Jan. 25, 2023

Benefit Updates Based on New Illinois Laws
Applies to Individual & Family, all groups

Blue Cross and Blue Shield of Illinois (BCBSIL) is updating some benefits due to new laws in Illinois. We’re also evaluating others that go into effect for plan years 2024 and beyond. Learn what’s changing and which laws are still under review.

Mandate with updated guidance
House Bill 3709: Infertility Coverage

• As we previously communicated, this bill from the 2021 Legislative Session clarified the definition of infertility. As part of that definition, the bill allowed insurance coverage to exclude payments made to a surrogate. The Illinois Department of Insurance has since amended the language to clarify that using a surrogate doesn’t mean a member can’t have infertility treatment coverage.
• Specifically, infertility benefits that would apply to the member should also apply to a surrogate.

• Payments or other services made to a surrogate after an embryo transfer can still be excluded, but services that would be covered for a member up to the point of transfer should be covered.

• Market segments impacted:
• Fully insured group, including small group, mid-market, large and national accounts
• Fully insured and ASO State Employees Plan
• Blue Balance Funded^SM
• Grandfathered/transitional

• Effective date:  Jan. 1, 2022
  

• What’s the impact?
• The current infertility benefit of four occyte retrievals per year (per covered member) should be covered if the services are provided to a surrogate, just as they would be if the services were provided to the member.

• Expenses associated with retrieval/transfer including physical exam, lab screening and prescription drugs are also covered.

• Once infertility services are completed and the surrogate is discharged from infertility specialist care to OB/GYN care, no further coverage of services for the surrogate are required.

• We’re updating our benefit booklets to reflect updated language.

Mandates with 2022/2023 effective dates
House Bill 2595: Accepted Standards of Behavioral Health Care
Requires BCBSIL to create training for employees on mental, emotional, nervous or substance use disorder (behavioral health or BH) medical necessity criteria. The bill also requires us to make the educational materials available to members and providers.

• Market segments impacted: the mandate applies to insurers, not specific markets or plans

• Effective date: Jan. 1, 2023

• What’s the impact? There are no benefit changes as a result of this mandate. As an insurer, BCBSIL is responsible for creating training materials for our employees, providers and members. We are working through the curriculum and will communicate once those training materials are available. We’ve created a member notice about the mandate, which is available on our website.

HB 4433: HDHP & HSA Eligibility
Amends the Managed Care Reform and Patient Rights Act to clarify that any third-party payments to reduce member cost sharing for prescription drugs costs (coupons, copay cards, discounts, vouchers, etc.) apply to health savings account (HSA) qualified high deductible health plans (HDHPs) after the IRS minimum deductible is met.

• Market segments impacted:
• Individual/Family
• Student
• Fully insured group, including small group, mid-market, large and national accounts
• Fully insured and ASO state governmental entity ASO group plans (County/Municipality/State Employee Plans) except School plans  
• Grandfathered/Transitional

• Effective date: April 22, 2022

• What’s the impact? HDHP Members who use a coupon, copay card, etc. to help pay for their prescription still need to meet the minimum required IRS deductible before that third-party payment applies toward their plan’s cst sharing limits (deductible/out-of-pocket maximum). Once the member has met the IRS minimum deductible, any third-party payments will apply to their cost sharing limits.
  
  
• Note: If a member uses a coupon, copay card, etc. to pay for services considered “preventive” under IRS law, those payments do apply to the member’s cost sharing, regardless of whether they’ve met their deductible.

House Bill 135: Pharmacists Dispensing Hormonal Contraceptives
Expands Pharmacists Scope of Practice to dispense and counsel patients on hormonal contraceptives with an order from a physician or local health department medical director.  The law requires insurers cover these services when provided by a pharmacist, if they would be covered when provided by a physician, advanced practice registered nurse, or physician’s assistant.

• Market segments impacted:
• Individual/Family
• Student
• Fully insured group, including small group, mid-market, large and national accounts and state governmental plans (County/Municipalities/School, State Employee Plans)
• ASO state governmental entity plans (County/Municipalities/Schools, State Employee Plans)
• Medicaid

• Effective date: Jan. 1. 2023

• What’s the impact? HB 135 expands the type of pharmacists that can counsel the member about hormonal contraceptive options at the pharmacy. The law also requires these claims to be covered the same as they would if a physician, advanced practice registered nurse, or physician’s assistant was providing the counsel.
• Note: The mandate does not expand pharmacists’ scope to prescribe these products.
  
  
• While there are existing codes for pharmacist counseling on medication therapy management, BCBSIL doesn’t often receive claims for these codes, so we don’t anticipate significant impact from this mandate.

House Bill 4703: Insurance Billing
HB 4703 updates Illinois law to address surprise billing by out-of-network providers for emergency and ancillary services.

• Market segments impacted:
• Individual/family
• Student
• Fully Insured group, including small group, mid-market, large and national accounts (does not include County/Municipality/School or State Employees plans)
• Grandfathered & Transitional

• Effective date: Some provisions of the bill went into effect July 1, 2022, while others are effective beginning Jan. 1, 2023

• What’s the impact? The bill reinforces provisions of the federal No Surprises Act on a state level and sets a dispute process for out-of-network providers and insurers.
• The dispute process is different than the federal NSA process and we’re reviewing those differences to implement the state mandated process.

• We recommend that ASO groups consult with their own legal counsel to determine if a particular state law applies to them. That being said, Illinois House Bill 4703 does not generally appear to apply to ASO groups.

House Bill 4430: Pharmacy HIV Care
Amends the Pharmacy Practice Act to update the definition of “practice of pharmacy” to include services related to HIV pre-exposure prophylaxis (PrEP) and HIV post-exposure prophylaxis (PEP). The mandate requires these services when provided by a pharmacist be covered at no less than 85% of the rate covered when administered by a physician.

HB 4430 also amends the Illinois Public Aid Code to clarify that any provisions of the code that set rules around how member care is covered when provided by a pharmacist apply to all member care provided by a pharmacist.

• Market segments impacted:
• Individual/family
• Fully insured group, including small group, mid-market, large group (does not include County/Municipality/School or State Employees plans)
• Grandfathered/Transitional
• Medicaid

• Effective date: Jan. 1, 2023

• What’s the impact? BCBSIL individual/family and fully insured group plan coverage already meets the requirement of HB 4430, so there won’t be any changes needed to plan benefits. We will be updating our audit process to document our alignment with the regulation.

Mandates still under review (2024 effective dates)
We’re continuing to assess the business impact of these laws and will provide more details once available:

House Bill 4349
House Bill 5254
House Bill 4338
House Bill 4271
House Bill 5318
House Bill 5334
House Bill 5585
House Bill 4408
Senate Bill 2969
Senate Bill 3819