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
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
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
LRB104 11460 BAB 21548 b
A BILL FOR
SB1603LRB104 11460 BAB 21548 b SB1603 LRB104 11460 BAB 21548 b
SB1603 LRB104 11460 BAB 21548 b
1 AN ACT concerning insurance.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The State Employees Group Insurance Act of 1971
5 is amended by adding Section 6.17 as follows:
6 (5 ILCS 375/6.17 new)
7 Sec. 6.17. Behavioral health services; no utilization or
8 prior approval mandates. The program of health benefits is
9 subject to the provisions of Section 370c.3 of the Illinois
10 Insurance Code prohibiting the implementation of prior
11 authorization mandates or utilization management controls for
12 the delivery of behavioral health services.
13 Section 10. The Illinois Municipal Code is amended by
14 adding Section 10-4-2.9 as follows:
15 (65 ILCS 5/10-4-2.9 new)
16 Sec. 10-4-2.9. Behavioral health services; no utilization
17 or prior approval mandates. The corporate authorities of all
18 municipalities are subject to the provisions of Section 370c.3
19 of the Illinois Insurance Code prohibiting the implementation
20 of prior authorization mandates or utilization management
21 controls for the delivery of behavioral health services.
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
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
LRB104 11460 BAB 21548 b
A BILL FOR
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
LRB104 11460 BAB 21548 b
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1 Section 15. The School Code is amended by adding Section
2 10-22.3g as follows:
3 (105 ILCS 5/10-22.3g new)
4 Sec. 10-22.3g. Behavioral health services; no utilization
5 or prior approval mandates. Insurance protection and benefits
6 for employees are subject to the provisions of Section 370c.3
7 of the Illinois Insurance Code prohibiting the implementation
8 of prior authorization mandates or utilization management
9 controls for the delivery of behavioral health services.
10 Section 20. The Illinois Insurance Code is amended by
11 adding Section 370c.3 as follows:
12 (215 ILCS 5/370c.3 new)
13 Sec. 370c.3. Behavioral health services; no utilization or
14 prior approval mandates.
15 (a) As used in this Section:
16 "Behavioral health service" means any service, including a
17 preventive service, intended to treat a mental, emotional,
18 nervous, or substance use disorder or condition across an
19 individual's entire life span.
20 "Mental, emotional, nervous, or substance use disorder or
21 condition" has the meaning given to that term in Section
22 370c.1 of this Code.
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1 (b) For all group or individual policies of accident and
2 health insurance or managed care plans that are amended,
3 delivered, issued, or renewed on or after January 1, 2026, a
4 health insurance issuer offering a health benefit plan in the
5 State of Illinois shall not impose any prior authorization or
6 utilization management controls on covered behavioral health
7 services.
8 (c) This Section shall not be construed to conflict with
9 any federal law, including, but not limited to, the federal
10 Social Security Act or any implementing regulations,
11 agreements, or decrees.
12 (d) The Department shall establish a process for receiving
13 complaints from providers and covered individuals for
14 violations of this Section. The Department shall timely review
15 and investigate all complaints received in accordance with
16 this Section. The Department shall adopt rules related to
17 enforcement of this Section and post information about how
18 providers can make complaints for violations of this Section
19 on the Department's publicly available website.
20 (e) The Department shall enforce the provisions of this
21 Section in accordance with the enforcement powers granted to
22 it by law. The Department is granted the specific authority to
23 issue a cease and desist order for violations of this Section.
24 Subject to the provisions of the Illinois Administrative
25 Procedure Act, the Department may impose upon a managed care
26 organization an administrative fine not to exceed $250,000 for
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1 failure to comply with the requirements of this Section or
2 repeated violations of this Section.
3 Section 25. The Health Maintenance Organization Act is
4 amended by changing Section 5-3 as follows:
5 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
6 (Text of Section before amendment by P.A. 103-808)
7 Sec. 5-3. Insurance Code provisions.
8 (a) Health Maintenance Organizations shall be subject to
9 the provisions of Sections 133, 134, 136, 137, 139, 140,
10 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
11 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
12 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1,
13 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a,
14 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
15 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
16 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25,
17 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33,
18 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40,
19 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47,
20 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55,
21 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62,
22 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69,
23 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77,
24 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
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1 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403, 403A,
2 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
3 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
4 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
5 Illinois Insurance Code.
6 (b) For purposes of the Illinois Insurance Code, except
7 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
8 Health Maintenance Organizations in the following categories
9 are deemed to be "domestic companies":
10 (1) a corporation authorized under the Dental Service
11 Plan Act or the Voluntary Health Services Plans Act;
12 (2) a corporation organized under the laws of this
13 State; or
14 (3) a corporation organized under the laws of another
15 state, 30% or more of the enrollees of which are residents
16 of this State, except a corporation subject to
17 substantially the same requirements in its state of
18 organization as is a "domestic company" under Article VIII
19 1/2 of the Illinois Insurance Code.
20 (c) In considering the merger, consolidation, or other
21 acquisition of control of a Health Maintenance Organization
22 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
23 (1) the Director shall give primary consideration to
24 the continuation of benefits to enrollees and the
25 financial conditions of the acquired Health Maintenance
26 Organization after the merger, consolidation, or other
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1 acquisition of control takes effect;
2 (2)(i) the criteria specified in subsection (1)(b) of
3 Section 131.8 of the Illinois Insurance Code shall not
4 apply and (ii) the Director, in making his determination
5 with respect to the merger, consolidation, or other
6 acquisition of control, need not take into account the
7 effect on competition of the merger, consolidation, or
8 other acquisition of control;
9 (3) the Director shall have the power to require the
10 following information:
11 (A) certification by an independent actuary of the
12 adequacy of the reserves of the Health Maintenance
13 Organization sought to be acquired;
14 (B) pro forma financial statements reflecting the
15 combined balance sheets of the acquiring company and
16 the Health Maintenance Organization sought to be
17 acquired as of the end of the preceding year and as of
18 a date 90 days prior to the acquisition, as well as pro
19 forma financial statements reflecting projected
20 combined operation for a period of 2 years;
21 (C) a pro forma business plan detailing an
22 acquiring party's plans with respect to the operation
23 of the Health Maintenance Organization sought to be
24 acquired for a period of not less than 3 years; and
25 (D) such other information as the Director shall
26 require.
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1 (d) The provisions of Article VIII 1/2 of the Illinois
2 Insurance Code and this Section 5-3 shall apply to the sale by
3 any health maintenance organization of greater than 10% of its
4 enrollee population (including, without limitation, the health
5 maintenance organization's right, title, and interest in and
6 to its health care certificates).
7 (e) In considering any management contract or service
8 agreement subject to Section 141.1 of the Illinois Insurance
9 Code, the Director (i) shall, in addition to the criteria
10 specified in Section 141.2 of the Illinois Insurance Code,
11 take into account the effect of the management contract or
12 service agreement on the continuation of benefits to enrollees
13 and the financial condition of the health maintenance
14 organization to be managed or serviced, and (ii) need not take
15 into account the effect of the management contract or service
16 agreement on competition.
17 (f) Except for small employer groups as defined in the
18 Small Employer Rating, Renewability and Portability Health
19 Insurance Act and except for medicare supplement policies as
20 defined in Section 363 of the Illinois Insurance Code, a
21 Health Maintenance Organization may by contract agree with a
22 group or other enrollment unit to effect refunds or charge
23 additional premiums under the following terms and conditions:
24 (i) the amount of, and other terms and conditions with
25 respect to, the refund or additional premium are set forth
26 in the group or enrollment unit contract agreed in advance
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1 of the period for which a refund is to be paid or
2 additional premium is to be charged (which period shall
3 not be less than one year); and
4 (ii) the amount of the refund or additional premium
5 shall not exceed 20% of the Health Maintenance
6 Organization's profitable or unprofitable experience with
7 respect to the group or other enrollment unit for the
8 period (and, for purposes of a refund or additional
9 premium, the profitable or unprofitable experience shall
10 be calculated taking into account a pro rata share of the
11 Health Maintenance Organization's administrative and
12 marketing expenses, but shall not include any refund to be
13 made or additional premium to be paid pursuant to this
14 subsection (f)). The Health Maintenance Organization and
15 the group or enrollment unit may agree that the profitable
16 or unprofitable experience may be calculated taking into
17 account the refund period and the immediately preceding 2
18 plan years.
19 The Health Maintenance Organization shall include a
20 statement in the evidence of coverage issued to each enrollee
21 describing the possibility of a refund or additional premium,
22 and upon request of any group or enrollment unit, provide to
23 the group or enrollment unit a description of the method used
24 to calculate (1) the Health Maintenance Organization's
25 profitable experience with respect to the group or enrollment
26 unit and the resulting refund to the group or enrollment unit
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1 or (2) the Health Maintenance Organization's unprofitable
2 experience with respect to the group or enrollment unit and
3 the resulting additional premium to be paid by the group or
4 enrollment unit.
5 In no event shall the Illinois Health Maintenance
6 Organization Guaranty Association be liable to pay any
7 contractual obligation of an insolvent organization to pay any
8 refund authorized under this Section.
9 (g) Rulemaking authority to implement Public Act 95-1045,
10 if any, is conditioned on the rules being adopted in
11 accordance with all provisions of the Illinois Administrative
12 Procedure Act and all rules and procedures of the Joint
13 Committee on Administrative Rules; any purported rule not so
14 adopted, for whatever reason, is unauthorized.
15 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
16 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
17 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
18 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
19 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
20 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
21 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
22 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
23 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
24 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
25 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
26 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
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1 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
2 103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
3 1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)
4 (Text of Section after amendment by P.A. 103-808)
5 Sec. 5-3. Insurance Code provisions.
6 (a) Health Maintenance Organizations shall be subject to
7 the provisions of Sections 133, 134, 136, 137, 139, 140,
8 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
9 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
10 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g,
11 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
12 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
13 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
14 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
15 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
16 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
17 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
18 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
19 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,
20 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
21 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75,
22 356z.77, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
23 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403,
24 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
25 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
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1 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
2 Illinois Insurance Code.
3 (b) For purposes of the Illinois Insurance Code, except
4 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
5 Health Maintenance Organizations in the following categories
6 are deemed to be "domestic companies":
7 (1) a corporation authorized under the Dental Service
8 Plan Act or the Voluntary Health Services Plans Act;
9 (2) a corporation organized under the laws of this
10 State; or
11 (3) a corporation organized under the laws of another
12 state, 30% or more of the enrollees of which are residents
13 of this State, except a corporation subject to
14 substantially the same requirements in its state of
15 organization as is a "domestic company" under Article VIII
16 1/2 of the Illinois Insurance Code.
17 (c) In considering the merger, consolidation, or other
18 acquisition of control of a Health Maintenance Organization
19 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
20 (1) the Director shall give primary consideration to
21 the continuation of benefits to enrollees and the
22 financial conditions of the acquired Health Maintenance
23 Organization after the merger, consolidation, or other
24 acquisition of control takes effect;
25 (2)(i) the criteria specified in subsection (1)(b) of
26 Section 131.8 of the Illinois Insurance Code shall not
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1 apply and (ii) the Director, in making his determination
2 with respect to the merger, consolidation, or other
3 acquisition of control, need not take into account the
4 effect on competition of the merger, consolidation, or
5 other acquisition of control;
6 (3) the Director shall have the power to require the
7 following information:
8 (A) certification by an independent actuary of the
9 adequacy of the reserves of the Health Maintenance
10 Organization sought to be acquired;
11 (B) pro forma financial statements reflecting the
12 combined balance sheets of the acquiring company and
13 the Health Maintenance Organization sought to be
14 acquired as of the end of the preceding year and as of
15 a date 90 days prior to the acquisition, as well as pro
16 forma financial statements reflecting projected
17 combined operation for a period of 2 years;
18 (C) a pro forma business plan detailing an
19 acquiring party's plans with respect to the operation
20 of the Health Maintenance Organization sought to be
21 acquired for a period of not less than 3 years; and
22 (D) such other information as the Director shall
23 require.
24 (d) The provisions of Article VIII 1/2 of the Illinois
25 Insurance Code and this Section 5-3 shall apply to the sale by
26 any health maintenance organization of greater than 10% of its
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1 enrollee population (including, without limitation, the health
2 maintenance organization's right, title, and interest in and
3 to its health care certificates).
4 (e) In considering any management contract or service
5 agreement subject to Section 141.1 of the Illinois Insurance
6 Code, the Director (i) shall, in addition to the criteria
7 specified in Section 141.2 of the Illinois Insurance Code,
8 take into account the effect of the management contract or
9 service agreement on the continuation of benefits to enrollees
10 and the financial condition of the health maintenance
11 organization to be managed or serviced, and (ii) need not take
12 into account the effect of the management contract or service
13 agreement on competition.
14 (f) Except for small employer groups as defined in the
15 Small Employer Rating, Renewability and Portability Health
16 Insurance Act and except for medicare supplement policies as
17 defined in Section 363 of the Illinois Insurance Code, a
18 Health Maintenance Organization may by contract agree with a
19 group or other enrollment unit to effect refunds or charge
20 additional premiums under the following terms and conditions:
21 (i) the amount of, and other terms and conditions with
22 respect to, the refund or additional premium are set forth
23 in the group or enrollment unit contract agreed in advance
24 of the period for which a refund is to be paid or
25 additional premium is to be charged (which period shall
26 not be less than one year); and
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1 (ii) the amount of the refund or additional premium
2 shall not exceed 20% of the Health Maintenance
3 Organization's profitable or unprofitable experience with
4 respect to the group or other enrollment unit for the
5 period (and, for purposes of a refund or additional
6 premium, the profitable or unprofitable experience shall
7 be calculated taking into account a pro rata share of the
8 Health Maintenance Organization's administrative and
9 marketing expenses, but shall not include any refund to be
10 made or additional premium to be paid pursuant to this
11 subsection (f)). The Health Maintenance Organization and
12 the group or enrollment unit may agree that the profitable
13 or unprofitable experience may be calculated taking into
14 account the refund period and the immediately preceding 2
15 plan years.
16 The Health Maintenance Organization shall include a
17 statement in the evidence of coverage issued to each enrollee
18 describing the possibility of a refund or additional premium,
19 and upon request of any group or enrollment unit, provide to
20 the group or enrollment unit a description of the method used
21 to calculate (1) the Health Maintenance Organization's
22 profitable experience with respect to the group or enrollment
23 unit and the resulting refund to the group or enrollment unit
24 or (2) the Health Maintenance Organization's unprofitable
25 experience with respect to the group or enrollment unit and
26 the resulting additional premium to be paid by the group or
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1 enrollment unit.
2 In no event shall the Illinois Health Maintenance
3 Organization Guaranty Association be liable to pay any
4 contractual obligation of an insolvent organization to pay any
5 refund authorized under this Section.
6 (g) Rulemaking authority to implement Public Act 95-1045,
7 if any, is conditioned on the rules being adopted in
8 accordance with all provisions of the Illinois Administrative
9 Procedure Act and all rules and procedures of the Joint
10 Committee on Administrative Rules; any purported rule not so
11 adopted, for whatever reason, is unauthorized.
12 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
13 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
14 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
15 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
16 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
17 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
18 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
19 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
20 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
21 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
22 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
23 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
24 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
25 103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
26 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised
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1 11-26-24.)
2 Section 30. The Prior Authorization Reform Act is amended
3 by changing Section 85 as follows:
4 (215 ILCS 200/85)
5 Sec. 85. Administration and enforcement.
6 (a) The Department shall enforce the provisions of this
7 Act pursuant to the enforcement powers granted to it by law. To
8 enforce the provisions of this Act, the Director is hereby
9 granted specific authority to issue a cease and desist order
10 or require a utilization review organization or health
11 insurance issuer to submit a plan of correction for violations
12 of this Act, or both, in accordance with the requirements and
13 authority set forth in Section 85 of the Managed Care Reform
14 and Patient Rights Act. Subject to the provisions of the
15 Illinois Administrative Procedure Act, the Director may,
16 pursuant to Section 403A of the Illinois Insurance Code,
17 impose upon a utilization review organization or health
18 insurance issuer an administrative fine not to exceed $250,000
19 for failure to submit a requested plan of correction, failure
20 to comply with its plan of correction, or repeated violations
21 of this Act.
22 (b) Any person who believes that his or her utilization
23 review organization or health insurance issuer is in violation
24 of the provisions of this Act may file a complaint with the
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1 Department. The Department shall review all complaints
2 received and investigate all complaints that it deems to state
3 a potential violation. The Department shall fairly,
4 efficiently, and timely review and investigate complaints.
5 Health insurance issuers and utilization review organizations
6 found to be in violation of this Act shall be penalized in
7 accordance with this Section.
8 (c) The Department of Healthcare and Family Services shall
9 enforce the provisions of this Act as it applies to persons
10 enrolled under Article V of the Illinois Public Aid Code or
11 under the Children's Health Insurance Program Act and shall
12 adopt rules consistent with this Act.
13 (Source: P.A. 102-409, eff. 1-1-22.)
14 Section 35. The Illinois Public Aid Code is amended by
15 adding Section 5-5.12g as follows:
16 (305 ILCS 5/5-5.12g new)
17 Sec. 5-5.12g. Behavioral health services; no utilization
18 or prior approval mandates.
19 (a) As used in this Section:
20 "Behavioral health service" means any service, including a
21 preventive service, intended to treat a mental, emotional,
22 nervous, or substance use disorder or condition across an
23 individual's entire life span.
24 "Mental, emotional, nervous, or substance use disorder or
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1 condition" has the meaning given to that term in Section
2 370c.1 of the Illinois Insurance Code.
3 (b) Notwithstanding any other provision of this Code to
4 the contrary, for the purpose of removing barriers to the
5 timely treatment of behavioral health conditions, including
6 both mental health and substance use disorders, beginning on
7 January 1, 2026, prior authorization, or any other utilization
8 management controls, shall be prohibited under the
9 fee-for-service and managed care medical assistance programs
10 on any behavioral health service.
11 (c) This Section shall not be construed to conflict with
12 any federal law, including, but not limited to, the federal
13 Social Security Act or any implementing regulations,
14 agreements, or decrees.
15 (d) The Department shall establish a process to accept
16 complaints from providers or individuals eligible for medical
17 assistance for any violations of this Section. The Department
18 shall review and investigate all complaints received. The
19 Department shall fairly, efficiently, and timely review and
20 investigate complaints. The Department shall adopt rules
21 related to enforcement of this Section and post information
22 about how providers can make complaints for violations of this
23 Section on the Department's publicly available website.
24 (e) The Department shall enforce the provisions of this
25 Section in accordance with the enforcement powers granted to
26 it by law. The Department is granted the specific authority to
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1 issue a cease and desist order for violations of this Section.
2 Subject to the provisions of the Illinois Administrative
3 Procedure Act, the Department may impose upon a managed care
4 organization an administrative fine not to exceed $250,000 for
5 failure to comply with the requirements of this Section or
6 repeated violations of this Section.
7 Section 95. No acceleration or delay. Where this Act makes
8 changes in a statute that is represented in this Act by text
9 that is not yet or no longer in effect (for example, a Section
10 represented by multiple versions), the use of that text does
11 not accelerate or delay the taking effect of (i) the changes
12 made by this Act or (ii) provisions derived from any other
13 Public Act.
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