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Illinois Senate Bill SB1603

Illinois 2025-2026 Regular Session

Illinois Senate Bill SB1603 Compare Versions

Only one version of the bill is available at this time.
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11 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB1603 Introduced 2/4/2025, by Sen. Laura Fine SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.17 new65 ILCS 5/10-4-2.9 new105 ILCS 5/10-22.3g new215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2215 ILCS 200/85305 ILCS 5/5-5.12g new Amends the Illinois Insurance Code. Provides that a group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026, shall not impose any prior authorization or utilization management controls on covered behavioral health services. Makes conforming changes to the State Employees Group Insurance Act of 1971, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, and the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Insurance and the Department of Healthcare and Family Services to establish a process for receiving complaints from providers and covered individuals for violations of the mandate. Grants the Department of Insurance and the Department of Healthcare and Family Services the authority to issue cease and desist orders and administrative fines. Amends the Prior Authorization Reform Act. Provides that the Department of Healthcare and Family Services shall adopt rules consistent with the Act. Provisions amending the Prior Authorization Reform Act are effective immediately. LRB104 11460 BAB 21548 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB1603 Introduced 2/4/2025, by Sen. Laura Fine SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.17 new65 ILCS 5/10-4-2.9 new105 ILCS 5/10-22.3g new215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2215 ILCS 200/85305 ILCS 5/5-5.12g new 5 ILCS 375/6.17 new 65 ILCS 5/10-4-2.9 new 105 ILCS 5/10-22.3g new 215 ILCS 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 200/85 305 ILCS 5/5-5.12g new Amends the Illinois Insurance Code. Provides that a group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026, shall not impose any prior authorization or utilization management controls on covered behavioral health services. Makes conforming changes to the State Employees Group Insurance Act of 1971, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, and the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Insurance and the Department of Healthcare and Family Services to establish a process for receiving complaints from providers and covered individuals for violations of the mandate. Grants the Department of Insurance and the Department of Healthcare and Family Services the authority to issue cease and desist orders and administrative fines. Amends the Prior Authorization Reform Act. Provides that the Department of Healthcare and Family Services shall adopt rules consistent with the Act. Provisions amending the Prior Authorization Reform Act are effective immediately. LRB104 11460 BAB 21548 b LRB104 11460 BAB 21548 b A BILL FOR
22 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB1603 Introduced 2/4/2025, by Sen. Laura Fine SYNOPSIS AS INTRODUCED:
33 5 ILCS 375/6.17 new65 ILCS 5/10-4-2.9 new105 ILCS 5/10-22.3g new215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2215 ILCS 200/85305 ILCS 5/5-5.12g new 5 ILCS 375/6.17 new 65 ILCS 5/10-4-2.9 new 105 ILCS 5/10-22.3g new 215 ILCS 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 200/85 305 ILCS 5/5-5.12g new
44 5 ILCS 375/6.17 new
55 65 ILCS 5/10-4-2.9 new
66 105 ILCS 5/10-22.3g new
77 215 ILCS 5/370c.3 new
88 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
99 215 ILCS 200/85
1010 305 ILCS 5/5-5.12g new
1111 Amends the Illinois Insurance Code. Provides that a group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026, shall not impose any prior authorization or utilization management controls on covered behavioral health services. Makes conforming changes to the State Employees Group Insurance Act of 1971, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, and the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Insurance and the Department of Healthcare and Family Services to establish a process for receiving complaints from providers and covered individuals for violations of the mandate. Grants the Department of Insurance and the Department of Healthcare and Family Services the authority to issue cease and desist orders and administrative fines. Amends the Prior Authorization Reform Act. Provides that the Department of Healthcare and Family Services shall adopt rules consistent with the Act. Provisions amending the Prior Authorization Reform Act are effective immediately.
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1717 1 AN ACT concerning insurance.
1818 2 Be it enacted by the People of the State of Illinois,
1919 3 represented in the General Assembly:
2020 4 Section 5. The State Employees Group Insurance Act of 1971
2121 5 is amended by adding Section 6.17 as follows:
2222 6 (5 ILCS 375/6.17 new)
2323 7 Sec. 6.17. Behavioral health services; no utilization or
2424 8 prior approval mandates. The program of health benefits is
2525 9 subject to the provisions of Section 370c.3 of the Illinois
2626 10 Insurance Code prohibiting the implementation of prior
2727 11 authorization mandates or utilization management controls for
2828 12 the delivery of behavioral health services.
2929 13 Section 10. The Illinois Municipal Code is amended by
3030 14 adding Section 10-4-2.9 as follows:
3131 15 (65 ILCS 5/10-4-2.9 new)
3232 16 Sec. 10-4-2.9. Behavioral health services; no utilization
3333 17 or prior approval mandates. The corporate authorities of all
3434 18 municipalities are subject to the provisions of Section 370c.3
3535 19 of the Illinois Insurance Code prohibiting the implementation
3636 20 of prior authorization mandates or utilization management
3737 21 controls for the delivery of behavioral health services.
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4141 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB1603 Introduced 2/4/2025, by Sen. Laura Fine SYNOPSIS AS INTRODUCED:
4242 5 ILCS 375/6.17 new65 ILCS 5/10-4-2.9 new105 ILCS 5/10-22.3g new215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2215 ILCS 200/85305 ILCS 5/5-5.12g new 5 ILCS 375/6.17 new 65 ILCS 5/10-4-2.9 new 105 ILCS 5/10-22.3g new 215 ILCS 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 200/85 305 ILCS 5/5-5.12g new
4343 5 ILCS 375/6.17 new
4444 65 ILCS 5/10-4-2.9 new
4545 105 ILCS 5/10-22.3g new
4646 215 ILCS 5/370c.3 new
4747 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
4848 215 ILCS 200/85
4949 305 ILCS 5/5-5.12g new
5050 Amends the Illinois Insurance Code. Provides that a group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026, shall not impose any prior authorization or utilization management controls on covered behavioral health services. Makes conforming changes to the State Employees Group Insurance Act of 1971, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, and the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Insurance and the Department of Healthcare and Family Services to establish a process for receiving complaints from providers and covered individuals for violations of the mandate. Grants the Department of Insurance and the Department of Healthcare and Family Services the authority to issue cease and desist orders and administrative fines. Amends the Prior Authorization Reform Act. Provides that the Department of Healthcare and Family Services shall adopt rules consistent with the Act. Provisions amending the Prior Authorization Reform Act are effective immediately.
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5353 A BILL FOR
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5959 5 ILCS 375/6.17 new
6060 65 ILCS 5/10-4-2.9 new
6161 105 ILCS 5/10-22.3g new
6262 215 ILCS 5/370c.3 new
6363 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
6464 215 ILCS 200/85
6565 305 ILCS 5/5-5.12g new
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8484 1 Section 15. The School Code is amended by adding Section
8585 2 10-22.3g as follows:
8686 3 (105 ILCS 5/10-22.3g new)
8787 4 Sec. 10-22.3g. Behavioral health services; no utilization
8888 5 or prior approval mandates. Insurance protection and benefits
8989 6 for employees are subject to the provisions of Section 370c.3
9090 7 of the Illinois Insurance Code prohibiting the implementation
9191 8 of prior authorization mandates or utilization management
9292 9 controls for the delivery of behavioral health services.
9393 10 Section 20. The Illinois Insurance Code is amended by
9494 11 adding Section 370c.3 as follows:
9595 12 (215 ILCS 5/370c.3 new)
9696 13 Sec. 370c.3. Behavioral health services; no utilization or
9797 14 prior approval mandates.
9898 15 (a) As used in this Section:
9999 16 "Behavioral health service" means any service, including a
100100 17 preventive service, intended to treat a mental, emotional,
101101 18 nervous, or substance use disorder or condition across an
102102 19 individual's entire life span.
103103 20 "Mental, emotional, nervous, or substance use disorder or
104104 21 condition" has the meaning given to that term in Section
105105 22 370c.1 of this Code.
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116116 1 (b) For all group or individual policies of accident and
117117 2 health insurance or managed care plans that are amended,
118118 3 delivered, issued, or renewed on or after January 1, 2026, a
119119 4 health insurance issuer offering a health benefit plan in the
120120 5 State of Illinois shall not impose any prior authorization or
121121 6 utilization management controls on covered behavioral health
122122 7 services.
123123 8 (c) This Section shall not be construed to conflict with
124124 9 any federal law, including, but not limited to, the federal
125125 10 Social Security Act or any implementing regulations,
126126 11 agreements, or decrees.
127127 12 (d) The Department shall establish a process for receiving
128128 13 complaints from providers and covered individuals for
129129 14 violations of this Section. The Department shall timely review
130130 15 and investigate all complaints received in accordance with
131131 16 this Section. The Department shall adopt rules related to
132132 17 enforcement of this Section and post information about how
133133 18 providers can make complaints for violations of this Section
134134 19 on the Department's publicly available website.
135135 20 (e) The Department shall enforce the provisions of this
136136 21 Section in accordance with the enforcement powers granted to
137137 22 it by law. The Department is granted the specific authority to
138138 23 issue a cease and desist order for violations of this Section.
139139 24 Subject to the provisions of the Illinois Administrative
140140 25 Procedure Act, the Department may impose upon a managed care
141141 26 organization an administrative fine not to exceed $250,000 for
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152152 1 failure to comply with the requirements of this Section or
153153 2 repeated violations of this Section.
154154 3 Section 25. The Health Maintenance Organization Act is
155155 4 amended by changing Section 5-3 as follows:
156156 5 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
157157 6 (Text of Section before amendment by P.A. 103-808)
158158 7 Sec. 5-3. Insurance Code provisions.
159159 8 (a) Health Maintenance Organizations shall be subject to
160160 9 the provisions of Sections 133, 134, 136, 137, 139, 140,
161161 10 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
162162 11 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
163163 12 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1,
164164 13 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a,
165165 14 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
166166 15 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
167167 16 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25,
168168 17 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33,
169169 18 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40,
170170 19 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47,
171171 20 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55,
172172 21 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62,
173173 22 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69,
174174 23 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77,
175175 24 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
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186186 1 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403, 403A,
187187 2 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
188188 3 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
189189 4 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
190190 5 Illinois Insurance Code.
191191 6 (b) For purposes of the Illinois Insurance Code, except
192192 7 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
193193 8 Health Maintenance Organizations in the following categories
194194 9 are deemed to be "domestic companies":
195195 10 (1) a corporation authorized under the Dental Service
196196 11 Plan Act or the Voluntary Health Services Plans Act;
197197 12 (2) a corporation organized under the laws of this
198198 13 State; or
199199 14 (3) a corporation organized under the laws of another
200200 15 state, 30% or more of the enrollees of which are residents
201201 16 of this State, except a corporation subject to
202202 17 substantially the same requirements in its state of
203203 18 organization as is a "domestic company" under Article VIII
204204 19 1/2 of the Illinois Insurance Code.
205205 20 (c) In considering the merger, consolidation, or other
206206 21 acquisition of control of a Health Maintenance Organization
207207 22 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
208208 23 (1) the Director shall give primary consideration to
209209 24 the continuation of benefits to enrollees and the
210210 25 financial conditions of the acquired Health Maintenance
211211 26 Organization after the merger, consolidation, or other
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222222 1 acquisition of control takes effect;
223223 2 (2)(i) the criteria specified in subsection (1)(b) of
224224 3 Section 131.8 of the Illinois Insurance Code shall not
225225 4 apply and (ii) the Director, in making his determination
226226 5 with respect to the merger, consolidation, or other
227227 6 acquisition of control, need not take into account the
228228 7 effect on competition of the merger, consolidation, or
229229 8 other acquisition of control;
230230 9 (3) the Director shall have the power to require the
231231 10 following information:
232232 11 (A) certification by an independent actuary of the
233233 12 adequacy of the reserves of the Health Maintenance
234234 13 Organization sought to be acquired;
235235 14 (B) pro forma financial statements reflecting the
236236 15 combined balance sheets of the acquiring company and
237237 16 the Health Maintenance Organization sought to be
238238 17 acquired as of the end of the preceding year and as of
239239 18 a date 90 days prior to the acquisition, as well as pro
240240 19 forma financial statements reflecting projected
241241 20 combined operation for a period of 2 years;
242242 21 (C) a pro forma business plan detailing an
243243 22 acquiring party's plans with respect to the operation
244244 23 of the Health Maintenance Organization sought to be
245245 24 acquired for a period of not less than 3 years; and
246246 25 (D) such other information as the Director shall
247247 26 require.
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258258 1 (d) The provisions of Article VIII 1/2 of the Illinois
259259 2 Insurance Code and this Section 5-3 shall apply to the sale by
260260 3 any health maintenance organization of greater than 10% of its
261261 4 enrollee population (including, without limitation, the health
262262 5 maintenance organization's right, title, and interest in and
263263 6 to its health care certificates).
264264 7 (e) In considering any management contract or service
265265 8 agreement subject to Section 141.1 of the Illinois Insurance
266266 9 Code, the Director (i) shall, in addition to the criteria
267267 10 specified in Section 141.2 of the Illinois Insurance Code,
268268 11 take into account the effect of the management contract or
269269 12 service agreement on the continuation of benefits to enrollees
270270 13 and the financial condition of the health maintenance
271271 14 organization to be managed or serviced, and (ii) need not take
272272 15 into account the effect of the management contract or service
273273 16 agreement on competition.
274274 17 (f) Except for small employer groups as defined in the
275275 18 Small Employer Rating, Renewability and Portability Health
276276 19 Insurance Act and except for medicare supplement policies as
277277 20 defined in Section 363 of the Illinois Insurance Code, a
278278 21 Health Maintenance Organization may by contract agree with a
279279 22 group or other enrollment unit to effect refunds or charge
280280 23 additional premiums under the following terms and conditions:
281281 24 (i) the amount of, and other terms and conditions with
282282 25 respect to, the refund or additional premium are set forth
283283 26 in the group or enrollment unit contract agreed in advance
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294294 1 of the period for which a refund is to be paid or
295295 2 additional premium is to be charged (which period shall
296296 3 not be less than one year); and
297297 4 (ii) the amount of the refund or additional premium
298298 5 shall not exceed 20% of the Health Maintenance
299299 6 Organization's profitable or unprofitable experience with
300300 7 respect to the group or other enrollment unit for the
301301 8 period (and, for purposes of a refund or additional
302302 9 premium, the profitable or unprofitable experience shall
303303 10 be calculated taking into account a pro rata share of the
304304 11 Health Maintenance Organization's administrative and
305305 12 marketing expenses, but shall not include any refund to be
306306 13 made or additional premium to be paid pursuant to this
307307 14 subsection (f)). The Health Maintenance Organization and
308308 15 the group or enrollment unit may agree that the profitable
309309 16 or unprofitable experience may be calculated taking into
310310 17 account the refund period and the immediately preceding 2
311311 18 plan years.
312312 19 The Health Maintenance Organization shall include a
313313 20 statement in the evidence of coverage issued to each enrollee
314314 21 describing the possibility of a refund or additional premium,
315315 22 and upon request of any group or enrollment unit, provide to
316316 23 the group or enrollment unit a description of the method used
317317 24 to calculate (1) the Health Maintenance Organization's
318318 25 profitable experience with respect to the group or enrollment
319319 26 unit and the resulting refund to the group or enrollment unit
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330330 1 or (2) the Health Maintenance Organization's unprofitable
331331 2 experience with respect to the group or enrollment unit and
332332 3 the resulting additional premium to be paid by the group or
333333 4 enrollment unit.
334334 5 In no event shall the Illinois Health Maintenance
335335 6 Organization Guaranty Association be liable to pay any
336336 7 contractual obligation of an insolvent organization to pay any
337337 8 refund authorized under this Section.
338338 9 (g) Rulemaking authority to implement Public Act 95-1045,
339339 10 if any, is conditioned on the rules being adopted in
340340 11 accordance with all provisions of the Illinois Administrative
341341 12 Procedure Act and all rules and procedures of the Joint
342342 13 Committee on Administrative Rules; any purported rule not so
343343 14 adopted, for whatever reason, is unauthorized.
344344 15 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
345345 16 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
346346 17 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
347347 18 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
348348 19 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
349349 20 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
350350 21 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
351351 22 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
352352 23 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
353353 24 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
354354 25 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
355355 26 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
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366366 1 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
367367 2 103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
368368 3 1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)
369369 4 (Text of Section after amendment by P.A. 103-808)
370370 5 Sec. 5-3. Insurance Code provisions.
371371 6 (a) Health Maintenance Organizations shall be subject to
372372 7 the provisions of Sections 133, 134, 136, 137, 139, 140,
373373 8 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
374374 9 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
375375 10 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g,
376376 11 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
377377 12 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
378378 13 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
379379 14 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
380380 15 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
381381 16 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
382382 17 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
383383 18 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
384384 19 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,
385385 20 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
386386 21 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75,
387387 22 356z.77, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
388388 23 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403,
389389 24 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
390390 25 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
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401401 1 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
402402 2 Illinois Insurance Code.
403403 3 (b) For purposes of the Illinois Insurance Code, except
404404 4 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
405405 5 Health Maintenance Organizations in the following categories
406406 6 are deemed to be "domestic companies":
407407 7 (1) a corporation authorized under the Dental Service
408408 8 Plan Act or the Voluntary Health Services Plans Act;
409409 9 (2) a corporation organized under the laws of this
410410 10 State; or
411411 11 (3) a corporation organized under the laws of another
412412 12 state, 30% or more of the enrollees of which are residents
413413 13 of this State, except a corporation subject to
414414 14 substantially the same requirements in its state of
415415 15 organization as is a "domestic company" under Article VIII
416416 16 1/2 of the Illinois Insurance Code.
417417 17 (c) In considering the merger, consolidation, or other
418418 18 acquisition of control of a Health Maintenance Organization
419419 19 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
420420 20 (1) the Director shall give primary consideration to
421421 21 the continuation of benefits to enrollees and the
422422 22 financial conditions of the acquired Health Maintenance
423423 23 Organization after the merger, consolidation, or other
424424 24 acquisition of control takes effect;
425425 25 (2)(i) the criteria specified in subsection (1)(b) of
426426 26 Section 131.8 of the Illinois Insurance Code shall not
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437437 1 apply and (ii) the Director, in making his determination
438438 2 with respect to the merger, consolidation, or other
439439 3 acquisition of control, need not take into account the
440440 4 effect on competition of the merger, consolidation, or
441441 5 other acquisition of control;
442442 6 (3) the Director shall have the power to require the
443443 7 following information:
444444 8 (A) certification by an independent actuary of the
445445 9 adequacy of the reserves of the Health Maintenance
446446 10 Organization sought to be acquired;
447447 11 (B) pro forma financial statements reflecting the
448448 12 combined balance sheets of the acquiring company and
449449 13 the Health Maintenance Organization sought to be
450450 14 acquired as of the end of the preceding year and as of
451451 15 a date 90 days prior to the acquisition, as well as pro
452452 16 forma financial statements reflecting projected
453453 17 combined operation for a period of 2 years;
454454 18 (C) a pro forma business plan detailing an
455455 19 acquiring party's plans with respect to the operation
456456 20 of the Health Maintenance Organization sought to be
457457 21 acquired for a period of not less than 3 years; and
458458 22 (D) such other information as the Director shall
459459 23 require.
460460 24 (d) The provisions of Article VIII 1/2 of the Illinois
461461 25 Insurance Code and this Section 5-3 shall apply to the sale by
462462 26 any health maintenance organization of greater than 10% of its
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473473 1 enrollee population (including, without limitation, the health
474474 2 maintenance organization's right, title, and interest in and
475475 3 to its health care certificates).
476476 4 (e) In considering any management contract or service
477477 5 agreement subject to Section 141.1 of the Illinois Insurance
478478 6 Code, the Director (i) shall, in addition to the criteria
479479 7 specified in Section 141.2 of the Illinois Insurance Code,
480480 8 take into account the effect of the management contract or
481481 9 service agreement on the continuation of benefits to enrollees
482482 10 and the financial condition of the health maintenance
483483 11 organization to be managed or serviced, and (ii) need not take
484484 12 into account the effect of the management contract or service
485485 13 agreement on competition.
486486 14 (f) Except for small employer groups as defined in the
487487 15 Small Employer Rating, Renewability and Portability Health
488488 16 Insurance Act and except for medicare supplement policies as
489489 17 defined in Section 363 of the Illinois Insurance Code, a
490490 18 Health Maintenance Organization may by contract agree with a
491491 19 group or other enrollment unit to effect refunds or charge
492492 20 additional premiums under the following terms and conditions:
493493 21 (i) the amount of, and other terms and conditions with
494494 22 respect to, the refund or additional premium are set forth
495495 23 in the group or enrollment unit contract agreed in advance
496496 24 of the period for which a refund is to be paid or
497497 25 additional premium is to be charged (which period shall
498498 26 not be less than one year); and
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509509 1 (ii) the amount of the refund or additional premium
510510 2 shall not exceed 20% of the Health Maintenance
511511 3 Organization's profitable or unprofitable experience with
512512 4 respect to the group or other enrollment unit for the
513513 5 period (and, for purposes of a refund or additional
514514 6 premium, the profitable or unprofitable experience shall
515515 7 be calculated taking into account a pro rata share of the
516516 8 Health Maintenance Organization's administrative and
517517 9 marketing expenses, but shall not include any refund to be
518518 10 made or additional premium to be paid pursuant to this
519519 11 subsection (f)). The Health Maintenance Organization and
520520 12 the group or enrollment unit may agree that the profitable
521521 13 or unprofitable experience may be calculated taking into
522522 14 account the refund period and the immediately preceding 2
523523 15 plan years.
524524 16 The Health Maintenance Organization shall include a
525525 17 statement in the evidence of coverage issued to each enrollee
526526 18 describing the possibility of a refund or additional premium,
527527 19 and upon request of any group or enrollment unit, provide to
528528 20 the group or enrollment unit a description of the method used
529529 21 to calculate (1) the Health Maintenance Organization's
530530 22 profitable experience with respect to the group or enrollment
531531 23 unit and the resulting refund to the group or enrollment unit
532532 24 or (2) the Health Maintenance Organization's unprofitable
533533 25 experience with respect to the group or enrollment unit and
534534 26 the resulting additional premium to be paid by the group or
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545545 1 enrollment unit.
546546 2 In no event shall the Illinois Health Maintenance
547547 3 Organization Guaranty Association be liable to pay any
548548 4 contractual obligation of an insolvent organization to pay any
549549 5 refund authorized under this Section.
550550 6 (g) Rulemaking authority to implement Public Act 95-1045,
551551 7 if any, is conditioned on the rules being adopted in
552552 8 accordance with all provisions of the Illinois Administrative
553553 9 Procedure Act and all rules and procedures of the Joint
554554 10 Committee on Administrative Rules; any purported rule not so
555555 11 adopted, for whatever reason, is unauthorized.
556556 12 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
557557 13 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
558558 14 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
559559 15 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
560560 16 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
561561 17 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
562562 18 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
563563 19 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
564564 20 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
565565 21 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
566566 22 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
567567 23 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
568568 24 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
569569 25 103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
570570 26 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised
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581581 1 11-26-24.)
582582 2 Section 30. The Prior Authorization Reform Act is amended
583583 3 by changing Section 85 as follows:
584584 4 (215 ILCS 200/85)
585585 5 Sec. 85. Administration and enforcement.
586586 6 (a) The Department shall enforce the provisions of this
587587 7 Act pursuant to the enforcement powers granted to it by law. To
588588 8 enforce the provisions of this Act, the Director is hereby
589589 9 granted specific authority to issue a cease and desist order
590590 10 or require a utilization review organization or health
591591 11 insurance issuer to submit a plan of correction for violations
592592 12 of this Act, or both, in accordance with the requirements and
593593 13 authority set forth in Section 85 of the Managed Care Reform
594594 14 and Patient Rights Act. Subject to the provisions of the
595595 15 Illinois Administrative Procedure Act, the Director may,
596596 16 pursuant to Section 403A of the Illinois Insurance Code,
597597 17 impose upon a utilization review organization or health
598598 18 insurance issuer an administrative fine not to exceed $250,000
599599 19 for failure to submit a requested plan of correction, failure
600600 20 to comply with its plan of correction, or repeated violations
601601 21 of this Act.
602602 22 (b) Any person who believes that his or her utilization
603603 23 review organization or health insurance issuer is in violation
604604 24 of the provisions of this Act may file a complaint with the
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615615 1 Department. The Department shall review all complaints
616616 2 received and investigate all complaints that it deems to state
617617 3 a potential violation. The Department shall fairly,
618618 4 efficiently, and timely review and investigate complaints.
619619 5 Health insurance issuers and utilization review organizations
620620 6 found to be in violation of this Act shall be penalized in
621621 7 accordance with this Section.
622622 8 (c) The Department of Healthcare and Family Services shall
623623 9 enforce the provisions of this Act as it applies to persons
624624 10 enrolled under Article V of the Illinois Public Aid Code or
625625 11 under the Children's Health Insurance Program Act and shall
626626 12 adopt rules consistent with this Act.
627627 13 (Source: P.A. 102-409, eff. 1-1-22.)
628628 14 Section 35. The Illinois Public Aid Code is amended by
629629 15 adding Section 5-5.12g as follows:
630630 16 (305 ILCS 5/5-5.12g new)
631631 17 Sec. 5-5.12g. Behavioral health services; no utilization
632632 18 or prior approval mandates.
633633 19 (a) As used in this Section:
634634 20 "Behavioral health service" means any service, including a
635635 21 preventive service, intended to treat a mental, emotional,
636636 22 nervous, or substance use disorder or condition across an
637637 23 individual's entire life span.
638638 24 "Mental, emotional, nervous, or substance use disorder or
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649649 1 condition" has the meaning given to that term in Section
650650 2 370c.1 of the Illinois Insurance Code.
651651 3 (b) Notwithstanding any other provision of this Code to
652652 4 the contrary, for the purpose of removing barriers to the
653653 5 timely treatment of behavioral health conditions, including
654654 6 both mental health and substance use disorders, beginning on
655655 7 January 1, 2026, prior authorization, or any other utilization
656656 8 management controls, shall be prohibited under the
657657 9 fee-for-service and managed care medical assistance programs
658658 10 on any behavioral health service.
659659 11 (c) This Section shall not be construed to conflict with
660660 12 any federal law, including, but not limited to, the federal
661661 13 Social Security Act or any implementing regulations,
662662 14 agreements, or decrees.
663663 15 (d) The Department shall establish a process to accept
664664 16 complaints from providers or individuals eligible for medical
665665 17 assistance for any violations of this Section. The Department
666666 18 shall review and investigate all complaints received. The
667667 19 Department shall fairly, efficiently, and timely review and
668668 20 investigate complaints. The Department shall adopt rules
669669 21 related to enforcement of this Section and post information
670670 22 about how providers can make complaints for violations of this
671671 23 Section on the Department's publicly available website.
672672 24 (e) The Department shall enforce the provisions of this
673673 25 Section in accordance with the enforcement powers granted to
674674 26 it by law. The Department is granted the specific authority to
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685685 1 issue a cease and desist order for violations of this Section.
686686 2 Subject to the provisions of the Illinois Administrative
687687 3 Procedure Act, the Department may impose upon a managed care
688688 4 organization an administrative fine not to exceed $250,000 for
689689 5 failure to comply with the requirements of this Section or
690690 6 repeated violations of this Section.
691691 7 Section 95. No acceleration or delay. Where this Act makes
692692 8 changes in a statute that is represented in this Act by text
693693 9 that is not yet or no longer in effect (for example, a Section
694694 10 represented by multiple versions), the use of that text does
695695 11 not accelerate or delay the taking effect of (i) the changes
696696 12 made by this Act or (ii) provisions derived from any other
697697 13 Public Act.
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