SB3491enr 100TH GENERAL ASSEMBLY

  
  
  

 


 
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1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Network Adequacy and Transparency Act is
5amended by changing Sections 3, 10, and 25 as follows:
 
6    (215 ILCS 124/3)
7    Sec. 3. Applicability of Act. This Act applies to an
8individual or group policy of accident and health insurance
9with a network plan amended, delivered, issued, or renewed in
10this State on or after January 1, 2019. This Act does not apply
11to an individual or group policy for dental or vision insurance
12or a limited health service organization with a network plan
13amended, delivered, issued, or renewed in this State on or
14after January 1, 2019.
15(Source: P.A. 100-502, eff. 9-15-17.)
 
16    (215 ILCS 124/10)
17    Sec. 10. Network adequacy.
18    (a) An insurer providing a network plan shall file a
19description of all of the following with the Director:
20        (1) The written policies and procedures for adding
21    providers to meet patient needs based on increases in the
22    number of beneficiaries, changes in the

 

 

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1    patient-to-provider ratio, changes in medical and health
2    care capabilities, and increased demand for services.
3        (2) The written policies and procedures for making
4    referrals within and outside the network.
5        (3) The written policies and procedures on how the
6    network plan will provide 24-hour, 7-day per week access to
7    network-affiliated primary care, emergency services, and
8    woman's principal health care providers.
9    An insurer shall not prohibit a preferred provider from
10discussing any specific or all treatment options with
11beneficiaries irrespective of the insurer's position on those
12treatment options or from advocating on behalf of beneficiaries
13within the utilization review, grievance, or appeals processes
14established by the insurer in accordance with any rights or
15remedies available under applicable State or federal law.
16    (b) Insurers must file for review a description of the
17services to be offered through a network plan. The description
18shall include all of the following:
19        (1) A geographic map of the area proposed to be served
20    by the plan by county service area and zip code, including
21    marked locations for preferred providers.
22        (2) As deemed necessary by the Department, the names,
23    addresses, phone numbers, and specialties of the providers
24    who have entered into preferred provider agreements under
25    the network plan.
26        (3) The number of beneficiaries anticipated to be

 

 

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1    covered by the network plan.
2        (4) An Internet website and toll-free telephone number
3    for beneficiaries and prospective beneficiaries to access
4    current and accurate lists of preferred providers,
5    additional information about the plan, as well as any other
6    information required by Department rule.
7        (5) A description of how health care services to be
8    rendered under the network plan are reasonably accessible
9    and available to beneficiaries. The description shall
10    address all of the following:
11            (A) the type of health care services to be provided
12        by the network plan;
13            (B) the ratio of physicians and other providers to
14        beneficiaries, by specialty and including primary care
15        physicians and facility-based physicians when
16        applicable under the contract, necessary to meet the
17        health care needs and service demands of the currently
18        enrolled population;
19            (C) the travel and distance standards for plan
20        beneficiaries in county service areas; and
21            (D) a description of how the use of telemedicine,
22        telehealth, or mobile care services may be used to
23        partially meet the network adequacy standards, if
24        applicable.
25        (6) A provision ensuring that whenever a beneficiary
26    has made a good faith effort, as evidenced by accessing the

 

 

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1    provider directory, calling the network plan, and calling
2    the provider, to utilize preferred providers for a covered
3    service and it is determined the insurer does not have the
4    appropriate preferred providers due to insufficient
5    number, type, or unreasonable travel distance or delay, the
6    insurer shall ensure, directly or indirectly, by terms
7    contained in the payer contract, that the beneficiary will
8    be provided the covered service at no greater cost to the
9    beneficiary than if the service had been provided by a
10    preferred provider. This paragraph (6) does not apply to:
11    (A) a beneficiary who willfully chooses to access a
12    non-preferred provider for health care services available
13    through the panel of preferred providers, or (B) a
14    beneficiary enrolled in a health maintenance organization.
15    In these circumstances, the contractual requirements for
16    non-preferred provider reimbursements shall apply.
17        (7) A provision that the beneficiary shall receive
18    emergency care coverage such that payment for this coverage
19    is not dependent upon whether the emergency services are
20    performed by a preferred or non-preferred provider and the
21    coverage shall be at the same benefit level as if the
22    service or treatment had been rendered by a preferred
23    provider. For purposes of this paragraph (7), "the same
24    benefit level" means that the beneficiary is provided the
25    covered service at no greater cost to the beneficiary than
26    if the service had been provided by a preferred provider.

 

 

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1        (8) A limitation that, if the plan provides that the
2    beneficiary will incur a penalty for failing to pre-certify
3    inpatient hospital treatment, the penalty may not exceed
4    $1,000 per occurrence in addition to the plan cost sharing
5    provisions.
6    (c) The network plan shall demonstrate to the Director a
7minimum ratio of providers to plan beneficiaries as required by
8the Department.
9        (1) The ratio of physicians or other providers to plan
10    beneficiaries shall be established annually by the
11    Department in consultation with the Department of Public
12    Health based upon the guidance from the federal Centers for
13    Medicare and Medicaid Services. The Department shall not
14    establish ratios for vision or dental providers who provide
15    services under dental-specific or vision-specific
16    benefits. The Department shall consider establishing
17    ratios for the following physicians or other providers:
18            (A) Primary Care;
19            (B) Pediatrics;
20            (C) Cardiology;
21            (D) Gastroenterology;
22            (E) General Surgery;
23            (F) Neurology;
24            (G) OB/GYN;
25            (H) Oncology/Radiation;
26            (I) Ophthalmology;

 

 

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1            (J) Urology;
2            (K) Behavioral Health;
3            (L) Allergy/Immunology;
4            (M) Chiropractic;
5            (N) Dermatology;
6            (O) Endocrinology;
7            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
8            (Q) Infectious Disease;
9            (R) Nephrology;
10            (S) Neurosurgery;
11            (T) Orthopedic Surgery;
12            (U) Physiatry/Rehabilitative;
13            (V) Plastic Surgery;
14            (W) Pulmonary;
15            (X) Rheumatology;
16            (Y) Anesthesiology;
17            (Z) Pain Medicine;
18            (AA) Pediatric Specialty Services;
19            (BB) Outpatient Dialysis; and
20            (CC) HIV.
21        (2) The Director shall establish a process for the
22    review of the adequacy of these standards, along with an
23    assessment of additional specialties to be included in the
24    list under this subsection (c).
25    (d) The network plan shall demonstrate to the Director
26maximum travel and distance standards for plan beneficiaries,

 

 

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1which shall be established annually by the Department in
2consultation with the Department of Public Health based upon
3the guidance from the federal Centers for Medicare and Medicaid
4Services. These standards shall consist of the maximum minutes
5or miles to be traveled by a plan beneficiary for each county
6type, such as large counties, metro counties, or rural counties
7as defined by Department rule.
8    The maximum travel time and distance standards must include
9standards for each physician and other provider category listed
10for which ratios have been established.
11    The Director shall establish a process for the review of
12the adequacy of these standards along with an assessment of
13additional specialties to be included in the list under this
14subsection (d).
15    (e) Except for network plans solely offered as a group
16health plan, these ratio and time and distance standards apply
17to the lowest cost-sharing tier of any tiered network.
18    (f) The network plan may consider use of other health care
19service delivery options, such as telemedicine or telehealth,
20mobile clinics, and centers of excellence, or other ways of
21delivering care to partially meet the requirements set under
22this Section.
23    (g) Insurers who are not able to comply with the provider
24ratios and time and distance standards established by the
25Department may request an exception to these requirements from
26the Department. The Department may grant an exception in the

 

 

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1following circumstances:
2        (1) if no providers or facilities meet the specific
3    time and distance standard in a specific service area and
4    the insurer (i) discloses information on the distance and
5    travel time points that beneficiaries would have to travel
6    beyond the required criterion to reach the next closest
7    contracted provider outside of the service area and (ii)
8    provides contact information, including names, addresses,
9    and phone numbers for the next closest contracted provider
10    or facility;
11        (2) if patterns of care in the service area do not
12    support the need for the requested number of provider or
13    facility type and the insurer provides data on local
14    patterns of care, such as claims data, referral patterns,
15    or local provider interviews, indicating where the
16    beneficiaries currently seek this type of care or where the
17    physicians currently refer beneficiaries, or both; or
18        (3) other circumstances deemed appropriate by the
19    Department consistent with the requirements of this Act.
20    (h) Insurers are required to report to the Director any
21material change to an approved network plan within 15 days
22after the change occurs and any change that would result in
23failure to meet the requirements of this Act. Upon notice from
24the insurer, the Director shall reevaluate the network plan's
25compliance with the network adequacy and transparency
26standards of this Act.

 

 

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1(Source: P.A. 100-502, eff. 9-15-17.)
 
2    (215 ILCS 124/25)
3    Sec. 25. Network transparency.
4    (a) A network plan shall post electronically an up-to-date,
5accurate, and complete provider directory for each of its
6network plans, with the information and search functions, as
7described in this Section.
8        (1) In making the directory available electronically,
9    the network plans shall ensure that the general public is
10    able to view all of the current providers for a plan
11    through a clearly identifiable link or tab and without
12    creating or accessing an account or entering a policy or
13    contract number.
14        (2) The network plan shall update the online provider
15    directory at least monthly. Providers shall notify the
16    network plan electronically or in writing of any changes to
17    their information as listed in the provider directory. The
18    network plan shall update its online provider directory in
19    a manner consistent with the information provided by the
20    provider within 10 business days after being notified of
21    the change by the provider. Nothing in this paragraph (2)
22    shall void any contractual relationship between the
23    provider and the plan.
24        (3) The network plan shall audit periodically at least
25    25% of its provider directories for accuracy, make any

 

 

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1    corrections necessary, and retain documentation of the
2    audit. The network plan shall submit the audit to the
3    Director upon request. As part of these audits, the network
4    plan shall contact any provider in its network that has not
5    submitted a claim to the plan or otherwise communicated his
6    or her intent to continue participation in the plan's
7    network.
8        (4) A network plan shall provide a print copy of a
9    current provider directory or a print copy of the requested
10    directory information upon request of a beneficiary or a
11    prospective beneficiary. Print copies must be updated
12    quarterly and an errata that reflects changes in the
13    provider network must be updated quarterly.
14        (5) For each network plan, a network plan shall
15    include, in plain language in both the electronic and print
16    directory, the following general information:
17            (A) in plain language, a description of the
18        criteria the plan has used to build its provider
19        network;
20            (B) if applicable, in plain language, a
21        description of the criteria the insurer or network plan
22        has used to create tiered networks;
23            (C) if applicable, in plain language, how the
24        network plan designates the different provider tiers
25        or levels in the network and identifies for each
26        specific provider, hospital, or other type of facility

 

 

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1        in the network which tier each is placed, for example,
2        by name, symbols, or grouping, in order for a
3        beneficiary-covered person or a prospective
4        beneficiary-covered person to be able to identify the
5        provider tier; and
6            (D) if applicable, a notation that authorization
7        or referral may be required to access some providers.
8        (6) A network plan shall make it clear for both its
9    electronic and print directories what provider directory
10    applies to which network plan, such as including the
11    specific name of the network plan as marketed and issued in
12    this State. The network plan shall include in both its
13    electronic and print directories a customer service email
14    address and telephone number or electronic link that
15    beneficiaries or the general public may use to notify the
16    network plan of inaccurate provider directory information
17    and contact information for the Department's Office of
18    Consumer Health Insurance.
19        (7) A provider directory, whether in electronic or
20    print format, shall accommodate the communication needs of
21    individuals with disabilities, and include a link to or
22    information regarding available assistance for persons
23    with limited English proficiency.
24    (b) For each network plan, a network plan shall make
25available through an electronic provider directory the
26following information in a searchable format:

 

 

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1        (1) for health care professionals:
2            (A) name;
3            (B) gender;
4            (C) participating office locations;
5            (D) specialty, if applicable;
6            (E) medical group affiliations, if applicable;
7            (F) facility affiliations, if applicable;
8            (G) participating facility affiliations, if
9        applicable;
10            (H) languages spoken other than English, if
11        applicable;
12            (I) whether accepting new patients; and
13            (J) board certifications, if applicable.
14        (2) for hospitals:
15            (A) hospital name;
16            (B) hospital type (such as acute, rehabilitation,
17        children's, or cancer);
18            (C) participating hospital location; and
19            (D) hospital accreditation status; and
20        (3) for facilities, other than hospitals, by type:
21            (A) facility name;
22            (B) facility type;
23            (C) types of services performed; and
24            (D) participating facility location or locations.
25    (c) For the electronic provider directories, for each
26network plan, a network plan shall make available all of the

 

 

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1following information in addition to the searchable
2information required in this Section:
3        (1) for health care professionals:
4            (A) contact information; and
5            (B) languages spoken other than English by
6        clinical staff, if applicable;
7        (2) for hospitals, telephone number; and
8        (3) for facilities other than hospitals, telephone
9    number.
10    (d) The insurer or network plan shall make available in
11print, upon request, the following provider directory
12information for the applicable network plan:
13        (1) for health care professionals:
14            (A) name;
15            (B) contact information;
16            (C) participating office location or locations;
17            (D) specialty, if applicable;
18            (E) languages spoken other than English, if
19        applicable; and
20            (F) whether accepting new patients.
21        (2) for hospitals:
22            (A) hospital name;
23            (B) hospital type (such as acute, rehabilitation,
24        children's, or cancer); and
25            (C) participating hospital location and telephone
26        number; and

 

 

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1        (3) for facilities, other than hospitals, by type:
2            (A) facility name;
3            (B) facility type;
4            (C) types of services performed; and
5            (D) participating facility location or locations
6        and telephone numbers.
7    (e) The network plan shall include a disclosure in the
8print format provider directory that the information included
9in the directory is accurate as of the date of printing and
10that beneficiaries or prospective beneficiaries should consult
11the insurer's electronic provider directory on its website and
12contact the provider. The network plan shall also include a
13telephone number in the print format provider directory for a
14customer service representative where the beneficiary can
15obtain current provider directory information.
16    (f) The Director may conduct periodic audits of the
17accuracy of provider directories. A network plan shall not be
18subject to any fines or penalties for information required in
19this Section that a provider submits that is inaccurate or
20incomplete.
21(Source: P.A. 100-502, eff. 9-15-17.)
 
22    Section 99. Effective date. This Act takes effect upon
23becoming law.