New Law Prevents Midyear Health Plan Coverage Changes for Treatments Patients Rely Upon – Helping to Ensure that the People of Illinois Receive the Coverage They Selected for the Year

August 29, 2018 – The Illinois Fair Care Coalition, a group of state-based and national patient and provider groups working to protect health benefits throughout the health plan year, today commended Illinois Governor Bruce Rauner for signing a law protecting Illinoisans from “non-medical switching” – unfair treatment coverage reductions made throughout the plan year, when Illinois families and individuals are locked into their health plans. The law, Public Act 100-1052, amends the Managed Care Reform and Patient Rights Act and applies to commercially insured patients already receiving treatments whose coverage has been reduced during the plan year. The law will take effect January 1, 2019.

“My family’s experience is proof that unfair treatment coverage reductions are prevalent, unfair and dangerous,” said Joanne Guthrie-Gard, an Illinois mom and advocate of Public Act 100-1052 whose story was profiled in the Chicago Tribune earlier this year. “When our insurance company switched my daughter’s epilepsy medication in the middle of the year and we couldn’t afford it, Erin’s side effects returned, causing her to miss school and putting her health in jeopardy. This new law means Erin and so many others like her will be protected, and that the health plans we sign up for will actually be what we receive for the year.”

Under Public Act 100-1052, health plans cannot undercut access to care by removing a drug from the formulary or negatively changing its preferred status or cost-sharing tier, unless the plan notifies the patient at least 60 days before the coverage change occurs. Health plans must:

  • Notify patients of the specific drugs involved in the coverage change;
  • Include the steps patients may take to request coverage determinations and exceptions; and
  • Notify the prescribing provider and provide a mechanism to authorize continuation of coverage.

When a health plan notifies a prescriber about a midyear formulary change, they must include a one-page form or instructions to access an online portal where the doctor can easily request that the health plan continue providing coverage because the drug is medically necessary. That prescriber certification alone will authorize continuation of coverage for the drug.

“I’m proud to have worked with colleagues across the aisle in the Illinois General Assembly to fight for stronger patient protections,” said Representative Laura Fine (D – 17th District), Chief Sponsor of HB 4146, now Public Act 100-1052. “I want to thank the Senate Chief Sponsor, Senator Heather Steans, for her leadership and partnership in delivering on commonsense reforms that hold Illinois’ insurers accountable and help Illinoisans manage their health.”

“This new law protects Illinois families from the health and financial harms of midyear prescription coverage changes by keeping decisions about treatment between patients and their prescriber,” said Bryan Anderson, President and CEO of the Epilepsy Foundation of Greater Chicago. “Illinoisans, especially those who are managing complex conditions, will be able to rest easier knowing that they can’t be blindsided by coverage switches that can deteriorate their health, impose financial hardships, and affect their overall quality of life.”

Public Act 100-1052 still allows insurers to add new drugs to a formulary and remove a drug from a formulary if the Food and Drug Administration (FDA) deems it unsafe or if the FDA or the manufacturer withdraws the drug from the market. The law only covers state regulated, non-ERISA employer-sponsored plans.

Illinois joins California, Maine, Nevada, Louisiana and Texas in implementing policies that protect commercially insured patients from coverage reductions during the plan year.

About the Illinois Fair Care Coalition

The Illinois Fair Care Coalition is a group of the Prairie State’s leading patient and provider groups working to ensure that commercial health insurance coverage will be concrete over the course of each year.

Members include: American Autoimmune Related Diseases Association (AARDA), American Diabetes Association, Arthritis Foundation, Global Healthy Living Foundation, Illinois Psychiatric Society, Lupus and Allied Diseases Association, National Infusion Center Association (NICA), U.S. Pain Foundation.