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Insurance

Payment issues with health insurance companies continue to cause headaches for physicians and their practices, the result of which continues to threaten the economic sustainability of healthcare. Access

Access to quality patient care is often disrupted due to barriers caused by health insurance companies, roadblocks that ultimately threaten the care Illinois patients’ need.

ISMS has worked to streamline onerous prior authorization requests and ensure transparency from insurance companies.

  • Network Adequacy & Transparency Act: ISMS crafted law which ensures the adequacy, accessibility and transparency of health care network plans.
  • Prevented Prescription Drug Formulary Disruptions: ISMS helped enact legislation that will prevent insurance companies from modifying an enrollee’s drug formulary coverage after the enrollee is already locked into a health plan for the year.
  • Right-to-Shop: ISMS blocked legislation that would encourage patients to focus exclusively on cost when seeking medical care, with complete disregard for physician experience, expertise or other factors related to quality of care, amongst other harmful provisions.
  • Drug Pricing: ISMS stopped legislation by insurers that would have coerced patients to choose the lowest-cost healthcare option by offering financial incentives.

To see ISMS’ specific work on more insurance related issues, please view the end of session legislative reports.

Currently Tracked Bills

ISMS Supports

Removing Prior Authorization for Chronic Condition Care: SB 3732 (Sponsor: Sen. Cristina Castro) - In 2021, the Illinois General Assembly approved, and the governor signed into law the Prior Authorization Reform Act to reduce prior authorization requirements instituted by health insurance entities that force patients to wait too long for medically necessary treatments and services.  Senate Bill 3732 further seeks to help patients by prohibiting prior authorization for medication that is prescribed for a chronic condition, long-term illness, or mental health condition that has been prescribed for six months or longer.SB 3732 has passed Senate Committee and awaits further floor action.

Healthcare Protection Act (HPA): HB 5395 and SB 3739 (Sponsors: Rep. Anna Moeller, Sen. Robert Peters) - The Governor’s initiative HB 5395/SB 3739 makes reforms and changes to Network Adequacy and Prior Authorization items.  It prohibits insurance companies from making up their own clinical criteria and require them to use generally accepted standards of care when deciding whether to cover a treatment recommended by a doctor. The bill also bans step therapy so healthcare consumers can get the care they need without requiring them to try less-effective treatments and fail before they can get the care their doctors prescribed. HB 5395 passed the House and will likely be negotiated in the Senate. 

Related Resources

Understanding the Patient’s Out-of-Pocket Expenses
Understanding the Patient’s Out-of-Pocket Expenses
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