committee Amendment No. 2 Referred to Assignments

Senate

Senate Committee Amendment No. 2 Filed with Secretary by Sen. Robert Peters

May 17, 2024

Senate

Rule 2-10 Committee Deadline Established As May 24, 2024

May 16, 2024

Senate

Added as Alternate Co-Sponsor Sen. Mary Edly-Allen

May 14, 2024

Senate

Added as Alternate Co-Sponsor Sen. Mike Porfirio

May 13, 2024

Senate

Added as Alternate Co-Sponsor Sen. Lakesia Collins

May 10, 2024

Senate

Added as Alternate Co-Sponsor Sen. Javier L. Cervantes

Senate

Rule 2-10 Committee Deadline Established As May 17, 2024

Senate

Added as Alternate Co-Sponsor Sen. Adriane Johnson

May 08, 2024

Senate

Added as Alternate Co-Sponsor Sen. Christopher Belt

May 07, 2024

Senate

Added as Alternate Co-Sponsor Sen. Laura Ellman

Senate

Senate Committee Amendment No. 1 Assignments Refers to Insurance

May 03, 2024

Senate

Added as Alternate Co-Sponsor Sen. Julie A. Morrison

Senate

Added as Alternate Co-Sponsor Sen. Steve Stadelman

May 02, 2024

Senate

Senate Committee Amendment No. 1 Referred to Assignments

Senate

Senate Committee Amendment No. 1 Filed with Secretary by Sen. Robert Peters

May 01, 2024

Senate

Added as Alternate Co-Sponsor Sen. Sara Feigenholtz

Senate

Added as Alternate Co-Sponsor Sen. Ram Villivalam

Apr 30, 2024

Senate

Added as Alternate Chief Co-Sponsor Sen. Patrick J. Joyce

Senate

Rule 2-10 Committee Deadline Established As May 10, 2024

Senate

Assigned to Insurance

Apr 29, 2024

Senate

Added as Alternate Co-Sponsor Sen. Mike Simmons

Apr 26, 2024

Senate

Added as Alternate Chief Co-Sponsor Sen. Willie Preston

Apr 25, 2024

Senate

Added as Alternate Chief Co-Sponsor Sen. Rachel Ventura

Senate

Added as Alternate Chief Co-Sponsor Sen. Laura Fine

Apr 23, 2024

Senate

Added as Alternate Co-Sponsor Sen. Karina Villa

Senate

Added as Alternate Co-Sponsor Sen. Kimberly A. Lightford

Apr 19, 2024

Senate

Chief Senate Sponsor Sen. Robert Peters

Senate

Arrive in Senate

Senate

Referred to Assignments

Senate

First Reading

Senate

Placed on Calendar Order of First Reading

Apr 18, 2024

House

Added Co-Sponsor Rep. Laura Faver Dias

House

House Floor Amendment No. 4 Recommends Be Adopted Human Services Committee; 009-000-000

House

Added Co-Sponsor Rep. Anne Stava-Murray

House

House Floor Amendment No. 4 Adopted

House

Correctional Note Requested - Withdrawn by Rep. Robyn Gabel

House

Home Rule Note Requested - Withdrawn by Rep. Robyn Gabel

House

Housing Affordability Impact Note Requested - Withdrawn by Rep. Robyn Gabel

House

Judicial Note Requested - Withdrawn by Rep. Robyn Gabel

House

Land Conveyance Appraisal Note Requested - Withdrawn by Rep. Robyn Gabel

House

Pension Note Requested - Withdrawn by Rep. Robyn Gabel

House

Racial Impact Note Requested - Withdrawn by Rep. Robyn Gabel

House

State Debt Impact Note Requested - Withdrawn by Rep. Robyn Gabel

House

State Mandates Fiscal Note Requested - Withdrawn by Rep. Ryan Spain

House

Placed on Calendar Order of 3rd Reading - Short Debate

House

Third Reading - Short Debate - Passed 081-025-002

House

House Floor Amendment No. 2 Tabled

House

House Floor Amendment No. 3 Tabled

House

Added Co-Sponsor Rep. Jennifer Gong-Gershowitz

House

Added Co-Sponsor Rep. Gregg Johnson

House

Added Co-Sponsor Rep. Harry Benton

House

Added Co-Sponsor Rep. Norma Hernandez

House

Added Co-Sponsor Rep. Lilian Jiménez

House

Added Co-Sponsor Rep. Debbie Meyers-Martin

House

Added Co-Sponsor Rep. Hoan Huynh

Apr 17, 2024

House

House Floor Amendment No. 4 Rules Refers to Human Services Committee

House

House Floor Amendment No. 3 Rules Refers to Human Services Committee

House

House Floor Amendment No. 4 Referred to Rules Committee

House

House Floor Amendment No. 4 Filed with Clerk by Rep. Anna Moeller

Apr 16, 2024

House

Added Co-Sponsor Rep. Janet Yang Rohr

House

House Floor Amendment No. 3 Filed with Clerk by Rep. Anna Moeller

House

Held on Calendar Order of Second Reading - Short Debate

House

Second Reading - Short Debate

House

House Floor Amendment No. 3 Referred to Rules Committee

Apr 15, 2024

House

Added Co-Sponsor Rep. Stephanie A. Kifowit

House

House Floor Amendment No. 2 Rules Refers to Human Services Committee

Apr 05, 2024

House

House Floor Amendment No. 2 Referred to Rules Committee

House

House Floor Amendment No. 2 Filed with Clerk by Rep. Anna Moeller

Apr 01, 2024

House

Fiscal Note Filed

Mar 26, 2024

House

Balanced Budget Note Filed

Mar 22, 2024

House

Correctional Note Requested by Rep. Robyn Gabel

House

Added Co-Sponsor Rep. Emanuel "Chris" Welch

House

State Mandates Fiscal Note Requested by Rep. Robyn Gabel

House

State Debt Impact Note Requested by Rep. Robyn Gabel

House

Racial Impact Note Requested by Rep. Robyn Gabel

House

Pension Note Requested by Rep. Robyn Gabel

House

Land Conveyance Appraisal Note Requested by Rep. Robyn Gabel

House

Judicial Note Requested by Rep. Robyn Gabel

House

Housing Affordability Impact Note Requested by Rep. Robyn Gabel

House

Home Rule Note Requested by Rep. Robyn Gabel

House

Fiscal Note Requested by Rep. Robyn Gabel

House

Balanced Budget Note Requested by Rep. Robyn Gabel

Mar 21, 2024

House

Do Pass as Amended / Short Debate Human Services Committee; 006-003-000

House

Placed on Calendar 2nd Reading - Short Debate

House

Balanced Budget Note Requested by Rep. Ryan Spain

House

State Mandates Fiscal Note Requested by Rep. Ryan Spain

House

Fiscal Note Requested by Rep. Ryan Spain

House

House Committee Amendment No. 1 Adopted in Human Services Committee; by Voice Vote

Mar 12, 2024

House

Added Co-Sponsor Rep. La Shawn K. Ford

House

House Committee Amendment No. 1 Rules Refers to Human Services Committee

House

Added Co-Sponsor Rep. Kam Buckner

Mar 07, 2024

House

Added Co-Sponsor Rep. Kimberly Du Buclet

House

Added Co-Sponsor Rep. Sharon Chung

House

Added Co-Sponsor Rep. William E Hauter

House

Added Co-Sponsor Rep. Robert "Bob" Rita

House

Added Co-Sponsor Rep. Abdelnasser Rashid

House

Added Co-Sponsor Rep. Kevin John Olickal

House

Added Co-Sponsor Rep. Michelle Mussman

House

Added Co-Sponsor Rep. Rita Mayfield

House

Added Co-Sponsor Rep. Theresa Mah

House

Added Co-Sponsor Rep. Margaret Croke

Mar 06, 2024

House

House Committee Amendment No. 1 Referred to Rules Committee

House

House Committee Amendment No. 1 Filed with Clerk by Rep. Anna Moeller

Mar 05, 2024

House

Assigned to Human Services Committee

Mar 04, 2024

House

Added Co-Sponsor Rep. Tracy Katz Muhl

House

Added Co-Sponsor Rep. Michael J. Kelly

House

Added Co-Sponsor Rep. Maurice A. West, II

Feb 23, 2024

House

Chief Co-Sponsor Changed to Rep. Bob Morgan

House

Added Chief Co-Sponsor Rep. Bob Morgan

House

Added Chief Co-Sponsor Rep. Camille Y. Lilly

House

Chief Co-Sponsor Changed to Rep. Camille Y. Lilly

House

Added Co-Sponsor Rep. Maura Hirschauer

House

Added Co-Sponsor Rep. Michelle Mussman

House

Added Co-Sponsor Rep. Martin J. Moylan

House

Added Co-Sponsor Rep. Jehan Gordon-Booth

House

Chief Co-Sponsor Changed to Rep. Camille Y. Lilly

Feb 22, 2024

House

Added Co-Sponsor Rep. Elizabeth "Lisa" Hernandez

House

Removed Co-Sponsor Rep. Bob Morgan

House

Added Co-Sponsor Rep. Joyce Mason

House

Added Co-Sponsor Rep. Jaime M. Andrade, Jr.

House

Added Co-Sponsor Rep. Katie Stuart

House

Added Co-Sponsor Rep. Terra Costa Howard

House

Added Co-Sponsor Rep. Matt Hanson

House

Added Co-Sponsor Rep. Suzanne M. Ness

House

Added Co-Sponsor Rep. Dagmara Avelar

House

Added Co-Sponsor Rep. Lindsey LaPointe

House

Added Co-Sponsor Rep. Jenn Ladisch Douglass

House

Added Co-Sponsor Rep. Yolonda Morris

House

Added Chief Co-Sponsor Rep. Eva-Dina Delgado

House

Added Co-Sponsor Rep. Sue Scherer

House

Added Co-Sponsor Rep. Kelly M. Cassidy

House

Added Co-Sponsor Rep. Marcus C. Evans, Jr.

House

Added Co-Sponsor Rep. Sonya M. Harper

House

Added Co-Sponsor Rep. Mark L. Walker

House

Added Co-Sponsor Rep. Mary Beth Canty

House

Added Co-Sponsor Rep. Will Guzzardi

House

Added Co-Sponsor Rep. Bob Morgan

House

Added Co-Sponsor Rep. Ann M. Williams

House

Added Co-Sponsor Rep. Nabeela Syed

House

Added Co-Sponsor Rep. Natalie A. Manley

House

Added Co-Sponsor Rep. Nicholas K. Smith

Feb 20, 2024

House

Added Chief Co-Sponsor Rep. Robyn Gabel

Feb 09, 2024

House

First Reading

House

Referred to Rules Committee

House

Filed with the Clerk by Rep. Anna Moeller

Bill Text

Bill Text Versions Format
Introduced HTML PDF
Engrossed HTML PDF
Enrolled HTML PDF
House Amendment 001 HTML PDF
House Amendment 002 HTML PDF
House Amendment 003 HTML PDF
House Amendment 004 HTML PDF
Senate Amendment 001 HTML PDF
Senate Amendment 002 HTML PDF
Senate Amendment 003 HTML PDF

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Sources

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