104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2286 Introduced 2/7/2025, by Sen. Mike Simmons SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.62215 ILCS 200/78 new Amends the Prior Authorization Reform Act. Provides that, notwithstanding any other provision of law, a health insurance issuer or a contracted utilization review organization may not require prior authorization for preventive health services recommended by a health care professional. Amends the Illinois Insurance Code. Provides that a policy of group health insurance coverage or individual health insurance coverage shall, at a minimum, provide coverage and shall not require prior authorization or impose any cost-sharing requirements, including a copayment, coinsurance, or deductible, for specified preventive health services. Effective January 1, 2027. LRB104 10418 BAB 20493 b A BILL FOR 104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2286 Introduced 2/7/2025, by Sen. Mike Simmons SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.62215 ILCS 200/78 new 215 ILCS 5/356z.62 215 ILCS 200/78 new Amends the Prior Authorization Reform Act. Provides that, notwithstanding any other provision of law, a health insurance issuer or a contracted utilization review organization may not require prior authorization for preventive health services recommended by a health care professional. Amends the Illinois Insurance Code. Provides that a policy of group health insurance coverage or individual health insurance coverage shall, at a minimum, provide coverage and shall not require prior authorization or impose any cost-sharing requirements, including a copayment, coinsurance, or deductible, for specified preventive health services. Effective January 1, 2027. LRB104 10418 BAB 20493 b LRB104 10418 BAB 20493 b A BILL FOR
104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2286 Introduced 2/7/2025, by Sen. Mike Simmons SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.62215 ILCS 200/78 new 215 ILCS 5/356z.62 215 ILCS 200/78 new
215 ILCS 5/356z.62
215 ILCS 200/78 new
Amends the Prior Authorization Reform Act. Provides that, notwithstanding any other provision of law, a health insurance issuer or a contracted utilization review organization may not require prior authorization for preventive health services recommended by a health care professional. Amends the Illinois Insurance Code. Provides that a policy of group health insurance coverage or individual health insurance coverage shall, at a minimum, provide coverage and shall not require prior authorization or impose any cost-sharing requirements, including a copayment, coinsurance, or deductible, for specified preventive health services. Effective January 1, 2027.
LRB104 10418 BAB 20493 b LRB104 10418 BAB 20493 b
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A BILL FOR
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1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5 changing Section 356z.62 as follows:
6 (215 ILCS 5/356z.62)
7 Sec. 356z.62. Coverage of preventive health services.
8 (a) A policy of group health insurance coverage or
9 individual health insurance coverage as defined in Section 5
10 of the Illinois Health Insurance Portability and
11 Accountability Act shall, at a minimum, provide coverage for
12 and shall not require prior authorization or impose any
13 cost-sharing requirements, including a copayment, coinsurance,
14 or deductible, for:
15 (1) evidence-based items or services that have in
16 effect a rating of "A" or "B" in the current
17 recommendations of the United States Preventive Services
18 Task Force;
19 (2) immunizations that have in effect a recommendation
20 from the Advisory Committee on Immunization Practices of
21 the Centers for Disease Control and Prevention with
22 respect to the individual involved;
23 (3) with respect to infants, children, and
104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2286 Introduced 2/7/2025, by Sen. Mike Simmons SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.62215 ILCS 200/78 new 215 ILCS 5/356z.62 215 ILCS 200/78 new
215 ILCS 5/356z.62
215 ILCS 200/78 new
Amends the Prior Authorization Reform Act. Provides that, notwithstanding any other provision of law, a health insurance issuer or a contracted utilization review organization may not require prior authorization for preventive health services recommended by a health care professional. Amends the Illinois Insurance Code. Provides that a policy of group health insurance coverage or individual health insurance coverage shall, at a minimum, provide coverage and shall not require prior authorization or impose any cost-sharing requirements, including a copayment, coinsurance, or deductible, for specified preventive health services. Effective January 1, 2027.
LRB104 10418 BAB 20493 b LRB104 10418 BAB 20493 b
LRB104 10418 BAB 20493 b
A BILL FOR
215 ILCS 5/356z.62
215 ILCS 200/78 new
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1 adolescents, evidence-informed preventive care and
2 screenings provided for in the comprehensive guidelines
3 supported by the Health Resources and Services
4 Administration; and
5 (4) with respect to women, such additional preventive
6 care and screenings not described in paragraph (1) of this
7 subsection (a) as provided for in comprehensive guidelines
8 supported by the Health Resources and Services
9 Administration for purposes of this paragraph.
10 (b) For purposes of this Section, and for purposes of any
11 other provision of State law, recommendations of the United
12 States Preventive Services Task Force regarding breast cancer
13 screening, mammography, and prevention issued in or around
14 November 2009 are not considered to be current.
15 (c) For office visits:
16 (1) if an item or service described in subsection (a)
17 is billed separately or is tracked as individual encounter
18 data separately from an office visit, then a policy may
19 impose cost-sharing requirements with respect to the
20 office visit;
21 (2) if an item or service described in subsection (a)
22 is not billed separately or is not tracked as individual
23 encounter data separately from an office visit and the
24 primary purpose of the office visit is the delivery of
25 such an item or service, then a policy may not impose
26 cost-sharing requirements with respect to the office
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1 visit; and
2 (3) if an item or service described in subsection (a)
3 is not billed separately or is not tracked as individual
4 encounter data separately from an office visit and the
5 primary purpose of the office visit is not the delivery of
6 such an item or service, then a policy may impose
7 cost-sharing requirements with respect to the office
8 visit.
9 (d) A policy must provide coverage pursuant to subsection
10 (a) for plan or policy years that begin on or after the date
11 that is one year after the date the recommendation or
12 guideline is issued. If a recommendation or guideline is in
13 effect on the first day of the plan or policy year, the policy
14 shall cover the items and services specified in the
15 recommendation or guideline through the last day of the plan
16 or policy year unless either:
17 (1) a recommendation under paragraph (1) of subsection
18 (a) is downgraded to a "D" rating; or
19 (2) the item or service is subject to a safety recall
20 or is otherwise determined to pose a significant safety
21 concern by a federal agency authorized to regulate the
22 item or service during the plan or policy year.
23 (e) Network limitations.
24 (1) Subject to paragraph (3) of this subsection,
25 nothing in this Section requires coverage for items or
26 services described in subsection (a) that are delivered by
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1 an out-of-network provider under a health maintenance
2 organization health care plan, other than a
3 point-of-service contract, or under a voluntary health
4 services plan that generally excludes coverage for
5 out-of-network services except as otherwise required by
6 law.
7 (2) Subject to paragraph (3) of this subsection,
8 nothing in this Section precludes a policy with a
9 preferred provider program under Article XX-1/2 of this
10 Code, a health maintenance organization point-of-service
11 contract, or a similarly designed voluntary health
12 services plan from imposing cost-sharing requirements for
13 items or services described in subsection (a) that are
14 delivered by an out-of-network provider.
15 (3) If a policy does not have in its network a provider
16 who can provide an item or service described in subsection
17 (a), then the policy must cover the item or service when
18 performed by an out-of-network provider and it may not
19 impose cost-sharing with respect to the item or service.
20 (f) Nothing in this Section prevents a company from using
21 reasonable medical management techniques to determine the
22 frequency, method, treatment, or setting for an item or
23 service described in subsection (a) to the extent not
24 specified in the recommendation or guideline.
25 (g) Nothing in this Section shall be construed to prohibit
26 a policy from providing coverage for items or services in
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1 addition to those required under subsection (a) or from
2 denying coverage for items or services that are not required
3 under subsection (a). Unless prohibited by other law, a policy
4 may impose cost-sharing requirements for a treatment not
5 described in subsection (a) even if the treatment results from
6 an item or service described in subsection (a). Nothing in
7 this Section shall be construed to limit coverage requirements
8 provided under other law.
9 (h) The Director may develop guidelines to permit a
10 company to utilize value-based insurance designs. In the
11 absence of guidelines developed by the Director, any such
12 guidelines developed by the Secretary of the U.S. Department
13 of Health and Human Services that are in force under 42 U.S.C.
14 300gg-13 shall apply.
15 (i) For student health insurance coverage as defined at 45
16 CFR 147.145, student administrative health fees are not
17 considered cost-sharing requirements with respect to
18 preventive services specified under subsection (a). As used in
19 this subsection, "student administrative health fee" means a
20 fee charged by an institution of higher education on a
21 periodic basis to its students to offset the cost of providing
22 health care through health clinics regardless of whether the
23 students utilize the health clinics or enroll in student
24 health insurance coverage.
25 (j) For any recommendation or guideline specifically
26 referring to women or men, a company shall not deny or limit
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1 the coverage required or a claim made under subsection (a)
2 based solely on the individual's recorded sex or actual or
3 perceived gender identity, or for the reason that the
4 individual is gender nonconforming, intersex, transgender, or
5 has undergone, or is in the process of undergoing, gender
6 transition, if, notwithstanding the sex or gender assigned at
7 birth, the covered individual meets the conditions for the
8 recommendation or guideline at the time the item or service is
9 furnished.
10 (k) This Section does not apply to grandfathered health
11 plans, excepted benefits, or short-term, limited-duration
12 health insurance coverage.
13 (Source: P.A. 103-551, eff. 8-11-23.)
14 Section 10. The Prior Authorization Reform Act is amended
15 by adding Section 78 as follows:
16 (215 ILCS 200/78 new)
17 Sec. 78. Prior authorization for preventive care
18 recommended by a physician. Notwithstanding any other
19 provision of law, a health insurance issuer or a contracted
20 utilization review organization may not require prior
21 authorization for preventive health services recommended by a
22 health care professional, as defined in Section 10 of the
23 Managed Care Reform and Patient Rights Act.
24 Section 99. Effective date. This Act takes effect January
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