Rep. Gregory Harris
Filed: 3/11/2019
 
 


 




10100HB0465ham001LRB101 03398 KTG 57549 a



1
AMENDMENT TO HOUSE BILL 465




2 AMENDMENT NO. ______. Amend House Bill 465 by replacing 
3everything after the enacting clause with the following:


4 "Section 1. The Freedom of Information Act is amended by 
5changing Section 7.5 as follows:

6 (5 ILCS 140/7.5)
7 Sec. 7.5. Statutory exemptions. To the extent provided for 
8by the statutes referenced below, the following shall be exempt 
9from inspection and copying:
10  (a) All information determined to be confidential 
11 under Section 4002 of the Technology Advancement and 
12 Development Act.
13  (b) Library circulation and order records identifying 
14 library users with specific materials under the Library 
15 Records Confidentiality Act.
16  (c) Applications, related documents, and medical 
 
 
10100HB0465ham001- 2 -LRB101 03398 KTG 57549 a


1 records received by the Experimental Organ Transplantation 
2 Procedures Board and any and all documents or other records 
3 prepared by the Experimental Organ Transplantation 
4 Procedures Board or its staff relating to applications it 
5 has received.
6  (d) Information and records held by the Department of 
7 Public Health and its authorized representatives relating 
8 to known or suspected cases of sexually transmissible 
9 disease or any information the disclosure of which is 
10 restricted under the Illinois Sexually Transmissible 
11 Disease Control Act.
12  (e) Information the disclosure of which is exempted 
13 under Section 30 of the Radon Industry Licensing Act.
14  (f) Firm performance evaluations under Section 55 of 
15 the Architectural, Engineering, and Land Surveying 
16 Qualifications Based Selection Act.
17  (g) Information the disclosure of which is restricted 
18 and exempted under Section 50 of the Illinois Prepaid 
19 Tuition Act.
20  (h) Information the disclosure of which is exempted 
21 under the State Officials and Employees Ethics Act, and 
22 records of any lawfully created State or local inspector 
23 general's office that would be exempt if created or 
24 obtained by an Executive Inspector General's office under 
25 that Act.
26  (i) Information contained in a local emergency energy 
 
 
10100HB0465ham001- 3 -LRB101 03398 KTG 57549 a


1 plan submitted to a municipality in accordance with a local 
2 emergency energy plan ordinance that is adopted under 
3 Section 11-21.5-5 of the Illinois Municipal Code.
4  (j) Information and data concerning the distribution 
5 of surcharge moneys collected and remitted by carriers 
6 under the Emergency Telephone System Act.
7  (k) Law enforcement officer identification information 
8 or driver identification information compiled by a law 
9 enforcement agency or the Department of Transportation 
10 under Section 11-212 of the Illinois Vehicle Code.
11  (l) Records and information provided to a residential 
12 health care facility resident sexual assault and death 
13 review team or the Executive Council under the Abuse 
14 Prevention Review Team Act.
15  (m) Information provided to the predatory lending 
16 database created pursuant to Article 3 of the Residential 
17 Real Property Disclosure Act, except to the extent 
18 authorized under that Article.
19  (n) Defense budgets and petitions for certification of 
20 compensation and expenses for court appointed trial 
21 counsel as provided under Sections 10 and 15 of the Capital 
22 Crimes Litigation Act. This subsection (n) shall apply 
23 until the conclusion of the trial of the case, even if the 
24 prosecution chooses not to pursue the death penalty prior 
25 to trial or sentencing.
26  (o) Information that is prohibited from being 
 
 
10100HB0465ham001- 4 -LRB101 03398 KTG 57549 a


1 disclosed under Section 4 of the Illinois Health and 
2 Hazardous Substances Registry Act.
3  (p) Security portions of system safety program plans, 
4 investigation reports, surveys, schedules, lists, data, or 
5 information compiled, collected, or prepared by or for the 
6 Regional Transportation Authority under Section 2.11 of 
7 the Regional Transportation Authority Act or the St. Clair 
8 County Transit District under the Bi-State Transit Safety 
9 Act. 
10  (q) Information prohibited from being disclosed by the 
11 Personnel Record Records Review Act. 
12  (r) Information prohibited from being disclosed by the 
13 Illinois School Student Records Act. 
14  (s) Information the disclosure of which is restricted 
15 under Section 5-108 of the Public Utilities Act. 

16  (t) All identified or deidentified health information 
17 in the form of health data or medical records contained in, 
18 stored in, submitted to, transferred by, or released from 
19 the Illinois Health Information Exchange, and identified 
20 or deidentified health information in the form of health 
21 data and medical records of the Illinois Health Information 
22 Exchange in the possession of the Illinois Health 
23 Information Exchange Authority due to its administration 
24 of the Illinois Health Information Exchange. The terms 
25 "identified" and "deidentified" shall be given the same 
26 meaning as in the Health Insurance Portability and 
 
 
10100HB0465ham001- 5 -LRB101 03398 KTG 57549 a


1 Accountability Act of 1996, Public Law 104-191, or any 
2 subsequent amendments thereto, and any regulations 
3 promulgated thereunder. 
4  (u) Records and information provided to an independent 
5 team of experts under the Developmental Disability and 
6 Mental Health Safety Act (also known as Brian's Law). 
7  (v) Names and information of people who have applied 
8 for or received Firearm Owner's Identification Cards under 
9 the Firearm Owners Identification Card Act or applied for 
10 or received a concealed carry license under the Firearm 
11 Concealed Carry Act, unless otherwise authorized by the 
12 Firearm Concealed Carry Act; and databases under the 
13 Firearm Concealed Carry Act, records of the Concealed Carry 
14 Licensing Review Board under the Firearm Concealed Carry 
15 Act, and law enforcement agency objections under the 
16 Firearm Concealed Carry Act. 
17  (w) Personally identifiable information which is 
18 exempted from disclosure under subsection (g) of Section 
19 19.1 of the Toll Highway Act.
20  (x) Information which is exempted from disclosure 
21 under Section 5-1014.3 of the Counties Code or Section 
22 8-11-21 of the Illinois Municipal Code. 
23  (y) Confidential information under the Adult 
24 Protective Services Act and its predecessor enabling 
25 statute, the Elder Abuse and Neglect Act, including 
26 information about the identity and administrative finding 
 
 
10100HB0465ham001- 6 -LRB101 03398 KTG 57549 a


1 against any caregiver of a verified and substantiated 
2 decision of abuse, neglect, or financial exploitation of an 
3 eligible adult maintained in the Registry established 
4 under Section 7.5 of the Adult Protective Services Act. 
5  (z) Records and information provided to a fatality 
6 review team or the Illinois Fatality Review Team Advisory 
7 Council under Section 15 of the Adult Protective Services 
8 Act. 
9  (aa) Information which is exempted from disclosure 
10 under Section 2.37 of the Wildlife Code. 
11  (bb) Information which is or was prohibited from 
12 disclosure by the Juvenile Court Act of 1987. 
13  (cc) Recordings made under the Law Enforcement 
14 Officer-Worn Body Camera Act, except to the extent 
15 authorized under that Act.
16  (dd) Information that is prohibited from being 
17 disclosed under Section 45 of the Condominium and Common 
18 Interest Community Ombudsperson Act. 
19  (ee) Information that is exempted from disclosure 
20 under Section 30.1 of the Pharmacy Practice Act. 
21  (ff) Information that is exempted from disclosure 
22 under the Revised Uniform Unclaimed Property Act. 
23  (gg) Information that is prohibited from being 
24 disclosed under Section 7-603.5 of the Illinois Vehicle 
25 Code. 
26  (hh) Records that are exempt from disclosure under 
 
 
10100HB0465ham001- 7 -LRB101 03398 KTG 57549 a


1 Section 1A-16.7 of the Election Code. 
2  (ii) Information which is exempted from disclosure 
3 under Section 2505-800 of the Department of Revenue Law of 
4 the Civil Administrative Code of Illinois. 
5  (jj) Information and reports that are required to be 
6 submitted to the Department of Labor by registering day and 
7 temporary labor service agencies but are exempt from 
8 disclosure under subsection (a-1) of Section 45 of the Day 
9 and Temporary Labor Services Act. 
10  (kk) Information prohibited from disclosure under the 
11 Seizure and Forfeiture Reporting Act. 
12  (ll) Information the disclosure of which is restricted 
13 and exempted under Section 5-30.8 of the Illinois Public 
14 Aid Code. 
15  (mm) (ll) Records that are exempt from disclosure under 
16 Section 4.2 of the Crime Victims Compensation Act. 
17  (nn) (ll) Information that is exempt from disclosure 
18 under Section 70 of the Higher Education Student Assistance 
19 Act. 
20  (oo) Information that is exempt from disclosure under 
21 subsection (j) of Section 5-36 of the Illinois Public Aid 
22 Code. 
23(Source: P.A. 99-78, eff. 7-20-15; 99-298, eff. 8-6-15; 99-352, 
24eff. 1-1-16; 99-642, eff. 7-28-16; 99-776, eff. 8-12-16; 
2599-863, eff. 8-19-16; 100-20, eff. 7-1-17; 100-22, eff. 1-1-18; 
26100-201, eff. 8-18-17; 100-373, eff. 1-1-18; 100-464, eff. 
 
 
10100HB0465ham001- 8 -LRB101 03398 KTG 57549 a


18-28-17; 100-465, eff. 8-31-17; 100-512, eff. 7-1-18; 100-517, 
2eff. 6-1-18; 100-646, eff. 7-27-18; 100-690, eff. 1-1-19; 
3100-863, eff. 8-14-18; 100-887, eff. 8-14-18; revised 
410-12-18.)

5 Section 5. The State Employees Group Insurance Act of 1971 
6is amended by changing Section 6.11 as follows:



7 (5 ILCS 375/6.11)

8 Sec. 6.11. Required health benefits; Illinois Insurance 
9Code
requirements. The program of health
benefits shall provide 
10the post-mastectomy care benefits required to be covered
by a 
11policy of accident and health insurance under Section 356t of 
12the Illinois
Insurance Code. The program of health benefits 
13shall provide the coverage
required under Sections 356g, 
14356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, 
15356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 
16356z.14, 356z.15, 356z.17, 356z.22, 356z.25, and 356z.26, and 
17356z.29, and 356z.32 of the
Illinois Insurance Code.
The 
18program of health benefits must comply with Sections 155.22a, 
19155.37, 355b, 356z.19, 370c, and 370c.1, and Article XXXIIB of 
20the
Illinois Insurance Code. The Department of Insurance shall 
21enforce the requirements of this Section.

22 Rulemaking authority to implement Public Act 95-1045, if 
23any, is conditioned on the rules being adopted in accordance 
24with all provisions of the Illinois Administrative Procedure 
 
 
10100HB0465ham001- 9 -LRB101 03398 KTG 57549 a


1Act and all rules and procedures of the Joint Committee on 
2Administrative Rules; any purported rule not so adopted, for 
3whatever reason, is unauthorized. 
4(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; 
5100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff. 
61-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised 
710-3-18.)

8 Section 10. The Illinois Insurance Code is amended by 
9adding Article XXXIIB as follows:

10 (215 ILCS 5/Art. XXXIIB heading new)
11
ARTICLE XXXIIB.  PHARMACY BENEFIT MANAGERS


12 (215 ILCS 5/513b1 new)
13 Sec. 513b1. Pharmacy benefit manager contracts.
14 (a) As used in this Section: 
15 "Maximum allowable cost" means the per-unit amount that a 
16pharmacy benefit manager reimburses a pharmacist for a 
17prescription drug, excluding dispensing fees, prior to the 
18application of copayments, coinsurance, and other cost-sharing 
19charges, if any. 
20 "Pharmacy benefit manager" means a person, business, or 
21entity, including a wholly or partially owned or controlled 
22subsidiary of a pharmacy benefit manager, that provides claims 
23processing services or other prescription drug or device 
 
 
10100HB0465ham001- 10 -LRB101 03398 KTG 57549 a


1services, or both, for health benefit plans. 
2 (b) A contract between a health insurer and a pharmacy 
3benefit manager must require that the pharmacy benefit manager: 
4  (1) Update maximum allowable cost pricing information 
5 at least every 7 calendar days. 
6  (2) Maintain a process that will, in a timely manner, 
7 eliminate drugs from maximum allowable cost lists or modify 
8 drug prices to remain consistent with changes in pricing 
9 data used in formulating maximum allowable cost prices and 
10 product availability. 
11 (c) In order to place a particular prescription drug on a 
12maximum allowable cost list, the pharmacy benefit manager must, 
13at a minimum, ensure that: 
14  (1) The drug must have at least 3 or more nationally 
15 available, therapeutically equivalent, multiple source 
16 generic drugs with a significant cost difference. 
17  (2) The products must be listed as therapeutically and 
18 pharmaceutically equivalent or "A" or "AB" rated in the 
19 Food and Drug Administration's most recent version of the 
20 "Orange Book." 
21  (3) The product must be available for purchase without 
22 limitations by all pharmacies in the State from national or 
23 regional wholesalers and not obsolete or temporarily 
24 unavailable. 
25 (d) A contract between a health insurer and a pharmacy 
26benefit manager must prohibit the pharmacy benefit manager from 
 
 
10100HB0465ham001- 11 -LRB101 03398 KTG 57549 a


1limiting a pharmacist's ability to disclose whether the 
2cost-sharing obligation exceeds the retail price for a covered 
3prescription drug, and the availability of a more affordable 
4alternative drug, in accordance with Section 42 of the Pharmacy 
5Practice Act. 
6 (e) A contract between a health insurer and a pharmacy 
7benefit manager must prohibit the pharmacy benefit manager from 
8requiring an insured to make a payment for a prescription drug 
9at the point of sale in an amount that exceeds the lesser of: 
10  (1) the applicable cost-sharing amount; or
11  (2) the retail price of the drug in the absence of 
12 prescription drug coverage. 
13 (f) This Section applies to contracts entered into or 
14renewed on or after July 1, 2020. 
15 (g) This Section applies to any group or individual policy 
16of accident and health insurance or managed care plan that 
17provides coverage for prescription drugs and that is amended, 
18delivered, issued, or renewed on or after July 1, 2020. 

19 (215 ILCS 5/513b2 new)
20 Sec. 513b2. Licensure requirements.
21 (a) Beginning on July 1, 2020, to conduct business in this 
22State, a pharmacy benefit manager must register with the 
23Director. To initially register or renew a registration, a 
24pharmacy benefit manager shall submit: 
25  (1) A nonrefundable fee not to exceed $500. 
 
 
10100HB0465ham001- 12 -LRB101 03398 KTG 57549 a


1  (2) A copy of the registrant's corporate charter, 
2 articles of incorporation, or other charter document. 
3  (3) A completed registration form adopted by the 
4 Director containing: 
5   (A) The name and address of the registrant. 
6   (B) The name, address, and official position of 
7 each officer and director of the registrant. 
8 (b) The registrant shall report any change in information 
9required under this Section to the Director in writing within 
1060 days after the change occurs. 
11 (c) Upon receipt of a completed registration form, the 
12required documents, and the registration fee, the Director 
13shall issue a registration certificate. The certificate may be 
14in paper or electronic form, and shall clearly indicate the 
15expiration date of the registration. Registration certificates 
16are nontransferable. 
17 (d) A registration certificate is valid for 2 years after 
18its date of issue. The Director shall adopt by rule an initial 
19registration fee not to exceed $500 and a registration renewal 
20fee not to exceed $500, both of which shall be nonrefundable. 
21Total fees may not exceed the cost of administering this 
22Section. 
23 (e) The Department shall adopt any rules necessary to 
24implement this Section. 

25 (215 ILCS 5/513b3 new)
 
 
10100HB0465ham001- 13 -LRB101 03398 KTG 57549 a


1 Sec. 513b3. Examination.
2 (a) The Director, or his or her designee, may examine a 
3registered pharmacy benefit manager.
4 (b) Any pharmacy benefit manager being examined shall 
5provide to the Director, or his or her designee, convenient and 
6free access to all books, records, documents, and other papers 
7relating to such pharmacy benefit manager's business affairs at 
8all reasonable hours at its offices.
9 (c) The Director, or his or her designee, may administer 
10oaths and thereafter examine any individual about the business 
11of the pharmacy benefit manager.
12 (d) The examiners designated by the Director under this 
13Section may make reports to the Director. Any report alleging 
14substantive violations of this Article, any applicable 
15provisions of this Code, or any applicable Part of Title 50 of 
16the Illinois Administrative Code shall be in writing and be 
17based upon facts obtained by the examiners. The report shall be 
18verified by the examiners.
19 (e) If a report is made, the Director shall either deliver 
20a duplicate report to the pharmacy benefit manager being 
21examined or send such duplicate by certified or registered mail 
22to the pharmacy benefit manager's address specified in the 
23records of the Department. The Director shall afford the 
24pharmacy benefit manager an opportunity to request a hearing to 
25object to the report. The pharmacy benefit manager may request 
26a hearing within 30 days after receipt of the duplicate report 
 
 
10100HB0465ham001- 14 -LRB101 03398 KTG 57549 a


1by giving the Director written notice of such request together 
2with written objections to the report. Any hearing shall be 
3conducted in accordance with Sections 402 and 403 of this Code. 
4The right to a hearing is waived if the delivery of the report 
5is refused or the report is otherwise undeliverable or the 
6pharmacy benefit manager does not timely request a hearing. 
7After the hearing or upon expiration of the time period during 
8which a pharmacy benefit manager may request a hearing, if the 
9examination reveals that the pharmacy benefit manager is 
10operating in violation of any applicable provision of this 
11Code, any applicable Part of Title 50 of the Illinois 
12Administrative Code, a provision of this Article, or prior 
13order, the Director, in the written order, may require the 
14pharmacy benefit manager to take any action the Director 
15considers necessary or appropriate in accordance with the 
16report or examination hearing. If the Director issues an order, 
17it shall be issued within 90 days after the report is filed, or 
18if there is a hearing, within 90 days after the conclusion of 
19the hearing. The order is subject to review under the 
20Administrative Review Law.

21 (215 ILCS 5/513b4 new)
22 Sec. 513b4. Administrative fine.
23 (a) If the Director finds that one or more grounds exist 
24for the revocation or suspension of a registration issued under 
25this Article, the Director may, in lieu of or in addition to 
 
 
10100HB0465ham001- 15 -LRB101 03398 KTG 57549 a


1such suspension or revocation, impose a fine upon the pharmacy 
2benefit manager as provided under subsection (b).
3 (b) With respect to any knowing and willful violation of a 
4lawful order of the Director, any applicable portion of this 
5Code, Part of Title 50 of the Illinois Administrative Code, or 
6provision of this Article, the Director may impose a fine upon 
7the pharmacy benefit manager in an amount not to exceed $50,000 
8for each violation.

9 (215 ILCS 5/513b5 new)
10 Sec. 513b5. Failure to register. Any pharmacy benefit 
11manager that operates without a registration or fails to 
12register with the Director and pay the fee prescribed by this 
13Article is an unauthorized insurer as defined in Article VII of 
14this Code and shall be subject to all penalties provided for 
15therein.

16 (215 ILCS 5/513b6 new)
17 Sec. 513b6. Insurance Producer Administration Fund.  All 
18fees and fines paid to and collected by the Director under this 
19Article shall be paid promptly after receipt thereof, together 
20with a detailed statement of such fees, into the Insurance 
21Producer Administration Fund. The moneys deposited into the 
22Insurance Producer Administration Fund may be transferred to 
23the Professions Indirect Cost Fund, as authorized under Section 
242105-300 of the Department of Professional Regulation Law of 
 
 
10100HB0465ham001- 16 -LRB101 03398 KTG 57549 a


1the Civil Administrative Code of Illinois.

2 Section 15. The Health Maintenance Organization Act is 
3amended by changing Section 5-3 as follows:



4 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)


5 Sec. 5-3. Insurance Code provisions. 

6 (a) Health Maintenance Organizations
shall be subject to 
7the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,

8141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 
9154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, 
10355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, 
11356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 
12356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 
13356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 364, 
14364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 
15370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 
16444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, 
17and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, 
18and XXVI, and XXXIIB of the Illinois Insurance Code.

19 (b) For purposes of the Illinois Insurance Code, except for 
20Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
21Maintenance Organizations in
the following categories are 
22deemed to be "domestic companies":

23  (1) a corporation authorized under the
Dental Service 
24 Plan Act or the Voluntary Health Services Plans Act;

 
 
10100HB0465ham001- 17 -LRB101 03398 KTG 57549 a


1  (2) a corporation organized under the laws of this 
2 State; or

3  (3) a corporation organized under the laws of another 
4 state, 30% or more
of the enrollees of which are residents 
5 of this State, except a
corporation subject to 
6 substantially the same requirements in its state of

7 organization as is a "domestic company" under Article VIII 
8 1/2 of the
Illinois Insurance Code.

9 (c) In considering the merger, consolidation, or other 
10acquisition of
control of a Health Maintenance Organization 
11pursuant to Article VIII 1/2
of the Illinois Insurance Code,

12  (1) the Director shall give primary consideration to 
13 the continuation of
benefits to enrollees and the financial 
14 conditions of the acquired Health
Maintenance Organization 
15 after the merger, consolidation, or other
acquisition of 
16 control takes effect;

17  (2)(i) the criteria specified in subsection (1)(b) of 
18 Section 131.8 of
the Illinois Insurance Code shall not 
19 apply and (ii) the Director, in making
his determination 
20 with respect to the merger, consolidation, or other

21 acquisition of control, need not take into account the 
22 effect on
competition of the merger, consolidation, or 
23 other acquisition of control;

24  (3) the Director shall have the power to require the 
25 following
information:

26   (A) certification by an independent actuary of the 
 
 
10100HB0465ham001- 18 -LRB101 03398 KTG 57549 a


1 adequacy
of the reserves of the Health Maintenance 
2 Organization sought to be acquired;

3   (B) pro forma financial statements reflecting the 
4 combined balance
sheets of the acquiring company and 
5 the Health Maintenance Organization sought
to be 
6 acquired as of the end of the preceding year and as of 
7 a date 90 days
prior to the acquisition, as well as pro 
8 forma financial statements
reflecting projected 
9 combined operation for a period of 2 years;

10   (C) a pro forma business plan detailing an 
11 acquiring party's plans with
respect to the operation 
12 of the Health Maintenance Organization sought to
be 
13 acquired for a period of not less than 3 years; and

14   (D) such other information as the Director shall 
15 require.

16 (d) The provisions of Article VIII 1/2 of the Illinois 
17Insurance Code
and this Section 5-3 shall apply to the sale by 
18any health maintenance
organization of greater than 10% of its

19enrollee population (including without limitation the health 
20maintenance
organization's right, title, and interest in and to 
21its health care
certificates).

22 (e) In considering any management contract or service 
23agreement subject
to Section 141.1 of the Illinois Insurance 
24Code, the Director (i) shall, in
addition to the criteria 
25specified in Section 141.2 of the Illinois
Insurance Code, take 
26into account the effect of the management contract or
service 
 
 
10100HB0465ham001- 19 -LRB101 03398 KTG 57549 a


1agreement on the continuation of benefits to enrollees and the

2financial condition of the health maintenance organization to 
3be managed or
serviced, and (ii) need not take into account the 
4effect of the management
contract or service agreement on 
5competition.

6 (f) Except for small employer groups as defined in the 
7Small Employer
Rating, Renewability and Portability Health 
8Insurance Act and except for
medicare supplement policies as 
9defined in Section 363 of the Illinois
Insurance Code, a Health 
10Maintenance Organization may by contract agree with a
group or 
11other enrollment unit to effect refunds or charge additional 
12premiums
under the following terms and conditions:

13  (i) the amount of, and other terms and conditions with 
14 respect to, the
refund or additional premium are set forth 
15 in the group or enrollment unit
contract agreed in advance 
16 of the period for which a refund is to be paid or

17 additional premium is to be charged (which period shall not 
18 be less than one
year); and

19  (ii) the amount of the refund or additional premium 
20 shall not exceed 20%
of the Health Maintenance 
21 Organization's profitable or unprofitable experience
with 
22 respect to the group or other enrollment unit for the 
23 period (and, for
purposes of a refund or additional 
24 premium, the profitable or unprofitable
experience shall 
25 be calculated taking into account a pro rata share of the

26 Health Maintenance Organization's administrative and 
 
 
10100HB0465ham001- 20 -LRB101 03398 KTG 57549 a


1 marketing expenses, but
shall not include any refund to be 
2 made or additional premium to be paid
pursuant to this 
3 subsection (f)). The Health Maintenance Organization and 
4 the
group or enrollment unit may agree that the profitable 
5 or unprofitable
experience may be calculated taking into 
6 account the refund period and the
immediately preceding 2 
7 plan years.

8 The Health Maintenance Organization shall include a 
9statement in the
evidence of coverage issued to each enrollee 
10describing the possibility of a
refund or additional premium, 
11and upon request of any group or enrollment unit,
provide to 
12the group or enrollment unit a description of the method used 
13to
calculate (1) the Health Maintenance Organization's 
14profitable experience with
respect to the group or enrollment 
15unit and the resulting refund to the group
or enrollment unit 
16or (2) the Health Maintenance Organization's unprofitable

17experience with respect to the group or enrollment unit and the 
18resulting
additional premium to be paid by the group or 
19enrollment unit.

20 In no event shall the Illinois Health Maintenance 
21Organization
Guaranty Association be liable to pay any 
22contractual obligation of an
insolvent organization to pay any 
23refund authorized under this Section.

24 (g) Rulemaking authority to implement Public Act 95-1045, 
25if any, is conditioned on the rules being adopted in accordance 
26with all provisions of the Illinois Administrative Procedure 
 
 
10100HB0465ham001- 21 -LRB101 03398 KTG 57549 a


1Act and all rules and procedures of the Joint Committee on 
2Administrative Rules; any purported rule not so adopted, for 
3whatever reason, is unauthorized. 
4(Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17; 
5100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff. 
68-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised 
710-4-18.)

8 Section 20. The Managed Care Reform and Patient Rights Act 
9is amended by changing Sections 30 and 65 as follows:




10 (215 ILCS 134/30)



11 Sec. 30. Prohibitions. 

12 (a) No health care plan or its subcontractors may prohibit 
13or discourage
health care providers
by contract or policy from

14discussing any health care services and health care providers, 
15utilization
review and quality assurance policies, terms and 
16conditions of plans and plan
policy with enrollees, prospective 
17enrollees, providers, or the public.

18 (b) No health care plan by contract, written policy, or 
19procedure may
permit or allow an individual or entity to 
20dispense a different
drug in place of the drug or brand of drug 
21ordered or prescribed without the
express permission of the 
22person ordering or prescribing the drug, except as
provided 
23under Section 3.14 of the Illinois Food, Drug and Cosmetic Act.

24 (c) No health care plan or its subcontractors may by 
 
 
10100HB0465ham001- 22 -LRB101 03398 KTG 57549 a


1contract, written
policy, procedure, or otherwise mandate or 
2require an enrollee
to substitute his or her participating 
3primary care physician
under the plan during inpatient 
4hospitalization, such as with a hospitalist physician licensed 
5to practice medicine in all its branches,
without the agreement 
6of that enrollee's
participating primary care physician. 
7"Participating primary care
physician" for health care plans 
8and subcontractors that do not require
coordination of care by 
9a primary care physician means the participating
physician 
10treating the patient. All health care plans shall inform 
11enrollees
of any policies, recommendations, or guidelines 
12concerning the
substitution of the enrollee's primary care 
13physician when hospitalization is
necessary in the manner set 
14forth in subsections (d) and (e) of Section 15.

15 (d) A health care plan shall apply any third-party 
16payments, financial assistance, discount, product vouchers, or 
17any other reduction in out-of-pocket expenses made by or on 
18behalf of such insured for prescription drugs toward a covered 
19individual's deductible, copay, or cost-sharing 
20responsibility, or out-of-pocket maximum associated with the 
21individual's health insurance. 
22 (e) (d) Any violation of this Section shall be subject to 
23the
penalties under this Act.

24(Source: P.A. 94-866, eff. 6-16-06.)





25 (215 ILCS 134/65)



 
 
10100HB0465ham001- 23 -LRB101 03398 KTG 57549 a


1 Sec. 65. Emergency services prior to stabilization. 

2 (a) A health care plan
that provides or that is required by 
3law to provide coverage for emergency
services shall provide 
4coverage such that payment under this coverage is not
dependent 
5upon whether the services are performed by a plan or non-plan 
6health
care provider and without regard to prior authorization. 
7This coverage shall be
at the same benefit level as if the 
8services or treatment had been rendered by
the health care plan 
9physician licensed to practice medicine in all
its branches or 
10health care provider.

11 (b) Prior authorization or approval by the plan shall not 
12be required for
emergency services.

13 (c) Coverage and payment shall only be retrospectively 
14denied under the
following circumstances:


15  (1) upon reasonable determination that the emergency 
16 services claimed were
never performed;


17  (2) upon timely determination that the emergency 
18 evaluation and treatment
were
rendered to an enrollee who 
19 sought emergency services and whose circumstance
did not 
20 meet the definition of emergency medical condition; any 
21 denial under this paragraph (2) shall be based on the 
22 prudent layperson standard at the time the enrollee first 
23 sought emergency evaluation and treatment for his or her 
24 symptoms; insurers are prohibited from denying claims 
25 under this paragraph (2) based on the use of diagnosis or 
26 procedure codes; 


 
 
10100HB0465ham001- 24 -LRB101 03398 KTG 57549 a


1  (3) upon determination that the patient receiving such 
2 services was not an
enrollee of the health care plan; or


3  (4) upon material misrepresentation by the enrollee or 
4 health care
provider; "material" means a fact or situation 
5 that is not merely technical in
nature and results or could 
6 result in a substantial change in the situation.

7 (d) When an enrollee presents to a hospital seeking 
8emergency services,
the determination as to whether the need 
9for those
services exists shall be made for purposes of 
10treatment by a
physician licensed to practice medicine in all 
11its branches or, to the extent
permitted by applicable law, by 
12other appropriately licensed
personnel under the supervision 
13of
or in collaboration with a physician licensed to practice 
14medicine in all its
branches.
The physician or other

15appropriate personnel shall indicate in the patient's chart the 
16results of the
emergency medical screening examination.

17 (e) The appropriate use of the 911 emergency telephone 
18system or its local
equivalent shall not be discouraged or 
19penalized by the health care plan when
an emergency medical 
20condition exists.
This provision shall not imply that the use 
21of 911 or its local equivalent is a
factor in determining the 
22existence of an emergency medical condition.

23 (f) The medical director's or his or her designee's

24determination of whether the enrollee meets the standard of an 
25emergency
medical condition shall be based solely upon the 
26presenting symptoms documented
in the medical record at the 
 
 
10100HB0465ham001- 25 -LRB101 03398 KTG 57549 a


1time care was
sought.
Only a clinical peer may make an adverse 
2determination.

3 (g) Nothing in this Section shall prohibit the imposition 
4of deductibles,
copayments, and co-insurance.
Nothing in this 
5Section alters the prohibition on billing enrollees contained

6in the Health Maintenance Organization Act.

7(Source: P.A. 91-617, eff. 1-1-00.)


8 Section 25. The Pharmacy Practice Act is amended by adding 
9Section 42 as follows:

10 (225 ILCS 85/42 new)
11 Sec. 42. Information disclosure. A pharmacist or her or his 
12authorized employee must inform customers of a less expensive, 
13generically equivalent drug product for her or his prescription 
14and whether the cost-sharing obligation to the customer exceeds 
15the retail price of the prescription in the absence of 
16prescription drug coverage.

17 Section 30. The Illinois Public Aid Code is amended by 
18adding Section 5-36 as follows:

19 (305 ILCS 5/5-36 new)
20 Sec. 5-36. Pharmacy benefits. 
21 (a)(1) The Department may enter into a contract with any 
22third party on a fee-for-service reimbursement model for the 
 
 
10100HB0465ham001- 26 -LRB101 03398 KTG 57549 a


1purpose of administering pharmacy benefits as provided in this 
2Section; however, these services shall be approved by the 
3Department. The Department shall ensure coordination of care 
4between the third-party administrator and managed care 
5organizations as a consideration in any contracts established 
6in accordance with this Section. Any managed care techniques, 
7principles, or administration of benefits utilized in 
8accordance with this subsection shall comply with State law. 
9 (2) The following shall apply to contracts between entities 
10contracting relating to third-party administrators and 
11pharmacies: 
12  (A) the Department shall approve any contract between a 
13 third-party administrator and a pharmacy;
14  (B) a third-party administrator shall not change the 
15 terms of a contract between a third-party administrator and 
16 a pharmacy without written approval by the Department; and
17  (C) a third-party administrator shall not create, 
18 modify, implement, or indirectly establish any fee on a 
19 pharmacy, pharmacist, or a recipient of medical assistance 
20 without written approval by the Department. 
21 (b) The provisions of this Section shall not apply to 
22outpatient pharmacy services provided by a health care facility 
23registered as a covered entity pursuant to 42 U.S.C. 256b or 
24any pharmacy owned by or contracted with the covered entity. A 
25Medicaid managed care organization shall, either directly or 
26through a pharmacy benefit manager, administer and reimburse 
 
 
10100HB0465ham001- 27 -LRB101 03398 KTG 57549 a


1outpatient pharmacy claims submitted by a health care facility 
2registered as a covered entity pursuant to 42 U.S.C. 256b, its 
3owned pharmacies, and contracted pharmacies in accordance with 
4the contractual agreements the Medicaid managed care 
5organization or its pharmacy benefit manager has with such 
6facilities and pharmacies. A Medicaid managed care 
7organization or its pharmacy benefit manager shall not exclude 
8any health care facility registered as a covered entity 
9pursuant to 42 U.S.C. 256b from its pharmacy network. Any 
10pharmacy benefit manager that contracts with a Medicaid managed 
11care organization to administer and reimburse outpatient 
12pharmacy claims as provided in this Section must be registered 
13with the Director of Insurance in accordance with Section 513b2 
14of the Illinois Insurance Code. 
15 (c) On at least an annual basis, the Director of the 
16Department of Healthcare and Family Services shall submit a 
17report beginning no later than one year after the effective 
18date of this amendatory Act of the 101st General Assembly to 
19the House and Senate Human Services Committees and the House 
20and Senate Financial Institutions Committees that provides an 
21update on any contract, contract issues, formulary, dispensing 
22fees, and maximum allowable cost concerns regarding a 
23third-party administrator and managed care. 
24 (d) A pharmacy benefit manager shall notify the Department 
25in writing of any activity, policy, or practice of the pharmacy 
26benefit manager that directly or indirectly presents a conflict 
 
 
10100HB0465ham001- 28 -LRB101 03398 KTG 57549 a


1of interest that interferes with the discharge of the pharmacy 
2benefit manager's duty to a managed care organization to 
3exercise its contractual duties. 
4 (e) A pharmacy benefit manager shall, upon request, 
5disclose to the Department the following information: 
6  (1) whether the pharmacy benefit manager has a 
7 contract, agreement, or other arrangement with a 
8 pharmaceutical manufacturer to exclusively dispense or 
9 provide a drug to a managed care organization's enrollees, 
10 and the application of all consideration or economic 
11 benefits collected or received pursuant to that 
12 arrangement; 
13  (2) the percentage of claims payments made by the 
14 pharmacy benefit manager to pharmacies owned, managed, or 
15 controlled by the pharmacy benefit manager or any of the 
16 pharmacy benefit manager's management companies, parent 
17 companies, subsidiary companies, jointly held companies, 
18 or companies otherwise affiliated by a common owner, 
19 manager, or holding company for the previous year; 
20  (3) the aggregate amount of the fees or assessments 
21 imposed on, or collected from, pharmacy providers; and 
22  (4) the average annualized percentage of revenue 
23 collected by the pharmacy benefit manager as a result of 
24 each contract it has executed with a managed care 
25 organization contracted by the Department to provide 
26 medical assistance benefits which is not paid by the 
 
 
10100HB0465ham001- 29 -LRB101 03398 KTG 57549 a


1 pharmacy benefit manager to pharmacy providers and 
2 pharmaceutical manufacturers or labelers or in order to 
3 perform administrative functions pursuant to its contracts 
4 with managed care organizations. 
5 (f) The information disclosed under subsection (e) shall 
6include all retail, mail order, specialty, and compounded 
7prescription products. All information made
available to the 
8Department under subsection (e) is confidential and not subject 
9to disclosure under the Freedom of Information Act. 
10 (g) A pharmacy benefit manager shall disclose directly in 
11writing to a pharmacy provider contracting with the pharmacy 
12benefit manager of any material change to a contract provision 
13that affects the terms of the reimbursement, the process for 
14verifying benefits and eligibility, dispute resolution, 
15procedures for verifying drugs included on the formulary, and 
16contract termination at least 30 days prior to the date of the 
17change to the provision. 
18 (h) A pharmacy benefit manager shall not include the 
19following in a contract with a pharmacy provider: 
20  (1) a provision prohibiting the provider from 
21 informing a patient of a less costly alternative to a 
22 prescribed medication; or 
23  (2) a provision that prohibits the provider from 
24 dispensing a particular amount of a prescribed medication, 
25 if the pharmacy benefit manager allows that amount to be 
26 dispensed through a pharmacy owned or controlled by the 
 
 
10100HB0465ham001- 30 -LRB101 03398 KTG 57549 a


1 pharmacy benefit manager, unless the prescription drug is 
2 subject to restricted distribution by the United States 
3 Food and Drug Administration or requires special handling, 
4 provider coordination, or patient education that cannot be 
5 provided by a retail pharmacy. 
6 (i) Nothing in this Section shall be construed to prohibit 
7a pharmacy benefit manager from requiring the same 
8reimbursement and terms and conditions for a pharmacy provider 
9as for a pharmacy owned, controlled, or otherwise associated 
10with the pharmacy benefit manager. 
11 (j) A pharmacy benefit manager shall establish and 
12implement a process for the resolution of disputes arising out 
13of this Section, which shall be approved by the Department. 
14 (k) The Department shall adopt rules establishing 
15reasonable dispensing fees in accordance with guidance or 
16guidelines from the federal Centers for Medicare and Medicaid 
17Services.


18 Section 97. Severability. If any provision of this Act or 
19the application of this Act to any person or circumstance is 
20held invalid, the invalidity shall not affect other provisions 
21or applications of this Act which can be given effect without 
22the invalid provision or application, and to this end, the 
23provisions of this Act are declared severable.".