STANDARDIZED PRIOR AUTH ACT

Illinois General Assembly - Full Text of HB4709

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104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB4709

Introduced , by Rep. Rita Mayfield

SYNOPSIS AS INTRODUCED:

New Act
215 ILCS 5/356z.66
215 ILCS 5/370c

from Ch. 73, par. 982c
215 ILCS 124/10
305 ILCS 5/5-5.12e
215 ILCS 200/Act rep.

Creates the Standardized Prior Authorization Act. Requires a health
insurance issuer to maintain a complete list of services for which prior
authorization is required and to make any current prior authorization
requirements and restrictions readily accessible and conspicuously posted
on its website or online portals to enrollees, health care professionals,
and health care providers. Sets forth further provisions concerning
disclosure and review of prior authorization requirements; standard prior
authorizations; expedited prior authorizations; notifications of adverse
determinations; appeals of adverse determinations; prohibitions on
revocation of prior authorization and nonpayment by a health insurance
issuer; the length of approvals; approvals for chronic conditions;
continuity of prior approvals; and enforcement and administration of the
Act. Requires a health insurance issuer to periodically review its prior
authorization requirements and consider removal of prior authorization
requirements. Provides that a failure by a health insurance issuer to
comply with the deadlines and other requirements specified in the Act
shall result in any health care services subject to review to be
automatically deemed authorized by the health insurance issuer or its
contracted private review agent. Establishes reporting and notification
requirements for health insurance issuers. Grants rulemaking authority to
the Department of Insurance. Repeals the Prior Authorization Reform Act.
Amends the Illinois Insurance Code and the Illinois Public Aid Code to make
conforming changes. Effective January 1, 2027.
LRB104 17431 BAB 30856 b

A BILL FOR

HB4709
LRB104 17431 BAB 30856 b
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 1.
Short title.
This Act may be cited as the
5
Standardized Prior Authorization Act.

6

Section 5.
Purpose.
The purpose of this Act is to regulate
7
prior authorization by:
8

(1) protecting the health care professional-patient
9

relationship from unreasonable third-party interference;
10

(2) preventing prior authorization programs from
11

hindering the independent medical judgment of a physician
12

or other health care provider; and
13

(3) ensuring the transparency of a fair and consistent
14

process for health care providers and their patients.

15

Section 10.
Applicability and scope.
This Act applies to
16
health insurance coverage as defined in the Illinois Health
17
Insurance Portability and Accountability Act, and policies
18
issued or delivered in this State to the Department of
19
Healthcare and Family Services and providing coverage to
20
persons who are enrolled under Article V of the Illinois
21
Public Aid Code or under the Children's Health Insurance
22
Program Act, amended, delivered, issued, or renewed on or

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LRB104 17431 BAB 30856 b
1
after the effective date of this Act, except employee or
2
employer self-insured health benefit plans under the federal
3
Employee Retirement Income Security Act of 1974 or health care
4
provided pursuant to the Workers' Compensation Act or the
5
Workers' Occupational Diseases Act. This Act does not diminish
6
a health care plan's duties and responsibilities under other
7
federal or State law or rules adopted pursuant to those laws.
8
This Act is not intended to alter or impede the provisions of
9
any consent decree or judicial order to which the State or any
10
of its agencies is a party.

11

Section 15.
Definitions.
In this Act, unless the context
12
requires otherwise:
13

"Adverse determination" means a determination by a health
14
insurance issuer that, based on the information provided, a
15
pre-service request for a benefit under the health insurance
16
issuer's health benefit plan upon application of any
17
utilization review technique does not meet the health
18
insurance issuer's requirements for medical necessity,
19
appropriateness, health care setting, level of care, or
20
effectiveness or is determined to be experimental or
21
investigational and the requested benefit is therefore denied.
22

"Appeal" means a formal request, either orally or in
23
writing, to reconsider an adverse determination.
24

"Approval" means a determination by a health insurance
25
issuer that a health care service has been reviewed and, based

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1
on the information provided, satisfies the health insurance
2
issuer's requirements for medical necessity and
3
appropriateness.
4

"Clinical review criteria" means the written screening
5
procedures, decision abstracts, clinical protocols, and
6
practice guidelines used by a health insurance issuer to
7
determine the necessity and appropriateness of health care
8
services.
9

"Department" means the Department of Insurance.
10

"Emergency medical condition" means a medical condition
11
manifesting itself through acute symptoms of sufficient
12
severity, including, but not limited to, severe pain, such
13
that a prudent layperson who possesses an average knowledge of
14
health and medicine could reasonably expect the absence of
15
immediate medical attention to result in:
16

(1) placing the health of the individual or, with
17

respect to a pregnant woman, the health of the woman or her
18

unborn child in serious jeopardy;
19

(2) serious impairment to bodily functions; or
20

(3) serious dysfunction of any bodily organ or part.
21

"Emergency services" means health care items and services
22
furnished or required to evaluate and treat an emergency
23
medical condition.
24

"Enrollee" means any person and the person's dependents
25
enrolled in or covered by a health care plan.
26

"Expedited prior authorization request" means a request

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for prior authorization of a health care service when, in the
2
opinion of a treating health care professional or health care
3
provider with knowledge of the enrollee's medical condition,
4
nonexpedited prior authorization:
5

(1) could seriously jeopardize the life or health of
6

the enrollee or the ability of the enrollee to regain
7

maximum function;
8

(2) could subject the enrollee to severe pain that
9

cannot be adequately managed without the care or treatment
10

that is the subject of the utilization review; or
11

(3) could lead to a likely onset of an emergency
12

medical condition if the service is not rendered during
13

the time period to render a prior authorization
14

determination for an urgent medical service.
15

"Expedited prior authorization request" does not include
16
emergency services.
17

"Health care professional" means a physician licensed to
18
practice medicine under the Medical Practice Act of 1987, a
19
nurse licensed under the Nurse Practice Act, a physician
20
assistant licensed under the Physician Assistant Practice Act
21
of 1987, or any other individual that is licensed or otherwise
22
authorized to deliver health care services.
23

"Health care provider" means any physician, hospital,
24
ambulatory surgical treatment center, or other person or
25
facility that is licensed or otherwise authorized to deliver
26
health care services.

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"Health care service" means any service or level of
2
service included in the furnishing to an individual of medical
3
care or the hospitalization incident to the furnishing of such
4
care, as well as the furnishing to any person of any other
5
services for the purpose of preventing, diagnosing, screening
6
for, alleviating, curing, or healing human illness or injury,
7
including behavioral health, mental health, home health and
8
pharmaceutical services, products, and medications.
9

"Health insurance issuer" has the meaning given to that
10
term in Section 5 of the Illinois Health Insurance Portability
11
and Accountability Act.
12

"Medically necessary" means when a health care
13
professional exercising prudent clinical judgment would
14
provide care to a patient for the purpose of preventing,
15
diagnosing, or treating an illness, injury, or a disease or
16
its symptoms that are:
17

(1) in accordance with generally accepted standards of
18

medical practice; and
19

(2) clinically appropriate in terms of type,
20

frequency, extent, site, and duration and are considered
21

effective for the patient's illness, injury, or disease;
22

and not primarily for the convenience of the patient,
23

treating physician, other health care professional,
24

caregiver, family member, or other interested party, and
25

focused on what is best for the patient's health outcome.
26

"NCPDP SCRIPT Standard" means the National Council for

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LRB104 17431 BAB 30856 b
1
Prescription Drug Programs SCRIPT Standard Version 2017071 or
2
the most recent Standard adopted by the United States
3
Department of Health and Human Services. "NCPDP SCRIPT
4
Standard" includes subsequently released versions of the NCPDP
5
SCRIPT Standard.
6

"Physician" means any person licensed by the State of
7
Illinois to practice medicine in all its branches. "Physician"
8
includes any person holding a temporary license, as provided
9
in the Medical Practice Act of 1987.
10

"Prior authorization" means the process by which a health
11
insurance issuer determines the medical necessity and medical
12
appropriateness of an otherwise covered health care service
13
before rendering the health care service. "Prior
14
authorization" includes any notification required of an
15
enrollee, health care professional, or health care provider by
16
the health insurance issuer before, at the time of, or
17
concurrent with providing a health care service, regardless of
18
whether explicit approval is requested by the health insurance
19
issuer.
20

"Private review agent" means a third-party entity hired by
21
a health insurance issuer to perform utilization review.
22

"Utilization review" means to assess the medical
23
necessity, appropriateness, and cost-effectiveness of health
24
care services for prior authorization, concurrent review, or
25
retrospective auditing.

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LRB104 17431 BAB 30856 b
1

Section 20.
Disclosure and review of prior authorization
2
requirements.
3

(a) A health insurance issuer shall maintain a complete
4
list of services for which prior authorization is required,
5
including for all services where prior authorization is
6
performed by an entity under contract with the health
7
insurance issuer.
8

(b) A health insurance issuer shall make any current prior
9
authorization requirements and restrictions, including written
10
clinical review criteria, readily accessible and conspicuously
11
posted on its website or online portals to enrollees, health
12
care professionals, and health care providers. Content
13
published by a third party and licensed for use by a health
14
insurance issuer may be made available through the health
15
insurance issuer's secure, password-protected website or
16
online portals, so long as the access requirements of the
17
website do not unreasonably restrict access. Requirements
18
shall be described in detail, written in easily understandable
19
language, and readily available to the health care
20
professional and health care provider at the point of care.
21
The website shall indicate for each service subject to prior
22
authorization:
23

(1) when prior authorization became required for
24

policies issued or health benefit plan documents delivered
25

in Illinois, including the effective date or dates and the
26

termination date or dates, if applicable, in Illinois;

HB4709
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LRB104 17431 BAB 30856 b
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(2) the date the Illinois-specific requirement was
2

listed on the health insurance issuer's, health benefit
3

plan's, or private review agent's website; and
4

(3) when applicable, access to a standardized
5

electronic prior authorization request transaction
6

process.
7

(c) The clinical review criteria must:
8

(1) be consistent with nationally accepted standards
9

generally recognized by physicians and health care
10

providers practicing in relevant medical and clinical
11

specialties except where state law provides its own
12

standard;
13

(2) be developed in accordance with the current
14

standards of a national medical accreditation entity;
15

(3) ensure quality of care and access to needed health
16

care services;
17

(4) use evidence based on sources, such as
18

peer-reviewed scientific studies;
19

(5) be sufficiently flexible to allow deviations from
20

norms when justified on a case-by-case basis; and
21

(6) be evaluated and updated, if necessary, at least
22

annually.
23

(d) A health insurance issuer shall not deny a claim for
24
failure to obtain prior authorization if the prior
25
authorization requirement was not in effect on the date of
26
service on the claim or if prior authorization requirements

HB4709
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LRB104 17431 BAB 30856 b
1
were not publicly disclosed by the plan on the health
2
insurance issuer's website or other materials.
3

(e) A health insurance issuer shall not deem as incidental
4
or deny supplies or health care services that are routinely
5
used as part of a health care service when:
6

(1) an associated health care service has received
7

prior authorization; or
8

(2) prior authorization for the health care service is
9

not required.
10

(f) If a health insurance issuer intends either to
11
implement a new prior authorization requirement or restriction
12
or amend an existing requirement or restriction, the health
13
insurance issuer shall provide impacted enrollees, contracted
14
health care professionals, and contracted health care
15
providers of enrollees written notice of the new or amended
16
requirement or amendment no less than 60 days before the
17
requirement or restriction is implemented. Written notice may
18
take the form of a conspicuous notice posted on the health
19
insurance issuer's public website or portal for contracted
20
health care professionals and contracted health care
21
providers, or email notice to health care professionals or
22
providers. A health insurance issuer shall provide email
23
notices to all impacted enrollees and to health care
24
professionals or health care providers if the health care
25
professional or health care provider has requested to receive
26
the notice through email. A new or amended requirement shall

HB4709
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LRB104 17431 BAB 30856 b
1
not be implemented unless the health insurance issuer's
2
website has been updated to reflect the new or amended
3
requirement or restriction. Written notice of a new, amended,
4
or restricted prior authorization requirement, as required by
5
this subsection (f), may be provided less than 60 days in
6
advance if a health insurance issuer determines and
7
contemporaneously notifies the Department in writing that:
8

(1) the health insurance issuer has identified
9

fraudulent or abusive practices related to the health care
10

service;
11

(2) the health care service is unavailable or scarce,
12

which necessitates the use of an alternative health care
13

service;
14

(3) the health care service is newly introduced to the
15

health care market, and a delay in providing coverage for
16

the health care service would not be in the best interest
17

of enrollees;
18

(4) the health care service is the subject of a
19

clinical trial authorized by the United States Food and
20

Drug Administration;
21

(5) changes to the health care service or its
22

availability are otherwise required by law to be made by
23

the health insurance issuer in less than 60 days; or
24

(6) the prior authorization requirement is being
25

removed.
26

(g) Health insurance issuers using prior authorization

HB4709
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LRB104 17431 BAB 30856 b
1
shall make statistics available regarding prior authorization
2
approvals and denials on the health insurance issuer's website
3
in a readily accessible format. Following each calendar year,
4
the statistics must be updated annually by June 1 and include
5
all of the following information:
6

(1) a list of all health care services, including
7

medications, that are subject to prior authorization;
8

(2) the percentage of standard prior authorization
9

requests that were approved, aggregated for all items and
10

services;
11

(3) the percentage of standard prior authorization
12

requests that were denied, aggregated for all items and
13

services;
14

(4) the percentage of prior authorization requests
15

that were approved, aggregated for all items and services;
16

(5) the percentage of prior authorization requests for
17

which the time frame for review was extended, and the
18

request was approved, aggregated for all items and
19

services;
20

(6) the percentage of expedited prior authorization
21

requests that were approved, aggregated for all items and
22

services;
23

(7) the percentage of expedited authorization requests
24

that were denied, aggregated for all items and services;
25

(8) the average and median time that elapsed between
26

the submission of a request and a determination by the

HB4709
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LRB104 17431 BAB 30856 b
1

payer, plan, or health insurance issuer for standard prior
2

authorization, aggregated for all items and services; and
3

(9) the average and median time that elapsed between
4

the submission of a request and a decision by the payer,
5

plan, or health insurance issuer for expedited prior
6

authorization, aggregated for all times and services.
7

(h) In the case of a prior authorization request for a
8
clinical laboratory test, a health insurance issuer must
9
accept a prior authorization request prior to the date of
10
specimen collection or at any time between the date of
11
specimen collection and the date on which a timely claim for
12
reimbursement is submitted to the health insurance issuer.
13

(i) A health insurance issuer may request from a provider
14
or supplier only medical or other documentation that is
15
reasonably necessary to evaluate a prior authorization
16
request.

17

Section 25.
Standardized electronic prior authorization
18
request transaction process.
19

(a) On and after January 1, 2028, and until December 31,
20
2028, if any health insurance issuer requires prior
21
authorization of a health care service, the health insurance
22
issuer's or its designee's utilization review organization
23
shall make available a standardized electronic prior
24
authorization request transaction process using an Internet
25
webpage, Internet webpage portal, or similar Internet-based

HB4709
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LRB104 17431 BAB 30856 b
1
system. On and after January 1, 2029, a health insurance
2
issuer must accept and respond to prior authorization requests
3
under the pharmacy benefit through a secure electronic
4
transmission using NCPDP SCRIPT Standard ePA transactions.
5

(b) On and after January 1, 2029, all health care
6
professionals and health care providers shall be required to
7
use the standardized electronic prior authorization request
8
transaction process made available as required by subsection
9
(a).

10

Section 30.
Standard prior authorizations.
11

(a) As used in this Section, "necessary information"
12
includes the results of any face-to-face clinical evaluation,
13
second opinion, or other clinical information that is directly
14
applicable to the requested service that may be required.
15

(b) If a health insurance issuer requires prior
16
authorization of a health care service, the health insurance
17
issuer must make an approval or adverse determination and
18
notify the enrollee and the enrollee's health care
19
professional or provider of the approval or adverse
20
determination as expeditiously as the enrollee's condition
21
requires but no later than 5 calendar days after obtaining all
22
necessary information to make the approval or adverse
23
determination, unless a longer minimum time frame is required
24
under federal law for the health insurance issuer and the
25
health care service at issue.

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LRB104 17431 BAB 30856 b
1

(c) Notwithstanding any other provision of this Section,
2
health insurance issuers must comply with the requirements of
3
the Illinois Insurance Code that apply to prior authorization
4
requirements for pharmaceutical services.

5

Section 35.
Expedited prior authorizations.
6

(a) If requested by a treating health care provider or
7
health care professional for an enrollee, a health insurance
8
issuer must render an approval or adverse determination
9
concerning urgent health care services and notify the enrollee
10
and the enrollee's health care professional or provider of
11
that approval or adverse determination as expeditiously as the
12
enrollee's condition requires but no later than 24 hours after
13
receiving all information needed to complete the review of the
14
requested health care services, unless a longer minimum time
15
frame is required under federal law for the health insurance
16
issuer and the urgent health care service at issue.
17

(b) To facilitate the rendering of a prior authorization
18
determination in conformance with this Section, a health
19
insurance issuer must establish a mechanism to ensure health
20
care professionals have access to appropriately trained and
21
licensed physicians of the same specialty for consultation who
22
are designated by the plan to make such determinations for
23
prior authorization concerning urgent care services.

24

Section 40.
Notifications of adverse determinations;

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1
appeals.
If a health insurance issuer makes an adverse
2
determination, the health insurance issuer shall include the
3
following in the notification to the enrollee and the
4
enrollee's health care professional or health care provider:
5

(1) the reasons for the adverse determination and
6

related evidence-based criteria, including a description
7

of any missing or insufficient documentation;
8

(2) the right to appeal the adverse determination;
9

(3) instructions on how to file the appeal; and
10

(4) additional documentation necessary to support the
11

appeal.

12

Section 45.
Personnel qualified to review appeals.
A
13
health insurance issuer must ensure that all appeals are
14
reviewed by a physician when the request is by a physician or a
15
representative of a physician. The physician must:
16

(1) possess a current and valid unrestricted license
17

to practice medicine with substantially similar licensing
18

requirements to this State;
19

(2) be certified by the boards of the American Board
20

of Medical Specialties or the American Board of Osteopathy
21

within the relevant specialty of a physician who typically
22

manages the medical condition or disease;
23

(3) have training, knowledge, or experience of
24

providing the health care services under appeal;
25

(4) not have been directly involved in making the

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LRB104 17431 BAB 30856 b
1

adverse determination; and
2

(5) consider all known clinical aspects of the health
3

care service under review, including a review of all
4

pertinent medical records provided to the health insurance
5

issuer by the enrollee's health care professional or
6

health care provider, the health plan's clinical
7

guidelines, as well as peer-reviewed scientific studies.

8

Section 50.
Health insurance issuer review of prior
9
authorization requirements.
A health insurance issuer shall
10
periodically review its prior authorization requirements and
11
consider removal of prior authorization requirements.

12

Section 55.
Revocation of prior authorizations.
13

(a) A health insurance issuer may not revoke or further
14
limit, condition, or restrict a previously issued prior
15
authorization approval while it remains valid under this Act
16
unless:
17

(1) the health insurance issuer has identified
18

fraudulent or abusive practices related to the health care
19

service;
20

(2) the health care service is unavailable, which
21

necessitates the use of an alternative health care
22

service;
23

(3) the health care service is the subject of a new
24

safety alert from the United States Food and Drug

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1

Administration or is in response to a public health
2

emergency;
3

(4) the change is based on nationally recognized,
4

generally accepted standards developed in accordance with
5

current standards of a national medical accreditation
6

entity or specialty society; or
7

(5) changes to the health care service or its
8

availability are otherwise required by law to be made by
9

the health insurance issuer in less than 60 days.
10

(b) Notwithstanding any other provision of law, if a claim
11
is properly coded and submitted timely to a health insurance
12
issuer, the health insurance issuer shall make payment
13
according to the terms of coverage on claims for health care
14
services for which prior authorization was required and
15
approval received before the rendering of health care
16
services, unless one of the following occurs:
17

(1) it is determined that the enrollee's health care
18

professional or health care provider knowingly and without
19

exercising prudent clinical judgment provided health care
20

services that required prior authorization from the health
21

insurance issuer or its contracted private review agent
22

without first obtaining prior authorization for those
23

health care services;
24

(2) it is timely determined that the health care
25

services claimed were not performed;
26

(3) it is timely determined that the health care

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LRB104 17431 BAB 30856 b
1

services rendered were contrary to the instructions of the
2

health insurance issuer or its contracted private review
3

agent or delegated reviewer if contact was made between
4

those parties before the service being rendered;
5

(4) it is timely determined that the enrollee
6

receiving such health care services was not an enrollee of
7

the health care plan; or
8

(5) the approval was based upon a material
9

misrepresentation by the enrollee, health care
10

professional, or health care provider; as used in this
11

paragraph, "material" means a fact or situation that would
12

have resulted in a substantial change in the determination
13

had it accurately been disclosed in the submission.
14

(c) Nothing in this Section shall preclude a private
15
review agent or a health insurance issuer from performing
16
post-service reviews of health care claims for purposes of
17
payment integrity or for the prevention of fraud, waste, or
18
abuse.

19

Section 60.
Length of approvals.
20

(a) A prior authorization approval shall be valid for the
21
lesser of 12 months after the date the health care
22
professional or health care provider receives the prior
23
authorization approval or the length of the treatment as
24
determined by the patient's health care professional. However,
25
a health insurance issuer and an enrollee or the enrollee's

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health care professional may extend a prior authorization
2
approval for a longer period, by agreement. All dosage
3
increases must be based on established evidentiary standards,
4
and nothing in this Section shall prohibit a health insurance
5
issuer from having safety edits in place. This Section shall
6
not apply to the prescription of benzodiazepines or Schedule
7
II narcotic drugs, such as opioids.
8

(b) Nothing in this Section shall require a policy or plan
9
to cover any care, treatment, or services for any health
10
condition that the terms of coverage otherwise completely
11
exclude from the policy's or plan's covered benefits without
12
regard for whether the care, treatment, or services are
13
medically necessary.

14

Section 65.
Approvals for chronic conditions.
15

(a) If a health insurance issuer requires a prior
16
authorization for a recurring health care service or
17
maintenance medication for the treatment of a chronic or
18
long-term condition, including, but not limited to,
19
chemotherapy for the treatment of cancer, the approval shall
20
remain valid for the lesser of 12 months from the date the
21
health care professional or health care provider receives the
22
prior authorization approval or the length of the treatment as
23
determined by the patient's health care professional. However,
24
a health insurance issuer and an enrollee or the enrollee's
25
health care professional may extend a prior authorization

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approval for a longer period, by agreement. This Section shall
2
not apply to the prescription of benzodiazepines or Schedule
3
II narcotic drugs, such as opioids.
4

(b) Nothing in this Section shall require a policy or plan
5
to cover any care, treatment, or services for any health
6
condition that the terms of the coverage otherwise completely
7
exclude from the policy's or plan's covered benefits without
8
regard for whether the care, treatment, or services are
9
medically necessary.

10

Section 70.
Continuity of prior approvals.
11

(a) On receipt of information documenting a prior
12
authorization approval from the enrollee or from the
13
enrollee's health care professional or health care provider, a
14
health insurance issuer shall honor a prior authorization
15
granted to an enrollee from a previous health insurance issuer
16
for at least the initial 90 days of an enrollee's coverage
17
under a new health plan, subject to the terms of the member's
18
coverage agreement.
19

(b) During the time period described in subsection (a), a
20
health insurance issuer may perform its own review to grant a
21
prior authorization approval subject to the terms of the
22
member's coverage agreement.
23

(c) If there is a change in coverage of or approval
24
criteria for a previously authorized health care service, the
25
change in coverage or approval criteria does not affect an

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enrollee who received prior authorization approval before the
2
effective date of the change for the remainder of the
3
enrollee's plan year.
4

(d) Except to the extent required by medical exceptions
5
processes for prescription drugs, nothing in this Section
6
shall require a policy or plan to cover any care, treatment, or
7
services for any health condition that the terms of coverage
8
otherwise completely exclude from the policy's or plan's
9
covered benefits without regard for whether the care,
10
treatment, or services are medically necessary.

11

Section 75.
Effect of health insurance issuer's failure to
12
comply.
A failure by a health insurance issuer to comply with
13
the deadlines and other requirements specified in this Act
14
shall result in any health care services subject to review to
15
be automatically deemed authorized by the health insurance
16
issuer or its contracted private review agent.

17

Section 80.
Enforcement and administration.
18

(a) In addition to the enforcement powers granted to it by
19
law to enforce the provisions of this Act, the Department is
20
granted specific authority to issue a cease and desist order
21
or require a private review agent or health insurance issuer
22
to submit a plan of correction for violations of this Act, or
23
both. Subject to rules adopted by the Department under the
24
provisions of the Illinois Administrative Procedure Act, and

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after proper notice and opportunity for a hearing, the
2
Department may impose upon a private review agent, health
3
benefit plan, or health insurance issuer an administrative
4
fine not to exceed $2,000 per violation for failure to submit a
5
requested plan of correction, failure to comply with its plan
6
of correction, or repeated violations of this Act. All fines
7
collected by the Department under this Section shall be
8
deposited into the General Revenue Fund.
9

(b) Any person or the person's treating physician who has
10
evidence that the person's health insurance issuer or health
11
benefit plan is in violation of the provisions of this Act may
12
file a complaint with the Department. The Department shall
13
review all complaints received and investigate all complaints
14
that it deems to state a potential violation. The Department
15
shall fairly, efficiently, and timely review and investigate
16
complaints. Health insurance issuers, health benefit plans,
17
and private review agents found to be in violation of this Act
18
shall be penalized in accordance with this Section.
19

(c) Nothing in this Act may be construed to create a
20
private right of action.

21

Section 85.
Reports to the Department.
22

(a) By June 1, 2028 and each June 1 thereafter, a health
23
insurance issuer shall report to the Department, on a form
24
issued by the Department, the following aggregated trend data,
25
de-identified of protected health information, related to the

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health insurance issuer's practices and experience for the
2
prior plan year for health care services submitted for
3
payment:
4

(1) the number of prior authorization requests;
5

(2) the percentage of prior authorization requests
6

denied;
7

(3) the percentage of prior authorization appeals
8

received;
9

(4) the percentage of adverse determinations reversed
10

on appeal;
11

(5) the percentage of prior authorization requests
12

that were not submitted electronically;
13

(6) as a percentage of service, the 10 health care
14

services that were most frequently denied through prior
15

authorization; and
16

(7) the 5 reasons prior authorization requests were
17

most frequently denied.
18

(b) All reports required by this Section shall be
19
considered public records, and the Department shall make the
20
reports freely available upon request and post all reports to
21
its public website without redactions.

22

Section 90.
False requests for prior authorization.
If a
23
health insurance issuer has clear and convincing evidence that
24
a health care professional or health care provider has
25
knowingly and willfully submitted false or fraudulent requests

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for prior authorization to the health insurance issuer, the
2
issuer shall notify and provide that information to the
3
Department of Insurance. After receiving such information, the
4
Department of Insurance shall forward these reports to the
5
Department of Financial and Professional Regulation and the
6
Illinois Attorney General.

7

Section 95.
Rulemaking.
The Department shall adopt rules
8
necessary to implement and administer this Act.

9

Section 900.
The Illinois Insurance Code is amended by
10
changing Sections 356z.66 and 370c as follows:

11

(215 ILCS 5/356z.66)
12

Sec. 356z.66.
Proton beam therapy.
13

(a) As used in this Section:
14

"Medically necessary" has the meaning given to that term
15
in the
Standardized Prior Authorization Act

Prior
16
Authorization Reform Act
.
17

"Proton beam therapy" means a type of radiation therapy
18
treatment that utilizes protons as the radiation delivery
19
method for the treatment of tumors and cancerous cells.
20

"Radiation therapy treatment" means the delivery of
21
biological effective doses with proton therapy, intensity
22
modulated radiation therapy, brachytherapy, stereotactic body
23
radiation therapy, three-dimensional conformal radiation

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1
therapy, or other forms of therapy using radiation.
2

(b) A group or individual policy of accident and health
3
insurance or managed care plan that is amended, delivered,
4
issued, or renewed on or after January 1, 2025 that provides
5
coverage for the treatment of cancer shall not apply a higher
6
standard of clinical evidence for the coverage of proton beam
7
therapy than the insurer applies for the coverage of any other
8
form of radiation therapy treatment.
9

(c) A group or individual policy of accident and health
10
insurance or managed care plan that is amended, delivered,
11
issued, or renewed on or after January 1, 2025 that provides
12
coverage or benefits to any resident of this State for
13
radiation oncology shall include coverage or benefits for
14
medically necessary proton beam therapy for the treatment of
15
cancer.
16
(Source: P.A. 103-325, eff. 1-1-24; 103-605, eff. 7-1-24.)

17

(215 ILCS 5/370c)

(from Ch. 73, par. 982c)
18

Sec. 370c.
Mental and emotional disorders.
19

(a)(1) On and after January 1, 2022 (the effective date of
20
Public Act 102-579), every insurer that amends, delivers,
21
issues, or renews group accident and health policies providing
22
coverage for hospital or medical treatment or services for
23
illness shall provide coverage for the medically necessary
24
treatment of mental, emotional, nervous, or substance use
25
disorders or conditions consistent with the parity

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1
requirements of Section 370c.1 of this Code.
2

(2) Each insured that is covered for mental, emotional,
3
nervous, or substance use disorders or conditions shall be
4
free to select the physician licensed to practice medicine in
5
all its branches, licensed clinical psychologist, licensed
6
clinical social worker, licensed clinical professional
7
counselor, licensed marriage and family therapist, licensed
8
speech-language pathologist, or other licensed or certified
9
professional at a program licensed pursuant to the Substance
10
Use Disorder Act of his or her choice to treat such disorders,
11
and the insurer shall pay the covered charges of such
12
physician licensed to practice medicine in all its branches,
13
licensed clinical psychologist, licensed clinical social
14
worker, licensed clinical professional counselor, licensed
15
marriage and family therapist, licensed speech-language
16
pathologist, or other licensed or certified professional at a
17
program licensed pursuant to the Substance Use Disorder Act up
18
to the limits of coverage, provided (i) the disorder or
19
condition treated is covered by the policy, and (ii) the
20
physician, licensed psychologist, licensed clinical social
21
worker, licensed clinical professional counselor, licensed
22
marriage and family therapist, licensed speech-language
23
pathologist, or other licensed or certified professional at a
24
program licensed pursuant to the Substance Use Disorder Act is
25
authorized to provide said services under the statutes of this
26
State and in accordance with accepted principles of his or her

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1
profession.
2

(3) Insofar as this Section applies solely to licensed
3
clinical social workers, licensed clinical professional
4
counselors, licensed marriage and family therapists, licensed
5
speech-language pathologists, and other licensed or certified
6
professionals at programs licensed pursuant to the Substance
7
Use Disorder Act, those persons who may provide services to
8
individuals shall do so after the licensed clinical social
9
worker, licensed clinical professional counselor, licensed
10
marriage and family therapist, licensed speech-language
11
pathologist, or other licensed or certified professional at a
12
program licensed pursuant to the Substance Use Disorder Act
13
has informed the patient of the desirability of the patient
14
conferring with the patient's primary care physician.
15

(4) "Mental, emotional, nervous, or substance use disorder
16
or condition" means a condition or disorder that involves a
17
mental health condition or substance use disorder that falls
18
under any of the diagnostic categories listed in the mental
19
and behavioral disorders chapter of the current edition of the
20
World Health Organization's International Classification of
21
Disease or that is listed in the most recent version of the
22
American Psychiatric Association's Diagnostic and Statistical
23
Manual of Mental Disorders. "Mental, emotional, nervous, or
24
substance use disorder or condition" includes any mental
25
health condition that occurs during pregnancy or during the
26
postpartum period and includes, but is not limited to,

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postpartum depression.
2

(5) Medically necessary treatment and medical necessity
3
determinations shall be interpreted and made in a manner that
4
is consistent with and pursuant to subsections (h) through
5
(y).
6

(b)(1) (Blank).
7

(2) (Blank).
8

(2.5) (Blank).
9

(3) Unless otherwise prohibited by federal law and
10
consistent with the parity requirements of Section 370c.1 of
11
this Code, the insurer that amends, delivers, issues, or
12
renews a group or individual policy of accident and health
13
insurance, a qualified health plan offered through the health
14
insurance marketplace, or a provider of treatment of mental,
15
emotional, nervous, or substance use disorders or conditions
16
shall furnish medical records or other necessary data that
17
substantiate that initial or continued treatment is at all
18
times medically necessary. Nothing in this paragraph (3)
19
supersedes the prohibition on prior authorization requirements
20
to the extent provided under subsections (g) and (w) and
21
subparagraph (A) of paragraph (6.5) of this subsection.
22
Nothing prevents the insured from agreeing in writing to
23
continue treatment at his or her expense. When making a
24
determination of the medical necessity for a treatment
25
modality for mental, emotional, nervous, or substance use
26
disorders or conditions, an insurer must make the

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1
determination in a manner that is consistent with the manner
2
used to make that determination with respect to other diseases
3
or illnesses covered under the policy, including an appeals
4
process. Medical necessity determinations for substance use
5
disorders shall be made in accordance with appropriate patient
6
placement criteria established by the American Society of
7
Addiction Medicine. No additional criteria may be used to make
8
medical necessity determinations for substance use disorders.
9

(4) A group health benefit plan amended, delivered,
10
issued, or renewed on or after January 1, 2019 (the effective
11
date of Public Act 100-1024) or an individual policy of
12
accident and health insurance or a qualified health plan
13
offered through the health insurance marketplace amended,
14
delivered, issued, or renewed on or after January 1, 2019 (the
15
effective date of Public Act 100-1024):
16

(A) shall provide coverage based upon medical
17

necessity for the treatment of a mental, emotional,
18

nervous, or substance use disorder or condition consistent
19

with the parity requirements of Section 370c.1 of this
20

Code; provided, however, that in each calendar year
21

coverage shall not be less than the following:
22

(i) 45 days of inpatient treatment; and
23

(ii) beginning on June 26, 2006 (the effective
24

date of Public Act 94-921), 60 visits for outpatient
25

treatment including group and individual outpatient
26

treatment; and

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1

(iii) for plans or policies delivered, issued for
2

delivery, renewed, or modified after January 1, 2007
3

(the effective date of Public Act 94-906), 20
4

additional outpatient visits for speech therapy for
5

treatment of pervasive developmental disorders that
6

will be in addition to speech therapy provided
7

pursuant to item (ii) of this subparagraph (A); and
8

(B) may not include a lifetime limit on the number of
9

days of inpatient treatment or the number of outpatient
10

visits covered under the plan.
11

(C) (Blank).
12

(5) An issuer of a group health benefit plan or an
13
individual policy of accident and health insurance or a
14
qualified health plan offered through the health insurance
15
marketplace may not count toward the number of outpatient
16
visits required to be covered under this Section an outpatient
17
visit for the purpose of medication management and shall cover
18
the outpatient visits under the same terms and conditions as
19
it covers outpatient visits for the treatment of physical
20
illness.
21

(5.5) An individual or group health benefit plan amended,
22
delivered, issued, or renewed on or after September 9, 2015
23
(the effective date of Public Act 99-480) shall offer coverage
24
for medically necessary acute treatment services and medically
25
necessary clinical stabilization services. The treating
26
provider shall base all treatment recommendations and the

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1
health benefit plan shall base all medical necessity
2
determinations for substance use disorders in accordance with
3
the most current edition of the Treatment Criteria for
4
Addictive, Substance-Related, and Co-Occurring Conditions
5
established by the American Society of Addiction Medicine. The
6
treating provider shall base all treatment recommendations and
7
the health benefit plan shall base all medical necessity
8
determinations for medication-assisted treatment in accordance
9
with the most current Treatment Criteria for Addictive,
10
Substance-Related, and Co-Occurring Conditions established by
11
the American Society of Addiction Medicine.
12

As used in this subsection:
13

"Acute treatment services" means 24-hour medically
14
supervised addiction treatment that provides evaluation and
15
withdrawal management and may include biopsychosocial
16
assessment, individual and group counseling, psychoeducational
17
groups, and discharge planning.
18

"Clinical stabilization services" means 24-hour treatment,
19
usually following acute treatment services for substance
20
abuse, which may include intensive education and counseling
21
regarding the nature of addiction and its consequences,
22
relapse prevention, outreach to families and significant
23
others, and aftercare planning for individuals beginning to
24
engage in recovery from addiction.
25

"Prior authorization" has the meaning given to that term
26
in
the Standardized Prior Authorization Act

Section 15 of the

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1
Prior Authorization Reform Act
.
2

(6) An issuer of a group health benefit plan may provide or
3
offer coverage required under this Section through a managed
4
care plan.
5

(6.5) An individual or group health benefit plan amended,
6
delivered, issued, or renewed on or after January 1, 2019 (the
7
effective date of Public Act 100-1024):
8

(A) shall not impose prior authorization requirements,
9

including limitations on dosage, other than those
10

established under the Treatment Criteria for Addictive,
11

Substance-Related, and Co-Occurring Conditions
12

established by the American Society of Addiction Medicine,
13

on a prescription medication approved by the United States
14

Food and Drug Administration that is prescribed or
15

administered for the treatment of substance use disorders;
16

(B) shall not impose any step therapy requirements;
17

(C) shall place all prescription medications approved
18

by the United States Food and Drug Administration
19

prescribed or administered for the treatment of substance
20

use disorders on, for brand medications, the lowest tier
21

of the drug formulary developed and maintained by the
22

individual or group health benefit plan that covers brand
23

medications and, for generic medications, the lowest tier
24

of the drug formulary developed and maintained by the
25

individual or group health benefit plan that covers
26

generic medications; and

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1

(D) shall not exclude coverage for a prescription
2

medication approved by the United States Food and Drug
3

Administration for the treatment of substance use
4

disorders and any associated counseling or wraparound
5

services on the grounds that such medications and services
6

were court ordered.
7

(7) (Blank).
8

(8) (Blank).
9

(9) With respect to all mental, emotional, nervous, or
10
substance use disorders or conditions, coverage for inpatient
11
treatment shall include coverage for treatment in a
12
residential treatment center certified or licensed by the
13
Department of Public Health or the Department of Human
14
Services.
15

(c) This Section shall not be interpreted to require
16
coverage for speech therapy or other habilitative services for
17
those individuals covered under Section 356z.15 of this Code.
18

(d) With respect to a group or individual policy of
19
accident and health insurance or a qualified health plan
20
offered through the health insurance marketplace, the
21
Department and, with respect to medical assistance, the
22
Department of Healthcare and Family Services shall each
23
enforce the requirements of this Section and Sections 356z.23
24
and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
25
Mental Health Parity and Addiction Equity Act of 2008, 42
26
U.S.C. 18031(j), and any amendments to, and federal guidance

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1
or regulations issued under, those Acts, including, but not
2
limited to, final regulations issued under the Paul Wellstone
3
and Pete Domenici Mental Health Parity and Addiction Equity
4
Act of 2008 and final regulations applying the Paul Wellstone
5
and Pete Domenici Mental Health Parity and Addiction Equity
6
Act of 2008 to Medicaid managed care organizations, the
7
Children's Health Insurance Program, and alternative benefit
8
plans. Specifically, the Department and the Department of
9
Healthcare and Family Services shall take action:
10

(1) proactively ensuring compliance by individual and
11

group policies, including by requiring that insurers
12

submit comparative analyses, as set forth in paragraph (6)
13

of subsection (k) of Section 370c.1, demonstrating how
14

they design and apply nonquantitative treatment
15

limitations, both as written and in operation, for mental,
16

emotional, nervous, or substance use disorder or condition
17

benefits as compared to how they design and apply
18

nonquantitative treatment limitations, as written and in
19

operation, for medical and surgical benefits;
20

(2) evaluating all consumer or provider complaints
21

regarding mental, emotional, nervous, or substance use
22

disorder or condition coverage for possible parity
23

violations;
24

(3) performing parity compliance market conduct
25

examinations or, in the case of the Department of
26

Healthcare and Family Services, parity compliance audits

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1

of individual and group plans and policies, including, but
2

not limited to, reviews of:
3

(A) nonquantitative treatment limitations,
4

including, but not limited to, prior authorization
5

requirements, concurrent review, retrospective review,
6

step therapy, network admission standards,
7

reimbursement rates, and geographic restrictions;
8

(B) denials of authorization, payment, and
9

coverage; and
10

(C) other specific criteria as may be determined
11

by the Department.
12

The findings and the conclusions of the parity compliance
13
market conduct examinations and audits shall be made public.
14

The Director may adopt rules to effectuate any provisions
15
of the Paul Wellstone and Pete Domenici Mental Health Parity
16
and Addiction Equity Act of 2008 that relate to the business of
17
insurance.
18

(e) Availability of plan information.
19

(1) The criteria for medical necessity determinations
20

made under a group health plan, an individual policy of
21

accident and health insurance, or a qualified health plan
22

offered through the health insurance marketplace with
23

respect to mental health or substance use disorder
24

benefits (or health insurance coverage offered in
25

connection with the plan with respect to such benefits)
26

must be made available by the plan administrator (or the

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1

health insurance issuer offering such coverage) to any
2

current or potential participant, beneficiary, or
3

contracting provider upon request.
4

(2) The reason for any denial under a group health
5

benefit plan, an individual policy of accident and health
6

insurance, or a qualified health plan offered through the
7

health insurance marketplace (or health insurance coverage
8

offered in connection with such plan or policy) of
9

reimbursement or payment for services with respect to
10

mental, emotional, nervous, or substance use disorders or
11

conditions benefits in the case of any participant or
12

beneficiary must be made available within a reasonable
13

time and in a reasonable manner and in readily
14

understandable language by the plan administrator (or the
15

health insurance issuer offering such coverage) to the
16

participant or beneficiary upon request.
17

(f) As used in this Section, "group policy of accident and
18
health insurance" and "group health benefit plan" includes (1)
19
State-regulated employer-sponsored group health insurance
20
plans written in Illinois or which purport to provide coverage
21
for a resident of this State; and (2) State, county,
22
municipal, or school district employee health plans.
23
References to an insurer include all plans described in this
24
subsection.
25

(g) (1) As used in this subsection:
26

"Benefits", with respect to insurers that are not Medicaid

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1
managed care organizations, means the benefits provided for
2
treatment services for inpatient and outpatient treatment of
3
substance use disorders or conditions at American Society of
4
Addiction Medicine levels of treatment 2.1 (Intensive
5
Outpatient), 2.5 (High-Intensity Outpatient), 3.1 (Clinically
6
Managed Low-Intensity Residential), 3.5 (Clinically Managed
7
High-Intensity Residential), and 3.7 (Medically Managed
8
Residential) and OMT (Opioid Maintenance Therapy) services.
9

"Benefits", with respect to Medicaid managed care
10
organizations, means the benefits provided for treatment
11
services for inpatient and outpatient treatment of substance
12
use disorders or conditions at American Society of Addiction
13
Medicine levels of treatment 2.1 (Intensive Outpatient), 2.5
14
(High-Intensity Outpatient), 3.5 (Clinically Managed
15
High-Intensity Residential), and 3.7 (Medically Managed
16
Residential) and OMT (Opioid Maintenance Therapy) services.
17

"Substance use disorder treatment provider or facility"
18
means a licensed physician, licensed psychologist, licensed
19
psychiatrist, licensed advanced practice registered nurse, or
20
licensed, certified, or otherwise State-approved facility or
21
provider of substance use disorder treatment.
22

(2) A group health insurance policy, an individual health
23
benefit plan, or qualified health plan that is offered through
24
the health insurance marketplace, small employer group health
25
plan, and large employer group health plan that is amended,
26
delivered, issued, executed, or renewed in this State, or

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approved for issuance or renewal in this State, on or after
2
January 1, 2019 (the effective date of Public Act 100-1023)
3
shall comply with the requirements of this Section and Section
4
370c.1. The services for the treatment and the ongoing
5
assessment of the patient's progress in treatment shall follow
6
the requirements of 77 Ill. Adm. Code 2060.
7

(3) Prior authorization shall not be utilized for the
8
benefits under this subsection. Except to the extent
9
prohibited by Section 370c.1 with respect to treatment
10
limitations in a benefit classification or subclassification,
11
the insurer may require the substance use disorder treatment
12
provider or facility to notify the insurer of the initiation
13
of treatment. For an insurer that is not a Medicaid managed
14
care organization, the substance use disorder treatment
15
provider or facility may be required to give notification for
16
the initiation of treatment of the covered person within 2
17
business days. For Medicaid managed care organizations, the
18
substance use disorder treatment provider or facility may be
19
required to give notification in accordance with the protocol
20
set forth in the provider agreement for initiation of
21
treatment within 24 hours. If the Medicaid managed care
22
organization is not capable of accepting the notification in
23
accordance with the contractual protocol during the 24-hour
24
period following admission, the substance use disorder
25
treatment provider or facility shall have one additional
26
business day to provide the notification to the appropriate

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managed care organization. Treatment plans shall be developed
2
in accordance with the requirements and timeframes established
3
in 77 Ill. Adm. Code 2060. No such coverage shall be subject to
4
concurrent review prior to the applicable notification
5
deadline. If coverage is denied retrospectively, neither the
6
provider or facility nor the insurer shall bill, and the
7
covered individual shall not be liable, for any treatment
8
under this subsection through the date the adverse
9
determination is issued, other than any copayment,
10
coinsurance, or deductible for the treatment or stay through
11
that date as applicable under the policy. Coverage shall not
12
be retrospectively denied for benefits that were furnished at
13
a participating substance use disorder facility prior to the
14
applicable notification deadline except for the following:
15

(A) upon reasonable determination that the benefits
16

were not provided;
17

(B) upon determination that the patient receiving the
18

treatment was not an insured, enrollee, or beneficiary
19

under the policy;
20

(C) upon material misrepresentation by the patient or
21

provider. As used in this subparagraph (C), "material"
22

means a fact or situation that is not merely technical in
23

nature and results or could result in a substantial change
24

in the situation;
25

(D) upon determination that a service was excluded
26

under the terms of coverage. For situations that qualify

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under this subparagraph (D), the limitation to billing for
2

a copayment, coinsurance, or deductible shall not apply;
3

(E) upon determination that a service was not
4

medically necessary consistent with subsections (h)
5

through (n); or
6

(F) upon determination that the patient did not
7

consent to the treatment and that there was no court order
8

mandating the treatment.
9

(4) For an insurer that is not a Medicaid managed care
10
organization, if an insurer determines that benefits are no
11
longer medically necessary, the insurer shall notify the
12
covered person, the covered person's authorized
13
representative, if any, and the covered person's health care
14
provider in writing of the covered person's right to request
15
an external review pursuant to the Health Carrier External
16
Review Act. The notification shall occur within 24 hours
17
following the adverse determination.
18

Pursuant to the requirements of the Health Carrier
19
External Review Act, the covered person or the covered
20
person's authorized representative may request an expedited
21
external review. An expedited external review may not occur if
22
the substance use disorder treatment provider or facility
23
determines that continued treatment is no longer medically
24
necessary.
25

If an expedited external review request meets the criteria
26
of the Health Carrier External Review Act, an independent

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review organization shall make a final determination of
2
medical necessity within 72 hours. If an independent review
3
organization upholds an adverse determination, an insurer
4
shall remain responsible to provide coverage of benefits
5
through the day following the determination of the independent
6
review organization. A decision to reverse an adverse
7
determination shall comply with the Health Carrier External
8
Review Act.
9

(5) The substance use disorder treatment provider or
10
facility shall provide the insurer with 7 business days'
11
advance notice of the planned discharge of the patient from
12
the substance use disorder treatment provider or facility and
13
notice on the day that the patient is discharged from the
14
substance use disorder treatment provider or facility.
15

(6) The benefits required by this subsection shall be
16
provided to all covered persons with a diagnosis of substance
17
use disorder or conditions. The presence of additional related
18
or unrelated diagnoses shall not be a basis to reduce or deny
19
the benefits required by this subsection.
20

(7) Nothing in this subsection shall be construed to
21
require an insurer to provide coverage for any of the benefits
22
in this subsection.
23

(8) Any concurrent or retrospective review permitted by
24
this subsection must be consistent with the utilization review
25
provisions in subsections (h) through (n).
26

(h) As used in this Section:

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"Generally accepted standards of mental, emotional,
2
nervous, or substance use disorder or condition care" means
3
standards of care and clinical practice that are generally
4
recognized by health care providers practicing in relevant
5
clinical specialties such as psychiatry, psychology, clinical
6
sociology, social work, addiction medicine and counseling, and
7
behavioral health treatment. Valid, evidence-based sources
8
reflecting generally accepted standards of mental, emotional,
9
nervous, or substance use disorder or condition care include
10
peer-reviewed scientific studies and medical literature,
11
recommendations of nonprofit health care provider professional
12
associations and specialty societies, including, but not
13
limited to, patient placement criteria and clinical practice
14
guidelines, recommendations of federal government agencies,
15
and drug labeling approved by the United States Food and Drug
16
Administration.
17

"Medically necessary treatment of mental, emotional,
18
nervous, or substance use disorders or conditions" means a
19
service or product addressing the specific needs of that
20
patient, for the purpose of screening, preventing, diagnosing,
21
managing, or treating an illness, injury, or condition or its
22
symptoms and comorbidities, including minimizing the
23
progression of an illness, injury, or condition or its
24
symptoms and comorbidities in a manner that is all of the
25
following:
26

(1) in accordance with the generally accepted

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standards of mental, emotional, nervous, or substance use
2

disorder or condition care;
3

(2) clinically appropriate in terms of type,
4

frequency, extent, site, and duration; and
5

(3) not primarily for the economic benefit of the
6

insurer, purchaser, or for the convenience of the patient,
7

treating physician, or other health care provider.
8

"Utilization review" means either of the following:
9

(1) prospectively, retrospectively, or concurrently
10

reviewing and approving, modifying, delaying, or denying,
11

based in whole or in part on medical necessity, requests
12

by health care providers, insureds, or their authorized
13

representatives for coverage of health care services
14

before, retrospectively, or concurrently with the
15

provision of health care services to insureds.
16

(2) evaluating the medical necessity, appropriateness,
17

level of care, service intensity, efficacy, or efficiency
18

of health care services, benefits, procedures, or
19

settings, under any circumstances, to determine whether a
20

health care service or benefit subject to a medical
21

necessity coverage requirement in an insurance policy is
22

covered as medically necessary for an insured.
23

"Utilization review criteria" means patient placement
24
criteria or any criteria, standards, protocols, or guidelines
25
used by an insurer to conduct utilization review.
26

(i)(1) Every insurer that amends, delivers, issues, or

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renews a group or individual policy of accident and health
2
insurance or a qualified health plan offered through the
3
health insurance marketplace in this State and Medicaid
4
managed care organizations providing coverage for hospital or
5
medical treatment on or after January 1, 2023 shall, pursuant
6
to subsections (h) through (s), provide coverage for medically
7
necessary treatment of mental, emotional, nervous, or
8
substance use disorders or conditions.
9

(2) An insurer shall not set a specific limit on the
10
duration of benefits or coverage of medically necessary
11
treatment of mental, emotional, nervous, or substance use
12
disorders or conditions or limit coverage only to alleviation
13
of the insured's current symptoms.
14

(3) All utilization review conducted by the insurer
15
concerning diagnosis, prevention, and treatment of insureds
16
diagnosed with mental, emotional, nervous, or substance use
17
disorders or conditions shall be conducted in accordance with
18
the requirements of subsections (k) through (w).
19

(4) An insurer that authorizes a specific type of
20
treatment by a provider pursuant to this Section shall not
21
rescind or modify the authorization after that provider
22
renders the health care service in good faith and pursuant to
23
this authorization for any reason, including, but not limited
24
to, the insurer's subsequent cancellation or modification of
25
the insured's or policyholder's contract, or the insured's or
26
policyholder's eligibility. Nothing in this Section shall

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require the insurer to cover a treatment when the
2
authorization was granted based on a material
3
misrepresentation by the insured, the policyholder, or the
4
provider. Nothing in this Section shall require Medicaid
5
managed care organizations to pay for services if the
6
individual was not eligible for Medicaid at the time the
7
service was rendered. Nothing in this Section shall require an
8
insurer to pay for services if the individual was not the
9
insurer's enrollee at the time services were rendered. As used
10
in this paragraph, "material" means a fact or situation that
11
is not merely technical in nature and results in or could
12
result in a substantial change in the situation.
13

(j) An insurer shall not limit benefits or coverage for
14
medically necessary services on the basis that those services
15
should be or could be covered by a public entitlement program,
16
including, but not limited to, special education or an
17
individualized education program, Medicaid, Medicare,
18
Supplemental Security Income, or Social Security Disability
19
Insurance, and shall not include or enforce a contract term
20
that excludes otherwise covered benefits on the basis that
21
those services should be or could be covered by a public
22
entitlement program. Nothing in this subsection shall be
23
construed to require an insurer to cover benefits that have
24
been authorized and provided for a covered person by a public
25
entitlement program. Medicaid managed care organizations are
26
not subject to this subsection.

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(k) An insurer shall base any medical necessity
2
determination or the utilization review criteria that the
3
insurer, and any entity acting on the insurer's behalf,
4
applies to determine the medical necessity of health care
5
services and benefits for the diagnosis, prevention, and
6
treatment of mental, emotional, nervous, or substance use
7
disorders or conditions on current generally accepted
8
standards of mental, emotional, nervous, or substance use
9
disorder or condition care. All denials and appeals shall be
10
reviewed by a professional with experience or expertise
11
comparable to the provider requesting the authorization.
12

(l) In conducting utilization review of all covered health
13
care services for the diagnosis, prevention, and treatment of
14
mental, emotional, and nervous disorders or conditions, an
15
insurer shall apply the criteria and guidelines set forth in
16
the most recent version of the treatment criteria developed by
17
an unaffiliated nonprofit professional association for the
18
relevant clinical specialty or, for Medicaid managed care
19
organizations, criteria and guidelines determined by the
20
Department of Healthcare and Family Services that are
21
consistent with generally accepted standards of mental,
22
emotional, nervous or substance use disorder or condition
23
care. Pursuant to subsection (b), in conducting utilization
24
review of all covered services and benefits for the diagnosis,
25
prevention, and treatment of substance use disorders an
26
insurer shall use the most recent edition of the patient

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placement criteria established by the American Society of
2
Addiction Medicine.
3

(m) In conducting utilization review relating to level of
4
care placement, continued stay, transfer, discharge, or any
5
other patient care decisions that are within the scope of the
6
sources specified in subsection (l), an insurer shall not
7
apply different, additional, conflicting, or more restrictive
8
utilization review criteria than the criteria set forth in
9
those sources. For all level of care placement decisions, the
10
insurer shall authorize placement at the level of care
11
consistent with the assessment of the insured using the
12
relevant patient placement criteria as specified in subsection
13
(l). If that level of placement is not available, the insurer
14
shall authorize the next higher level of care. In the event of
15
disagreement, the insurer shall provide full detail of its
16
assessment using the relevant criteria as specified in
17
subsection (l) to the provider of the service and the patient.
18

If an insurer purchases or licenses utilization review
19
criteria pursuant to this subsection, the insurer shall verify
20
and document before use that the criteria were developed in
21
accordance with subsection (k).
22

(n) In conducting utilization review that is outside the
23
scope of the criteria as specified in subsection (l) or
24
relates to the advancements in technology or in the types or
25
levels of care that are not addressed in the most recent
26
versions of the sources specified in subsection (l), an

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insurer shall conduct utilization review in accordance with
2
subsection (k).
3

(o) This Section does not in any way limit the rights of a
4
patient under the Medical Patient Rights Act.
5

(p) This Section does not in any way limit early and
6
periodic screening, diagnostic, and treatment benefits as
7
defined under 42 U.S.C. 1396d(r).
8

(q) To ensure the proper use of the criteria described in
9
subsection (l), every insurer shall do all of the following:
10

(1) Educate the insurer's staff, including any third
11

parties contracted with the insurer to review claims,
12

conduct utilization reviews, or make medical necessity
13

determinations about the utilization review criteria.
14

(2) Make the educational program available to other
15

stakeholders, including the insurer's participating or
16

contracted providers and potential participants,
17

beneficiaries, or covered lives. The education program
18

must be provided at least once a year, in-person or
19

digitally, or recordings of the education program must be
20

made available to the aforementioned stakeholders.
21

(3) Provide, at no cost, the utilization review
22

criteria and any training material or resources to
23

providers and insured patients upon request. For
24

utilization review criteria not concerning level of care
25

placement, continued stay, transfer, discharge, or other
26

patient care decisions used by the insurer pursuant to

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subsection (m), the insurer may place the criteria on a
2

secure, password-protected website so long as the access
3

requirements of the website do not unreasonably restrict
4

access to insureds or their providers. No restrictions
5

shall be placed upon the insured's or treating provider's
6

access right to utilization review criteria obtained under
7

this paragraph at any point in time, including before an
8

initial request for authorization.
9

(4) Track, identify, and analyze how the utilization
10

review criteria are used to certify care, deny care, and
11

support the appeals process.
12

(5) Conduct interrater reliability testing to ensure
13

consistency in utilization review decision making that
14

covers how medical necessity decisions are made; this
15

assessment shall cover all aspects of utilization review
16

as defined in subsection (h).
17

(6) Run interrater reliability reports about how the
18

clinical guidelines are used in conjunction with the
19

utilization review process and parity compliance
20

activities.
21

(7) Achieve interrater reliability pass rates of at
22

least 90% and, if this threshold is not met, immediately
23

provide for the remediation of poor interrater reliability
24

and interrater reliability testing for all new staff
25

before they can conduct utilization review without
26

supervision.

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(8) Maintain documentation of interrater reliability
2

testing and the remediation actions taken for those with
3

pass rates lower than 90% and submit to the Department of
4

Insurance or, in the case of Medicaid managed care
5

organizations, the Department of Healthcare and Family
6

Services the testing results and a summary of remedial
7

actions as part of parity compliance reporting set forth
8

in subsection (k) of Section 370c.1.
9

(r) This Section applies to all health care services and
10
benefits for the diagnosis, prevention, and treatment of
11
mental, emotional, nervous, or substance use disorders or
12
conditions covered by an insurance policy, including
13
prescription drugs.
14

(s) This Section applies to an insurer that amends,
15
delivers, issues, or renews a group or individual policy of
16
accident and health insurance or a qualified health plan
17
offered through the health insurance marketplace in this State
18
providing coverage for hospital or medical treatment and
19
conducts utilization review as defined in this Section,
20
including Medicaid managed care organizations, and any entity
21
or contracting provider that performs utilization review or
22
utilization management functions on an insurer's behalf.
23

(t) If the Director determines that an insurer has
24
violated this Section, the Director may, after appropriate
25
notice and opportunity for hearing, by order, assess a civil
26
penalty between $1,000 and $5,000 for each violation. Moneys

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collected from penalties shall be deposited into the Parity
2
Advancement Fund established in subsection (i) of Section
3
370c.1.
4

(u) An insurer shall not adopt, impose, or enforce terms
5
in its policies or provider agreements, in writing or in
6
operation, that undermine, alter, or conflict with the
7
requirements of this Section.
8

(v) The provisions of this Section are severable. If any
9
provision of this Section or its application is held invalid,
10
that invalidity shall not affect other provisions or
11
applications that can be given effect without the invalid
12
provision or application.
13

(w) Beginning January 1, 2026, coverage for medically
14
necessary treatment of mental, emotional, or nervous disorders
15
or conditions shall comply with the following requirements:
16

(1) No policy shall require prior authorization for
17

outpatient or partial hospitalization services for
18

treatment of mental, emotional, or nervous disorders or
19

conditions provided by a physician licensed to practice
20

medicine in all branches, a licensed clinical
21

psychologist, a licensed clinical social worker, a
22

licensed clinical professional counselor, a licensed
23

marriage and family therapist, a licensed speech-language
24

pathologist, or any other type of licensed, certified, or
25

legally authorized provider, including trainees working
26

under the supervision of a licensed health care

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professional listed under this subsection, or facility
2

whose outpatient or partial hospitalization services the
3

policy covers for treatment of mental, emotional, or
4

nervous disorders or conditions. Such coverage may be
5

subject to concurrent and retrospective review consistent
6

with the utilization review provisions in subsections (h)
7

through (n) and Section 370c.1. Nothing in this paragraph
8

(1) supersedes a health maintenance organization's
9

referral requirement for services from nonparticipating
10

providers. An insurer may require providers or facilities
11

to notify the insurer of the initiation of treatment as
12

specified in this subsection, except to the extent
13

prohibited by Section 370c.1 with respect to treatment
14

limitations in a benefit classification or
15

subclassification. No such coverage shall be subject to
16

concurrent review for any services furnished before an
17

applicable notification deadline, subject to the
18

following:
19

(A) In the case of outpatient treatment, for an
20

insurer that is not a Medicaid managed care
21

organization, the insurer may set a notification
22

deadline of 2 business days after the initiation of
23

the covered person's treatment. A Medicaid managed
24

care organization may set a deadline of 24 hours after
25

the initiation of treatment. If the Medicaid managed
26

care organization is not capable of accepting the

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LRB104 17431 BAB 30856 b
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notification in accordance with the contractual
2

protocol within the 24-hour period following
3

initiation, the treatment provider or facility shall
4

have one additional business day to provide the
5

notification to the Medicaid managed care
6

organization.
7

(B) In the case of a partial hospitalization
8

program, for an insurer that is not a Medicaid managed
9

care organization, the insurer may set a notification
10

deadline of 48 hours after the initiation of the
11

covered person's treatment. A Medicaid managed care
12

organization may set a deadline of 24 hours after the
13

initiation of treatment. If the Medicaid managed care
14

organization is not capable of accepting the
15

notification in accordance with the contractual
16

protocol during the 24-hour period following
17

initiation, the treatment provider or facility shall
18

have one additional business day to provide the
19

notification to the Medicaid managed care
20

organization.
21

(2) No policy shall require prior authorization for
22

inpatient treatment at a hospital for mental, emotional,
23

or nervous disorders or conditions at a participating
24

provider. Additionally, no such coverage shall be subject
25

to concurrent review for the first 72 hours after
26

admission, provided that the provider must notify the

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insurer of both the admission and the initial treatment
2

plan within 48 hours of admission. A discharge plan must
3

be fully developed and continuity services prepared to
4

meet the patient's needs and the patient's community
5

preference upon release. Recommended level of care
6

placements identified in the discharge plan shall comply
7

with generally accepted standards of care, as defined in
8

subsection (h).
9

(A) If the provider satisfies the conditions of
10

paragraph (2), then the insurer shall approve coverage
11

of the recommended level of care, if applicable, upon
12

discharge subject to concurrent review.
13

(B) Nothing in this paragraph supersedes a health
14

maintenance organization's referral requirement for
15

services from nonparticipating providers upon a
16

patient's discharge from a hospital or facility.
17

(C) Concurrent review for such coverage must be
18

consistent with the utilization review provisions in
19

subsections (h) through (n).
20

(D) In this subsection, residential treatment that
21

is not otherwise identified in the discharge plan is
22

not inpatient hospitalization.
23

(3) Treatment provided under this subsection may be
24

reviewed retrospectively. If coverage is denied
25

retrospectively, neither the insurer nor the participating
26

provider shall bill, and the insured shall not be liable,

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1

for any treatment under this subsection through the date
2

the adverse determination is issued, other than any
3

copayment, coinsurance, or deductible for the stay through
4

that date as applicable under the policy. Coverage shall
5

not be retrospectively denied for the first 72 hours of
6

admission to inpatient hospitalization for treatment of
7

mental, emotional, or nervous disorders or conditions, or
8

before the applicable deadline under paragraph (1) of this
9

subsection for outpatient treatment or partial
10

hospitalization programs, at a participating provider
11

except:
12

(A) upon reasonable determination that the
13

inpatient mental health treatment was not provided;
14

(B) upon determination that the patient receiving
15

the treatment was not an insured, enrollee, or
16

beneficiary under the policy;
17

(C) upon material misrepresentation by the patient
18

or health care provider. In this item (C), "material"
19

means a fact or situation that is not merely technical
20

in nature and results or could result in a substantial
21

change in the situation;
22

(D) upon determination that a service was excluded
23

under the terms of coverage. In that case, the
24

limitation to billing for a copayment, coinsurance, or
25

deductible shall not apply;
26

(E) for outpatient treatment or partial

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hospitalization programs only, upon determination that
2

a service was not medically necessary consistent with
3

subsections (h) through (n); or
4

(F) upon determination that the patient did not
5

consent to the treatment and that there was no court
6

order mandating the treatment.
7

Nothing in this subsection shall be construed to
8

require a policy to cover any health care service excluded
9

under the terms of coverage.
10

This subsection does not apply to coverage for any
11

prescription or over-the-counter drug.
12

Nothing in this subsection shall be construed to
13

require the medical assistance program to reimburse for
14

services not covered by the medical assistance program as
15

authorized by the Illinois Public Aid Code or the
16

Children's Health Insurance Program Act.
17

(x) Notwithstanding any provision of this Section, nothing
18
shall require the medical assistance program under Article V
19
of the Illinois Public Aid Code or the Children's Health
20
Insurance Program Act to violate any applicable federal laws,
21
regulations, or grant requirements, including requirements for
22
utilization management, or any State or federal consent
23
decrees. Nothing in subsection (g) or (w) shall prevent the
24
Department of Healthcare and Family Services from requiring a
25
health care provider to use specified level of care,
26
admission, continued stay, or discharge criteria, including,

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1
but not limited to, those under Section 5-5.23 of the Illinois
2
Public Aid Code, as long as the Department of Healthcare and
3
Family Services, subject to applicable federal laws,
4
regulations, or grant requirements, including requirements for
5
utilization management, does not require a health care
6
provider to seek prior authorization or concurrent review from
7
the Department of Healthcare and Family Services, a Medicaid
8
managed care organization, or a utilization review
9
organization under the circumstances expressly prohibited by
10
subsections (g) and (w). Nothing in this Section prohibits a
11
health plan, including a Medicaid managed care organization,
12
from conducting reviews for medical necessity, clinical
13
appropriateness, safety, fraud, waste, or abuse and reporting
14
suspected fraud, waste, or abuse according to State and
15
federal requirements. Nothing in this Section limits the
16
authority of the Department of Healthcare and Family Services
17
or another State agency, or a Medicaid managed care
18
organization on the State agency's behalf, to (i) implement or
19
require programs, services, screenings, assessments, tools, or
20
reviews to comply with applicable federal law, federal
21
regulation, federal grant requirements, any State or federal
22
consent decrees or court orders, or any applicable case law,
23
such as Olmstead v. L.C., 527 U.S. 581 (1999), or (ii)
24
administer or require programs, services, screenings,
25
assessments, tools, or reviews established under State or
26
federal laws, rules, or regulations in compliance with State

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1
or federal laws, rules, or regulations, including, but not
2
limited to, the Children's Mental Health Act and the Mental
3
Health and Developmental Disabilities Administrative Act.
4

(y) (Blank).
5
(Source: P.A. 103-426, eff. 8-4-23; 103-650, eff. 1-1-25;
6
103-1040, eff. 8-9-24; 104-28, eff. 1-1-26; 104-417, eff.
7
8-15-25
.)

8

Section 905.
The Network Adequacy and Transparency Act is
9
amended by changing Section 10 as follows:

10

(215 ILCS 124/10)
11

Sec. 10.
Network adequacy.
12

(a) Before issuing, delivering, or renewing a network
13
plan, an issuer providing a network plan shall file a
14
description of all of the following with the Director:
15

(1) The written policies and procedures for adding
16

providers to meet patient needs based on increases in the
17

number of beneficiaries, changes in the
18

patient-to-provider ratio, changes in medical and health
19

care capabilities, and increased demand for services.
20

(2) The written policies and procedures for making
21

referrals within and outside the network.
22

(3) The written policies and procedures on how the
23

network plan will provide 24-hour, 7-day per week access
24

to network-affiliated primary care, emergency services,

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and obstetrical and gynecological health care
2

professionals.
3

An issuer shall not prohibit a preferred provider from
4
discussing any specific or all treatment options with
5
beneficiaries irrespective of the issuer's position on those
6
treatment options or from advocating on behalf of
7
beneficiaries within the utilization review, grievance, or
8
appeals processes established by the issuer in accordance with
9
any rights or remedies available under applicable State or
10
federal law.
11

(b) Before issuing, delivering, or renewing a network
12
plan, an issuer must file for review a description of the
13
services to be offered through a network plan. The description
14
shall include all of the following:
15

(1) A geographic map of the area proposed to be served
16

by the plan by county service area and zip code, including
17

marked locations for preferred providers.
18

(2) As deemed necessary by the Department, the names,
19

addresses, phone numbers, and specialties of the providers
20

who have entered into preferred provider agreements under
21

the network plan.
22

(3) The number of beneficiaries anticipated to be
23

covered by the network plan.
24

(4) An Internet website and toll-free telephone number
25

for beneficiaries and prospective beneficiaries to access
26

current and accurate lists of preferred providers in each

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plan, additional information about the plan, as well as
2

any other information required by Department rule.
3

(5) A description of how health care services to be
4

rendered under the network plan are reasonably accessible
5

and available to beneficiaries. The description shall
6

address all of the following:
7

(A) the type of health care services to be
8

provided by the network plan;
9

(B) the ratio of physicians and other providers to
10

beneficiaries, by specialty and including primary care
11

physicians and facility-based physicians when
12

applicable under the contract, necessary to meet the
13

health care needs and service demands of the currently
14

enrolled population;
15

(C) the travel and distance standards for plan
16

beneficiaries in county service areas; and
17

(D) a description of how the use of telemedicine,
18

telehealth, or mobile care services may be used to
19

partially meet the network adequacy standards, if
20

applicable.
21

(6) A provision ensuring that whenever a beneficiary
22

has made a good faith effort, as evidenced by accessing
23

the provider directory, calling the network plan, and
24

calling the provider, to utilize preferred providers for a
25

covered service and it is determined the issuer does not
26

have the appropriate preferred providers due to

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insufficient number, type, unreasonable travel distance or
2

delay, or preferred providers refusing to provide a
3

covered service because it is contrary to the conscience
4

of the preferred providers, as protected by the Health
5

Care Right of Conscience Act, the issuer shall give the
6

beneficiary a network exception and shall ensure, directly
7

or indirectly, by terms contained in the payer contract,
8

that the beneficiary will be provided the covered service
9

at no greater cost to the beneficiary than if the service
10

had been provided by a preferred provider. This paragraph
11

(6) does not apply to: (A) a beneficiary who willfully
12

chooses to access a non-preferred provider for health care
13

services available through the panel of preferred
14

providers, or (B) a beneficiary enrolled in a health
15

maintenance organization, except that the health
16

maintenance organization must notify the beneficiary when
17

a referral has been granted as a network exception based
18

on any preferred provider access deficiency described in
19

this paragraph or under the circumstances applicable in
20

paragraph (3) of subsection (d-5). In these circumstances,
21

the contractual requirements for non-preferred provider
22

reimbursements shall apply unless Section 356z.3a of the
23

Illinois Insurance Code requires otherwise. In no event
24

shall a beneficiary who receives care at a participating
25

health care facility be required to search for
26

participating providers under the circumstances described

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in subsection (b) or (b-5) of Section 356z.3a of the
2

Illinois Insurance Code except under the circumstances
3

described in paragraph (2) of subsection (b-5).
4

(7) A provision that the beneficiary shall receive
5

emergency care coverage such that payment for this
6

coverage is not dependent upon whether the emergency
7

services are performed by a preferred or non-preferred
8

provider and the coverage shall be at the same benefit
9

level as if the service or treatment had been rendered by a
10

preferred provider. For purposes of this paragraph (7),
11

"the same benefit level" means that the beneficiary is
12

provided the covered service at no greater cost to the
13

beneficiary than if the service had been provided by a
14

preferred provider. This provision shall be consistent
15

with Section 356z.3a of the Illinois Insurance Code.
16

(8) A limitation that complies with
the following
17

prior authorization requirements:

subsections (d) and (e)
18

of Section 55 of the Prior Authorization Reform Act.
19

(A) If a health insurance issuer imposes a
20

monetary penalty on the enrollee for the enrollee's,
21

health care professional's, or health care provider's
22

failure to obtain any form of prior authorization for
23

a health care service, the penalty may not exceed the
24

lesser of:

25

(i) the actual cost of the health care
26

service; or

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(ii) $1,000 per occurrence in addition to the
2

plan cost-sharing provisions.

3

(B) A health insurance issuer may not require both
4

the enrollee and the health care professional or
5

health care provider to obtain any form of prior
6

authorization for the same instance of a health care
7

service, nor otherwise require more than one prior
8

authorization for the same instance of a health care
9

service.
10

(9) For a network plan to be offered through the
11

Exchange in the individual or small group market, as well
12

as any off-Exchange mirror of such a network plan,
13

evidence that the network plan includes essential
14

community providers in accordance with rules established
15

by the Exchange that will operate in this State for the
16

applicable plan year.
17

(c) The issuer shall demonstrate to the Director a minimum
18
ratio of providers to plan beneficiaries as required by the
19
Department for each network plan.
20

(1) The minimum ratio of physicians or other providers
21

to plan beneficiaries shall be established by the
22

Department in consultation with the Department of Public
23

Health based upon the guidance from the federal Centers
24

for Medicare and Medicaid Services. The Department shall
25

not establish ratios for vision or dental providers who
26

provide services under dental-specific or vision-specific

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benefits, except to the extent provided under federal law
2

for stand-alone dental plans. The Department shall
3

consider establishing ratios for the following physicians
4

or other providers:
5

(A) Primary Care;
6

(B) Pediatrics;
7

(C) Cardiology;
8

(D) Gastroenterology;
9

(E) General Surgery;
10

(F) Neurology;
11

(G) OB/GYN;
12

(H) Oncology/Radiation;
13

(I) Ophthalmology;
14

(J) Urology;
15

(K) Behavioral Health;
16

(L) Allergy/Immunology;
17

(M) Chiropractic;
18

(N) Dermatology;
19

(O) Endocrinology;
20

(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
21

(Q) Infectious Disease;
22

(R) Nephrology;
23

(S) Neurosurgery;
24

(T) Orthopedic Surgery;
25

(U) Physiatry/Rehabilitative;
26

(V) Plastic Surgery;

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(W) Pulmonary;
2

(X) Rheumatology;
3

(Y) Anesthesiology;
4

(Z) Pain Medicine;
5

(AA) Pediatric Specialty Services;
6

(BB) Outpatient Dialysis;
7

(CC) HIV; and
8

(DD) Genetic Medicine and Genetic Counseling.
9

(1.5) Beginning January 1, 2026, every issuer shall
10

demonstrate to the Director that each in-network hospital
11

has at least one radiologist, pathologist,
12

anesthesiologist, and emergency room physician as a
13

preferred provider in a network plan. The Department may,
14

by rule, require additional types of hospital-based
15

medical specialists to be included as preferred providers
16

in each in-network hospital in a network plan.
17

(2) The Director shall establish a process for the
18

review of the adequacy of these standards, along with an
19

assessment of additional specialties to be included in the
20

list under this subsection (c).
21

(3) Notwithstanding any other law or rule, the minimum
22

ratio for each provider type shall be no less than any such
23

ratio established for qualified health plans in
24

Federally-Facilitated Exchanges by federal law or by the
25

federal Centers for Medicare and Medicaid Services, even
26

if the network plan is issued in the large group market or

HB4709
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is otherwise not issued through an exchange. Federal
2

standards for stand-alone dental plans shall only apply to
3

such network plans. In the absence of an applicable
4

Department rule, the federal standards shall apply for the
5

time period specified in the federal law, regulation, or
6

guidance. If the Centers for Medicare and Medicaid
7

Services establish standards that are more stringent than
8

the standards in effect under any Department rule, the
9

Department may amend its rules to conform to the more
10

stringent federal standards.
11

(4) If the federal Centers for Medicare and Medicaid
12

Services establishes minimum provider ratios for
13

stand-alone dental plans in the type of exchange in use in
14

this State for a given plan year, the Department shall
15

enforce those standards for stand-alone dental plans for
16

that plan year.
17

(d) The network plan shall demonstrate to the Director
18
maximum travel and distance standards and appointment
19
wait-time standards for plan beneficiaries, which shall be
20
established by the Department in consultation with the
21
Department of Public Health based upon the guidance from the
22
federal Centers for Medicare and Medicaid Services. These
23
standards shall consist of the maximum minutes or miles to be
24
traveled by a plan beneficiary for each county type, such as
25
large counties, metro counties, or rural counties as defined
26
by Department rule.

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The maximum travel time and distance standards must
2
include standards for each physician and other provider
3
category listed for which ratios have been established.
4

The Director shall establish a process for the review of
5
the adequacy of these standards along with an assessment of
6
additional specialties to be included in the list under this
7
subsection (d).
8

Notwithstanding any other law or Department rule, the
9
maximum travel time and distance standards and appointment
10
wait-time standards shall be no greater than any such
11
standards established for qualified health plans in
12
Federally-Facilitated Exchanges by federal law or by the
13
federal Centers for Medicare and Medicaid Services, even if
14
the network plan is issued in the large group market or is
15
otherwise not issued through an exchange. Federal standards
16
for stand-alone dental plans shall only apply to such network
17
plans. In the absence of an applicable Department rule, the
18
federal standards shall apply for the time period specified in
19
the federal law, regulation, or guidance. If the Centers for
20
Medicare and Medicaid Services establish standards that are
21
more stringent than the standards in effect under any
22
Department rule, the Department may amend its rules to conform
23
to the more stringent federal standards.
24

If the federal area designations for the maximum time or
25
distance or appointment wait-time standards required are
26
changed by the most recent Letter to Issuers in the

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Federally-facilitated Marketplaces, the Department shall post
2
on its website notice of such changes and may amend its rules
3
to conform to those designations if the Director deems
4
appropriate.
5

If the federal Centers for Medicare and Medicaid Services
6
establishes appointment wait-time standards for qualified
7
health plans, including stand-alone dental plans, in the type
8
of exchange in use in this State for a given plan year, the
9
Department shall enforce those standards for the same types of
10
qualified health plans for that plan year. If the federal
11
Centers for Medicare and Medicaid Services establishes time
12
and distance standards for stand-alone dental plans in the
13
type of exchange in use in this State for a given plan year,
14
the Department shall enforce those standards for stand-alone
15
dental plans for that plan year.
16

(d-5)(1) Every issuer shall ensure that beneficiaries have
17
timely and proximate access to treatment for mental,
18
emotional, nervous, or substance use disorders or conditions
19
in accordance with the provisions of paragraph (4) of
20
subsection (a) of Section 370c of the Illinois Insurance Code.
21
Issuers shall use a comparable process, strategy, evidentiary
22
standard, and other factors in the development and application
23
of the network adequacy standards for timely and proximate
24
access to treatment for mental, emotional, nervous, or
25
substance use disorders or conditions and those for the access
26
to treatment for medical and surgical conditions. As such, the

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network adequacy standards for timely and proximate access
2
shall equally be applied to treatment facilities and providers
3
for mental, emotional, nervous, or substance use disorders or
4
conditions and specialists providing medical or surgical
5
benefits pursuant to the parity requirements of Section 370c.1
6
of the Illinois Insurance Code and the federal Paul Wellstone
7
and Pete Domenici Mental Health Parity and Addiction Equity
8
Act of 2008. Notwithstanding the foregoing, the network
9
adequacy standards for timely and proximate access to
10
treatment for mental, emotional, nervous, or substance use
11
disorders or conditions shall, at a minimum, satisfy the
12
following requirements:
13

(A) For beneficiaries residing in the metropolitan
14

counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
15

network adequacy standards for timely and proximate access
16

to treatment for mental, emotional, nervous, or substance
17

use disorders or conditions means a beneficiary shall not
18

have to travel longer than 30 minutes or 30 miles from the
19

beneficiary's residence to receive outpatient treatment
20

for mental, emotional, nervous, or substance use disorders
21

or conditions. Beneficiaries shall not be required to wait
22

longer than 10 business days between requesting an initial
23

appointment and being seen by the facility or provider of
24

mental, emotional, nervous, or substance use disorders or
25

conditions for outpatient treatment or to wait longer than
26

20 business days between requesting a repeat or follow-up

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appointment and being seen by the facility or provider of
2

mental, emotional, nervous, or substance use disorders or
3

conditions for outpatient treatment; however, subject to
4

the protections of paragraph (3) of this subsection, a
5

network plan shall not be held responsible if the
6

beneficiary or provider voluntarily chooses to schedule an
7

appointment outside of these required time frames.
8

(B) For beneficiaries residing in Illinois counties
9

other than those counties listed in subparagraph (A) of
10

this paragraph, network adequacy standards for timely and
11

proximate access to treatment for mental, emotional,
12

nervous, or substance use disorders or conditions means a
13

beneficiary shall not have to travel longer than 60
14

minutes or 60 miles from the beneficiary's residence to
15

receive outpatient treatment for mental, emotional,
16

nervous, or substance use disorders or conditions.
17

Beneficiaries shall not be required to wait longer than 10
18

business days between requesting an initial appointment
19

and being seen by the facility or provider of mental,
20

emotional, nervous, or substance use disorders or
21

conditions for outpatient treatment or to wait longer than
22

20 business days between requesting a repeat or follow-up
23

appointment and being seen by the facility or provider of
24

mental, emotional, nervous, or substance use disorders or
25

conditions for outpatient treatment; however, subject to
26

the protections of paragraph (3) of this subsection, a

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network plan shall not be held responsible if the
2

beneficiary or provider voluntarily chooses to schedule an
3

appointment outside of these required time frames.
4

(2) For beneficiaries residing in all Illinois counties,
5
network adequacy standards for timely and proximate access to
6
treatment for mental, emotional, nervous, or substance use
7
disorders or conditions means a beneficiary shall not have to
8
travel longer than 60 minutes or 60 miles from the
9
beneficiary's residence to receive inpatient or residential
10
treatment for mental, emotional, nervous, or substance use
11
disorders or conditions.
12

(3) If there is no in-network facility or provider
13
available for a beneficiary to receive timely and proximate
14
access to treatment for mental, emotional, nervous, or
15
substance use disorders or conditions in accordance with the
16
network adequacy standards outlined in this subsection, the
17
issuer shall provide necessary exceptions to its network to
18
ensure admission and treatment with a provider or at a
19
treatment facility in accordance with the network adequacy
20
standards in this subsection at the in-network benefit level.
21

(A) For plan or policy years beginning on or after
22

January 1, 2026, the issuer also shall provide reasonable
23

reimbursement to a beneficiary who has received an
24

exception as outlined in this paragraph (3) for costs
25

including food, lodging, and travel.
26

(i) Reimbursement for food and lodging shall be at

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the prevailing federal per diem rates then in effect,
2

as set by the United States General Services
3

Administration. Reimbursement for travel by vehicle
4

shall be reimbursed at the current Internal Revenue
5

Service mileage standard for miles driven for
6

transportation or travel expenses.
7

(ii) At the time an issuer grants an exception
8

under this paragraph (3), the issuer shall give
9

written notification to the beneficiary of potential
10

eligibility for reimbursement under this subparagraph
11

(A) and instructions on how to file a claim for such
12

reimbursement, including a link to the claim form on
13

the issuer's public website and a phone number for a
14

beneficiary to request that the issuer send a hard
15

copy of the claim form by postal mail. The Department
16

shall create the template for the reimbursement
17

notification form, which issuers shall fill in and
18

post on their public website.
19

(iii) An issuer may require a beneficiary to
20

submit a claim for food, travel, or lodging
21

reimbursement within 60 days of the last date of the
22

health care service for which travel was undertaken,
23

and the beneficiary may appeal any denial of
24

reimbursement claims.
25

(iv) An issuer may deny reimbursement for food,
26

lodging, and travel if the provider's site of care is

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neither within this State nor within 100 miles of the
2

beneficiary's residence unless, after a good faith
3

effort, no provider can be found who is available
4

within those parameters to provide the medically
5

necessary health care service within 10 business days
6

of a request for appointment.
7

(B) Notwithstanding any other provision of this
8

Section to the contrary, subparagraph (A) of this
9

paragraph (3) does not apply to policies issued or
10

delivered in this State that provide medical assistance
11

under the Illinois Public Aid Code or the Children's
12

Health Insurance Program Act.
13

(4) If the federal Centers for Medicare and Medicaid
14
Services establishes or law requires more stringent standards
15
for qualified health plans in the Federally-Facilitated
16
Exchanges, the federal standards shall control for all network
17
plans for the time period specified in the federal law,
18
regulation, or guidance, even if the network plan is issued in
19
the large group market, is issued through a different type of
20
Exchange, or is otherwise not issued through an Exchange.
21

(5) If the federal Centers for Medicare and Medicaid
22
Services establishes a more stringent standard in any county
23
than specified in paragraph (1) or (2) of this subsection
24
(d-5) for qualified health plans in the type of exchange in use
25
in this State for a given plan year, the federal standard shall
26
apply in lieu of the standard in paragraph (1) or (2) of this

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subsection (d-5) for qualified health plans for that plan
2
year.
3

(e) Except for network plans solely offered as a group
4
health plan, these ratio and time and distance standards apply
5
to the lowest cost-sharing tier of any tiered network.
6

(f) The network plan may consider use of other health care
7
service delivery options, such as telemedicine or telehealth,
8
mobile clinics, and centers of excellence, or other ways of
9
delivering care to partially meet the requirements set under
10
this Section.
11

(g) Except for the requirements set forth in subsection
12
(d-5), issuers who are not able to comply with the provider
13
ratios, time and distance standards, and appointment wait-time
14
standards established under this Act or federal law may
15
request an exception to these requirements from the
16
Department. The Department may grant an exception in the
17
following circumstances:
18

(1) if no providers or facilities meet the specific
19

time and distance standard in a specific service area and
20

the issuer (i) discloses information on the distance and
21

travel time points that beneficiaries would have to travel
22

beyond the required criterion to reach the next closest
23

contracted provider outside of the service area and (ii)
24

provides contact information, including names, addresses,
25

and phone numbers for the next closest contracted provider
26

or facility;

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(2) if patterns of care in the service area do not
2

support the need for the requested number of provider or
3

facility type and the issuer provides data on local
4

patterns of care, such as claims data, referral patterns,
5

or local provider interviews, indicating where the
6

beneficiaries currently seek this type of care or where
7

the physicians currently refer beneficiaries, or both; or
8

(3) other circumstances deemed appropriate by the
9

Department consistent with the requirements of this Act.
10

(h) Issuers are required to report to the Director any
11
material change to an approved network plan within 15 business
12
days after the change occurs and any change that would result
13
in failure to meet the requirements of this Act. The issuer
14
shall submit a revised version of the portions of the network
15
adequacy filing affected by the material change, as determined
16
by the Director by rule, and the issuer shall attach versions
17
with the changes indicated for each document that was revised
18
from the previous version of the filing. Upon notice from the
19
issuer, the Director shall reevaluate the network plan's
20
compliance with the network adequacy and transparency
21
standards of this Act. For every day past 15 business days that
22
the issuer fails to submit a revised network adequacy filing
23
to the Director, the Director may order a fine of $5,000 per
24
day.
25

(i) If a network plan is inadequate under this Act with
26
respect to a provider type in a county, and if the network plan

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1
does not have an approved exception for that provider type in
2
that county pursuant to subsection (g), an issuer shall cover
3
out-of-network claims for covered health care services
4
received from that provider type within that county at the
5
in-network benefit level and shall retroactively adjudicate
6
and reimburse beneficiaries to achieve that objective if their
7
claims were processed at the out-of-network level contrary to
8
this subsection. Nothing in this subsection shall be construed
9
to supersede Section 356z.3a of the Illinois Insurance Code.
10

(j) If the Director determines that a network is
11
inadequate in any county and no exception has been granted
12
under subsection (g) and the issuer does not have a process in
13
place to comply with subsection (d-5), the Director may
14
prohibit the network plan from being issued or renewed within
15
that county until the Director determines that the network is
16
adequate apart from processes and exceptions described in
17
subsections (d-5) and (g). Nothing in this subsection shall be
18
construed to terminate any beneficiary's health insurance
19
coverage under a network plan before the expiration of the
20
beneficiary's policy period if the Director makes a
21
determination under this subsection after the issuance or
22
renewal of the beneficiary's policy or certificate because of
23
a material change. Policies or certificates issued or renewed
24
in violation of this subsection may subject the issuer to a
25
civil penalty of $5,000 per policy.
26

(k) For the Department to enforce any new or modified

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1
federal standard before the Department adopts the standard by
2
rule, the Department must, no later than May 15 before the
3
start of the plan year, give public notice to the affected
4
health insurance issuers through a bulletin.
5
(Source: P.A. 103-650, eff. 1-1-25; 103-656, eff. 1-1-25;
6
103-718, eff. 7-19-24; 103-777, eff. 1-1-25; 103-906, eff.
7
1-1-25; 104-28, eff. 1-1-26; 104-175, eff. 1-1-26; 104-334,
8
eff. 8-15-25; revised 10-28-25.)

9

Section 910.
The Illinois Public Aid Code is amended by
10
changing Section 5-5.12e as follows:

11

(305 ILCS 5/5-5.12e)
12

Sec. 5-5.12e.
Managed care organization prior
13
authorization of health care services.
14

(a) As used in this Section, "health care service" has the
15
meaning given to that term in the
Standardized Prior
16
Authorization Act

Prior Authorization Reform Act
.
17

(b) Notwithstanding any other provision of law to the
18
contrary, all managed care organizations shall comply with the
19
requirements of the Prior Authorization Reform Act.
20
(Source: P.A. 102-409, eff. 1-1-22; 102-813, eff. 5-13-22.)

21

(215 ILCS 200/Act rep.)
22

Section 915.
The Prior Authorization Reform Act is
23
repealed.

HB4709
- 78 -
LRB104 17431 BAB 30856 b
1

Section 999.
Effective date.
This Act takes effect January
2
1, 2027.

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