INS-ADVERSE DETERMINATION House SponsorsRep. Bob Morgan and Lilian Jiménez Senate Sponsors(Sen. Laura Fine) 7/19/2024HousePublic Act . . . . . . . . . 103-0656 215 ILCS 5/155.36215 ILCS 5/370s215 ILCS 124/10215 ILCS 134/10215 ILCS 134/45215 ILCS 134/70215 ILCS 134/85215 ILCS 180/10215 ILCS 200/55 Amends the Managed Care Reform and Patient Rights Act. Provides that if a health care plan uses an automated process to make an initial adverse determination or relies on a utilization review organization's automated process for an initial adverse determination, the health care plan shall ensure that any appeal is processed as required by the provisions, including the restriction that only a clinical peer may review an appeal. Provides that an automated process of a health care plan or registered utilization review program may make an initial adverse determination for services not included under specified provisions. Provides that utilization review programs that use automated processes to render an adverse determination shall base all adverse determinations on objective, evidence-based criteria that have been accredited by the American Accreditation Healthcare Commission or by the National Committee for Quality Assurance and shall provide proof of such accreditation to the Department of Insurance with any required registration. Provides that the utilization review program shall include with its registration materials attachments that contain specified policies and procedures. Amends the Health Carrier External Review Act. Changes the definition of "adverse determination". Amends the Prior Authorization Reform Act. Provides that if a health insurance issuer imposes a penalty for the failure to obtain any form of prior authorization for any health care service, the penalty may not exceed the lesser of the actual cost of the health care service or $1,000 per occurrence in addition to the plan cost-sharing provisions. Provides that a health insurance issuer may not require both the enrollee and the health care professional or health care provider to obtain any form of prior authorization for the same instance of a health care service, nor otherwise require more than one prior authorization for the same instance of a health care service. Makes conforming changes in the Illinois Insurance Code and the Network Adequacy and Transparency Act. Effective January 1, 2024.House Committee Amendment No. 1 Deletes reference to:215 ILCS 134/70Adds reference to:215 ILCS 5/143.31215 ILCS 5/315.6from Ch. 73, par. 927.6215 ILCS 110/25from Ch. 32, par. 690.25215 ILCS 125/5-3from Ch. 111 1/2, par. 1411.2215 ILCS 130/4003from Ch. 73, par. 1504-3215 ILCS 180/10Replaces everything after the enacting clause. Amends the Illinois Insurance Code. Makes changes in provisions concerning uniform medical claim and billing forms. Provides that no law or rule shall be construed to exempt any utilization review program from specified administration and enforcement requirements of the Managed Care Reform and Patient Rights Act with respect to specified forms of insurance. Amends the Dental Service Plan Act, the Health Maintenance Organization Act, the Limited Health Service Organization Act, and the Voluntary Health Services Plans Act. Provides that fraternal benefit societies, dental service plan corporations, health maintenance organizations, limited health service organizations, and health services plan corporations are subject to provisions of the Illinois Insurance Code concerning uniform medical claim and billing forms. Amends the Health Carrier External Review Act. Makes changes in the definitions of "adverse determination" and "final adverse determination". Amends the Managed Care Reform and Patient Rights Act. Provides that even if a health care plan or other utilization review program uses an algorithmic automated process in the course of utilization review, the health care plan or other utilization review program shall ensure that only a clinical peer makes any adverse determination, and that any appeal is processed as required under the provisions, including the restriction that only a clinical peer may review an appeal. Makes other changes concerning utilization review. Provides that utilization review programs that use algorithmic automated processes in the course of utilization review shall use objective, evidence-based criteria compliant with the accreditation requirements of the Health Utilization Management Standards of the Utilization Review Accreditation Commission or the National Committee for Quality Assurance (NCQA) and shall provide proof of such compliance to the Department of Insurance with the required registration. Amends the Prior Authorization Reform Act. Provides that if a health insurance issuer imposes a monetary penalty on the enrollee for the enrollee's, health care professional's, or health care provider's failure to obtain any form of prior authorization for a health care service, the penalty may not exceed the lesser of the actual cost of the health care service or $1,000 per occurrence in addition to the plan cost-sharing provisions. Provides that a health insurance issuer may not require both the enrollee and the health care professional or health care provider to obtain any form of prior authorization for the same instance of a health care service, nor otherwise require more than one prior authorization for the same instance of a health care service. Effective January 1, 2025.House Floor Amendment No. 2 Replaces everything after the enacting clause. Reinserts the provisions of the bill, as amended by House Amendment No. 1, with the following changes. Provides that even if a health care plan or other utilization review program uses an algorithmic automated process in the course of utilization review for medical necessity, the health care plan or other utilization review program shall ensure that only a clinical peer makes any adverse determination based on medical necessity and that any subsequent appeal is processed. Adds the National Committee for Quality Assurance to a provision requiring utilization review programs to certify compliance with certain accreditation entities. Provides that utilization review programs that use algorithmic automated processes to decide whether to render adverse determinations (rather than that use algorithmic automated processes) based on medical necessity in the course of utilization review shall use objective, evidence-based criteria compliant with the accreditation requirements. Makes changes in the definition of "adverse determination". Effective January 1, 2025. 2/15/2023HouseFiled with the Clerk by Rep. Bob Morgan 2/15/2023HouseFirst Reading 2/15/2023HouseReferred to Rules Committee 2/21/2023HouseAssigned to Insurance Committee 3/10/2023HouseRule 19(a) / Re-referred to Rules Committee 3/10/2023HouseRule 19(a) / Re-referred to Rules Committee 2/29/2024HouseAssigned to Insurance Committee 3/14/2024HouseHouse Committee Amendment No. 1 Filed with Clerk by Rep. Bob Morgan 3/14/2024HouseHouse Committee Amendment No. 1 Referred to Rules Committee 3/20/2024HouseHouse Committee Amendment No. 1 Rules Refers to Insurance Committee 3/20/2024HouseHouse Committee Amendment No. 1 Adopted in Insurance Committee; by Voice Vote 3/20/2024HouseDo Pass as Amended / Short Debate Insurance Committee; 013-000-000 3/21/2024HousePlaced on Calendar 2nd Reading - Short Debate 3/22/2024HouseAdded Co-Sponsor Rep. Lilian Jiménez 4/16/2024HouseHouse Floor Amendment No. 2 Filed with Clerk by Rep. Bob Morgan 4/16/2024HouseHouse Floor Amendment No. 2 Referred to Rules Committee 4/17/2024HouseHouse Floor Amendment No. 2 Rules Refers to Insurance Committee 4/17/2024HouseSecond Reading - Short Debate 4/17/2024HouseHeld on Calendar Order of Second Reading - Short Debate 4/18/2024HouseHouse Floor Amendment No. 2 Recommends Be Adopted Insurance Committee; 015-000-000 4/19/2024HouseHouse Floor Amendment No. 2 Adopted 4/19/2024HousePlaced on Calendar Order of 3rd Reading - Short Debate 4/19/2024HouseThird Reading - Short Debate - Passed 106-000-000 4/24/2024SenateArrive in Senate 4/24/2024SenatePlaced on Calendar Order of First Reading 4/24/2024SenateChief Senate Sponsor Sen. Laura Fine 4/24/2024SenateFirst Reading 4/24/2024SenateReferred to Assignments 4/30/2024SenateAssigned to Insurance 4/30/2024SenateRule 2-10 Committee Deadline Established As May 10, 2024 5/8/2024SenateDo Pass Insurance; 010-000-000 5/8/2024SenatePlaced on Calendar Order of 2nd Reading May 9, 2024 5/9/2024SenateSecond Reading 5/9/2024SenatePlaced on Calendar Order of 3rd Reading 5/15/2024SenateThird Reading - Passed; 057-000-000 5/15/2024HousePassed Both Houses 6/13/2024HouseSent to the Governor 7/19/2024HouseGovernor Approved 7/19/2024HouseEffective Date January 1, 2025 7/19/2024HousePublic Act . . . . . . . . . 103-0656