• Health Care Availability & Accessibility Committee
• This bill provides that all individuals residing in this State are covered under the Illinois Health Services Program for health insurance. Provides that it is unlawful for private health insurers to sell health insurance coverage that duplicates the coverage of the program. Requires the State to establish the Illinois Health Services Trust to provide financing for the program. The Chamber is monitoring this legislation as we anticipate healthcare reforms will become an active policy issue in 2021. 

• Insurance Committee
• Provides that all individual and small group accident and health policies written in compliance with the Patient Protection and Affordable Care Act must file rates with the Department of Insurance for approval. Provides that rate increases found to be unreasonable in relation to benefits under the policy provided shall be disapproved. The Department will approve or deny rate increases within 60 calendar days after the rate increase is filed. A rate increase that is not approved or denied by the Department on the 61st calendar day shall be automatically approved. The Chamber opposes this legislation due to the outsized power given to the Department of Insurance over private entities, lack of quantifiable rate standards concerning what is or is not “unreasonable.”  

•  House Rules
• Creates the Prior Authorization Reform Act to establish new requirements regarding disclosure and review of PA requirements, denial of claims or coverage by a utilization review organization for various levels of service, including nonurgent and urgent care effective January 1, 2022.  Identical to SB 177 (Holmes) 

• House Rules
• DOI Initiative adopting Holding Company Act 2014 amendments and providing for additional clean-up provisions to the existing Holding Company Act, effective immediately.

• House Rules
• DOI Initiative updating state statute to comply with the Covered Agreement by adopting the Credit for Reinsurance model law, and 2020 Holding Company Act amendments regarding Group Capital Calculation, effective December 31, 2022.

• House Rules
• DOI Initiative providing for various Insurance Code clean-up changes, including partial codification of EO 2020-29 to allow for producer prelicensure courses to take place via webinar effective immediately.

•  House Rules
• Mandates coverage for medically necessary treatment for mental health and substance use conditions. Requires insurers to base medical necessity and utilization review criteria on specific current generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care, including exclusively applying the criteria and guidelines set forth in the most recent versions of the treatment criteria developed by the nonprofit professional association for the relevant clinical specialty. Provides that an insurer shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria and guidelines set forth in the treatment criteria. Provides that the Director may, after appropriate notice and opportunity for hearing, assess a civil penalty between $5,000 and $20,000 for each violation.

•   House Rules
•  Provides that upon request by a party contracting with a pharmacy benefit manager, the party has an annual right to audit compliance with the terms of the contract by the pharmacy benefit manager, including, but not limited to, full disclosure of any value provided by a pharmaceutical manufacturer to a pharmacy benefit manager or the parent, subsidiary, or affiliate company of a pharmacy benefit manager. Provides for other PBM disclosure requirements.

•   House Rules
•  DOI Initiative seeking to address the copay accumulator ban implemented under P.A. 101-0452 as it applies to HSAs paired with a HDHP (to preserve the pre-tax advantages). The language, however, also requires insurers to identify a non-HSA eligible HDHP and offer a non-HSA eligible product if they do provide an HSA-eligible HDHP.

•   House Rules
•   DOI Initiative seeking to address the copay accumulator ban implemented under P.A. 101-0452 as it applies to HSAs paired with a HDHP (to preserve the pre-tax advantages). The language, however, also requires insurers to identify a non-HSA eligible HDHP and offer a non-HSA eligible product if they do provide an HSA-eligible HDHP.

• House Rules
• Amends the Illinois Public Aid Code. Provides that capitation rates established by the Department of Healthcare and Family Services for managed care organizations shall be reduced by 20% for the duration of a disaster proclamation, and any subsequent disaster proclamation, issued by the Governor in response to the COVID-19 public health emergency.

•  Senate Assignments
• Creates the Prior Authorization Reform Act to establish new requirements regarding disclosure and review of PA requirements, denial of claims or coverage by a utilization review organization for various levels of service, including nonurgent and urgent care effective January 1, 2022.

• Senate Assignments
• Amends the Illinois Public Aid Code. Provides that capitation rates established by the Department of Healthcare and Family Services for managed care organizations shall be reduced by 20% for the duration of a disaster proclamation, and any subsequent disaster proclamation, issued by the Governor in response to the COVID-19 public health emergency.

• Senate Assignments
• Mandates coverage for medically necessary treatment for mental health and substance use conditions. In general, requires insurers to base medical necessity and utilization review criteria on specific current generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care, including exclusively applying the criteria and guidelines set forth in the most recent versions of the treatment criteria developed by the nonprofit professional association for the relevant clinical specialty. Provides that an insurer shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria and guidelines set forth in the treatment criteria. Provides that the Director may, after appropriate notice and opportunity for hearing, assess a civil penalty between $5,000 and $20,000 for each violation.

• Senate Assignments
• Mandates coverage for cleft palate corrective surgery, including necessary dental procedures related to the cleft palate for the duration the correction is required until age 26. The provisions do not apply to standalone dental plans.

• Senate Assignments
• Provides the Department of Insurance with the authority to disapprove “unreasonable” or “inadequate” rates for individual and small group ACA compliant health insurance plans. The provisions require the Department to review the rates within 45 days with the option of a 30-day extension.

• Senate Assignments
• Prohibits any mid-year change in health insurance coverage, including changes to the formulary or provider network. The insurance industry and PBMs negotiated compromise language to provide consumers with an avenue to remain on their prescription drugs in situations where a midyear change to the formulary may have adversely impacted their coverage: P.A. 100-1052. Similarly, network adequacy requirements implemented in 2019 provide for continuity of care for certain individuals in the middle of treatment if there is a change in the provider network: P.A. 100-0502.

• Senate Assignments
• Amends the Nurse Practice Act. Ratifies and approves the Nurse Licensure Compact, which allows for the issuance of multistate licenses that allow nurses to practice in their home state and other compact states. Provides that the Compact does not supersede existing State labor laws. Similar to SB 2068 (Castro) and HB 580 (Zalewski).

• Senate Assignments
• Authorizes the Director of Insurance to actively disapprove “unreasonable” or “inadequate” rate increases. The provisions further require the DOI to post notice of the individual and small group premium rate filings, rate filing summaries, and other information about a rate increase or decrease online and provide for a 30-day public comment period prior to approve or disapproving the rates. 

• Senate Assignments
• Provides that an insurer, health maintenance organization, independent practice association, or physician hospital organization may not attempt a recoupment or offset until all appeal rights of a health care professional or health care provider are exhausted and no recoupment or offset may be requested or withheld from future payments 6 months or more after the original payment is made (rather than 18 months or more after the original payment is made).

• Senate Assignments
• Requires insurers to replace a brand name drug with a new generic equivalent on the formulary once it becomes available in the market or move the brand name drug to the lowest cost tier. In provisions concerning a contract between a health insurer and a pharmacy benefit manager, provides that a pharmacy benefit manager must update and publish maximum allowable cost pricing information according to specified requirements, must provide a reasonable administrative appeal procedure to allow pharmacies to challenge maximum allowable costs, and must comply with specified requirements if an appeal is denied. The legislation also sets forth contracting requirements for PBMs, including fiduciary responsibilities. Identical to HB 3630 (Harris).

• Senate Assignments
• DOI Initiative increasing the wellness coverage cap from 20% to 30% per federal rules and further provides clean-up of the Navigator Certification Act. Identical to HB 3175 (Jones)

• Senate Assignments
• Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires all Medicaid managed care organizations to reimburse pharmacy provider dispensing fees and acquisition costs at no less than the amounts established under the fee-for-service program whether the Medicaid managed care organization directly reimburses pharmacy providers or contracts with a pharmacy benefit manager to reimburse pharmacy providers. Provides that the reimbursement requirement applies to all pharmacy services for persons receiving benefits under the Code including pharmacy services. Effective immediately.