Healthcare (Insurance)

Amends the Accident and Health Article of the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2028 shall cover a medically necessary coronary calcium scan and scoring every 36 months for individuals over the age of 40. Defines "coronary calcium scan and scoring". Makes conforming changes in the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, the Voluntary Health Services Plans Act, and the Medical Assistance Article of the Illinois Public Aid Code. Effective January 1, 2027.

Amends the State Employees Group Insurance Act of 1971. Requires the Director of Central Management Services to designate one or more individuals who are employees of the Department of Central Management Services to serve as Health Care Ombudspersons. Requires the employees that are designated as Health Care Ombudspersons to monitor and respond to members' email and telephone questions to the Department of Central Management Services regarding the benefits that are available under the Act and the eligibility of members for those benefits. Requires contact information for the Health Care Ombudspersons to be included in any communications sent by the Department of Central Management Services regarding group health insurance benefits and to be readily available on the Department's website. Specifies that the primary goal of the Health Care Ombudspersons shall be to answer questions and generate information useful to participants in the program of group health benefits provided under the Act and, when possible, to resolve any issues between members and third-party providers of services established under this Act.

Amends the Illinois Insurance Code. Provides that any policy of insurance amended, delivered, issued, or renewed on or after January 1, 2027 that provides coverage for emergency services for medical or surgical conditions shall also provide coverage for behavioral health emergency services on coverage terms no more restrictive than those applied to emergency services for medical or surgical conditions. Requires coverage for post-stabilization services. Sets forth provisions concerning behavioral health emergency services parity; coverage of services provided by nonlicensed staff performing under direct supervision; restrictions on prior authorization, utilization review, and cost sharing; reimbursement rates; and rulemaking. Amends the Network Adequacy and Transparency Act. Includes behavioral health emergency services providers in network adequacy determinations under the Act. Establishes provisions concerning rulemaking for the Department of Insurance; behavioral health emergency services requirements for health insurance issuers; and enforcement coordination with specified federal law. Effective January 1, 2027.

Amends the Hospital Licensing Act. Provides that a hospital licensed under the Act shall not charge a covered hospital employee more than 10% of the total health insurance premium cost. Provides that any agreement permitting a charge to a covered hospital employee in excess of 10% of the total health insurance premium cost shall be deemed invalid, void, and unenforceable. Provides that a hospital in violation of those provisions shall pay a civil penalty of $500 to the Department of Public Health for each impacted covered hospital employee.

Amends the Network Adequacy and Transparency Act. Replaces provisions concerning uniform electronic provider directory information forms. Provides that each provider shall notify all contracted health insurance issuers of any change to the provider's information. Provides that the health insurance issuer shall use the information to update its provider directory within the time frames required under the Act. Provides that nothing in the provisions shall prohibit a health insurance issuer from using its own process, platform, or electronic system to receive provider directory updates, so long as the system allows providers to submit the required information. Effective immediately.

Amends the Genetic Information Privacy Act. Removes language exempting insurers that are issuing a long-term care policy from specified provisions. Provides that, with regard to any policy, contract, or plan offered, entered into, issued, amended, or renewed on or after January 1, 2027 by a health insurer, life insurer, disability insurer, or long-term care insurer authorized to transact insurance in this State, a health insurer, life insurer, disability insurer, or long-term care insurer may not: (1) cancel, limit, or deny coverage or establish differentials in premium rates based on a person's genetic information; or (2) require or solicit an individual's genetic information, use an individual's genetic test results, or consider an individual's decisions or actions relating to genetic information or a genetic test in any manner for any insurance purpose. Provides that the provisions may not be construed as: (1) preventing a life insurer, disability insurer, or long-term care insurer from accessing an individual's medical record as part of an application; or (2) prohibiting a life insurer, disability insurer, or long-term care insurer from considering a clinical diagnosis, such as a manifest disease or disorder, included in an individual's medical record for insurance purposes to the extent otherwise allowable by law. Effective July 1, 2026.

Creates the Illinois All-Payer Health Care Payment and Global Budget Act. Creates the Illinois Health Care Cost and Payment Board as an independent body within the Department of Healthcare and Family Services and sets forth its membership and powers. Defines "commercial payer" as any health insurance issuer, health maintenance organization, or third-party administrator subject to regulation by the Illinois Department of Insurance, excluding self-funded plans governed solely by ERISA. Provides that all commercial payers shall reimburse hospitals for covered services at standardized rates established by the Board. Defines "global hospital budget" as a prospective, fixed annual operating revenue amount established for a hospital to cover all inpatient and outpatient hospital services. Provides that the Board shall establish prospective annual global hospital budgets for Illinois hospitals. Provides that the Board shall establish a unified health care data system in coordination with State agencies. Creates the Health Care Payment Reform Advisory Council to advise the Board. Provides that the Governor, in consultation with the Board, shall seek all necessary federal approvals, including Medicare demonstrations and Medicaid waivers, to implement the Act. Amends the Illinois Administrative Procedure Act, Hospital Licensing Act, Illinois Insurance Code, Health Maintenance Organization Act, and Illinois Public Aid Code with regard to the new Act. Contains a severability clause. Effective immediately.

Creates the 340B Integrity Act. Defines terms. Provides that, beginning January 1, 2027, 340B covered entities shall not bill any medical assistance fee-for-service or medical assistance managed care programs under the Illinois Public Aid Code for 340B drugs. Provides that, beginning July 1, 2026 a 340B covered entity shall use 80% of 340B profits from the prior year to decrease at the point of sale, including at the 340B contract pharmacy, the out-of-pocket costs paid for 340B drugs that are dispensed or administered to low-income patients of the 340B covered entity. Provides that, on or before September 1, 2026, and on or before September 1 of each year thereafter, each 340B covered entity shall annually report to the Department of Insurance, with respect to the 340B covered entity and separately for each offsite outpatient facility associated with the 340B covered entity, the specified information about the prior year. Provides that, on or before December 31, 2026, the Department of Central Management Services shall submit a report to the General Assembly on any impact to the State employee health plan arising from 340B covered entity purchases, 340B contract pharmacy arrangements, and general practices related to 340B drugs, regardless of whether the 340B drugs were self-administered or provider-administered. Provides that the report shall include, but not be limited to, an analysis of foregone rebates, the impact on premiums, and the impact to State employee out-of-pocket costs. Provides that, on or before December 31, 2026, the Department of Healthcare and Family Services shall report to the General Assembly on certain items for total aggregated covered outpatient drug units dispensed or administered in the State for the prior calendar year in connection with the medical assistance program under the Illinois Public Aid Code, broken out by fee-for-service and by each managed care plan. Makes other changes. Effective immediately.

Amends the Illinois Insurance Code. Sets forth provisions requiring an individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2028 to provide coverage for up to a 12-month supply of prescription hormone therapy, and the necessary supplies for self-administration, that is prescribed by a network provider within the provider's scope of practice and dispensed at one time for an enrollee by a provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies. Amends the Pharmacy Practice Act. Provides that, notwithstanding any other provision of law, a dispensing provider or pharmacist shall dispense, at a patient's request, up to a 12-month supply of a prescription hormone therapy and the necessary supplies for self-administration pursuant to a valid prescription that specifies an initial quantity followed by periodic refills, except as specified. Amends the State Employees Group Insurance Act of 1971 and the Illinois Public Aid Code to require coverage under the provisions of those Acts.

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.