Public Act 100-0601
 
SB3491 EnrolledLRB100 20404 LNS 35726 b


  
    AN ACT concerning regulation.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  



 
 
    Section 5. The Network Adequacy and Transparency Act is 
amended  by changing Sections 3, 10,  and 25 as follows:
 
    (215 ILCS 124/3)

    Sec. 3. Applicability of Act. This Act applies to an 
individual or group policy of accident and health insurance 
with a network plan amended, delivered, issued, or renewed in 
this State on or after January 1, 2019. This Act does not apply 
to an individual or group policy for dental or vision insurance 
or a limited health service organization with a network plan 
amended, delivered, issued, or renewed in this State on or 
after January 1, 2019. 

(Source: P.A. 100-502, eff. 9-15-17.)
 
    (215 ILCS 124/10)

    Sec. 10. Network adequacy.
    (a)  An insurer providing a network plan shall file a 
description of all of the following with the Director:
        (1)  The written policies and procedures for adding 
    providers to meet patient needs based on increases in the 
    number of beneficiaries, changes in the 
    patient-to-provider ratio, changes in medical and health 
    care capabilities, and increased demand for services.
        (2)  The written policies and procedures for making 
    referrals within and outside the network.
        (3)  The written policies and procedures on how the 
    network plan will provide 24-hour, 7-day per week access to 
    network-affiliated primary care, emergency services, and 
    woman's principal health care providers.
    An insurer shall not prohibit a preferred provider from 
discussing any specific or all treatment options with 
beneficiaries irrespective of the insurer's position on those 
treatment options or from advocating on behalf of beneficiaries 
within the utilization review, grievance, or appeals processes 
established by the insurer in accordance with any rights or 
remedies available under applicable State or federal law.
    (b) Insurers must file for review a description of the 
services to be offered through a network plan.  The description 
shall include all of the following:
        (1) A geographic map of the area proposed to be served 
    by the plan by county service area and zip code, including 
    marked locations for preferred providers.
        (2) As deemed necessary by the Department, the names, 
    addresses, phone numbers, and specialties of the providers 
    who have entered into preferred provider agreements under 
    the network plan.
        (3) The number of beneficiaries anticipated to be 
    covered by the network plan.
        (4) An Internet website and toll-free telephone number 
    for beneficiaries and prospective beneficiaries to access 
    current and accurate lists of preferred providers, 
    additional information about the plan, as well as any other 
    information required by Department rule.
        (5) A description of how health care services to be 
    rendered under the network plan are reasonably accessible 
    and available to beneficiaries. The description shall 
    address all of the following:
            (A)  the type of health care services to be provided 
        by the network plan;
            (B)  the ratio of  physicians and other providers to 
        beneficiaries, by specialty and including primary care 
        physicians and facility-based physicians when 
        applicable under the contract, necessary to meet the 
        health care needs and service demands of the currently 
        enrolled population; 
            (C) the travel and distance standards for plan 
        beneficiaries in county service areas; and
            (D)  a description of how the use of telemedicine, 
        telehealth, or mobile care services may be used to 
        partially meet the network adequacy standards, if 
        applicable.
        (6) A provision ensuring that whenever a beneficiary 
    has made a good faith effort, as evidenced by accessing the 
    provider directory, calling the network plan, and calling 
    the provider, to utilize preferred providers for a covered 
    service and it is determined the insurer does not have the 
    appropriate preferred providers due to insufficient 
    number, type, or unreasonable travel distance or delay, the 
    insurer shall ensure, directly or indirectly, by terms 
    contained in the payer contract, that the beneficiary will 
    be provided the covered service at no greater cost to the 
    beneficiary than if the service had been provided by a 
    preferred provider. This paragraph (6) does not apply to: 
    (A) a beneficiary who willfully chooses to access a 
    non-preferred provider for health care services available 
    through the panel of preferred providers, or (B) a 
    beneficiary enrolled in a health maintenance organization. 
    In these circumstances, the contractual requirements for 
    non-preferred provider reimbursements shall apply.
        (7) A provision that the beneficiary shall receive 
    emergency care coverage such that payment for this coverage 
    is not dependent upon whether the emergency services are 
    performed by a preferred or non-preferred provider and the 
    coverage shall be at the same benefit level as if the 
    service or treatment had been rendered by a preferred 
    provider.  For purposes of this paragraph (7), "the same 
    benefit level" means that the beneficiary is provided the 
    covered service at no greater cost to the beneficiary than 
    if the service had been provided by a preferred provider.
        (8) A limitation that, if the plan provides that the 
    beneficiary will incur a penalty for failing to pre-certify 
    inpatient hospital treatment, the penalty may not exceed 
    $1,000 per occurrence in addition to the plan cost sharing 
    provisions.
    (c) The network plan shall demonstrate to the Director a 
minimum ratio of providers to plan beneficiaries as required by 
the Department.
        (1)  The ratio of physicians or other providers to plan 
    beneficiaries shall be established annually by the 
    Department in consultation with the Department of Public 
    Health based upon the guidance from the federal Centers for 
    Medicare and Medicaid Services. The Department shall not 
    establish ratios for vision or dental providers who provide 
    services under dental-specific or vision-specific 
    benefits.  The Department shall consider establishing 
    ratios for the following physicians or other providers:
            (A)  Primary Care;
            (B)  Pediatrics;
            (C)  Cardiology;
            (D)  Gastroenterology;
            (E)  General Surgery;
            (F)  Neurology;
            (G)  OB/GYN;
            (H)  Oncology/Radiation;
            (I)  Ophthalmology;
            (J)  Urology;
            (K)  Behavioral Health;
            (L)  Allergy/Immunology;
            (M)  Chiropractic;
            (N)  Dermatology;
            (O)  Endocrinology;
            (P)  Ears, Nose, and Throat (ENT)/Otolaryngology;
            (Q)  Infectious Disease;
            (R)  Nephrology;
            (S)  Neurosurgery;
            (T)  Orthopedic Surgery;
            (U)  Physiatry/Rehabilitative;
            (V)  Plastic Surgery;
            (W)  Pulmonary;
            (X)  Rheumatology;
            (Y)  Anesthesiology;
            (Z)  Pain Medicine;
            (AA)  Pediatric Specialty Services;
            (BB)  Outpatient Dialysis; and
            (CC)  HIV.
        (2)  The Director shall establish a process for the 
    review of the adequacy of these standards, along with an 
    assessment of additional specialties to be included in the 
    list under this subsection (c).
    (d) The network plan shall demonstrate to the Director 
maximum travel and distance standards for plan beneficiaries, 
which shall be established annually by the Department in 
consultation with the Department of Public Health based upon 
the guidance from the federal Centers for Medicare and Medicaid 
Services.  These standards shall consist of the maximum minutes 
or miles to be traveled by a plan beneficiary for each county 
type, such as large counties, metro counties, or rural counties 
as defined by Department rule.
    The maximum travel time and distance standards must include 
standards for each physician and other provider category listed 
for which ratios have been established.
    The Director shall establish a process for the review of 
the adequacy of these standards along with an assessment of 
additional specialties to be included in the list under this 
subsection (d).
    (e) Except for network plans solely offered as a group 
health plan, these ratio and time and distance standards apply 
to the lowest cost-sharing tier of any tiered network.
    (f) The network plan may consider use of other health care 
service delivery options, such as telemedicine or telehealth, 
mobile clinics, and centers of excellence, or other ways of 
delivering care to partially meet the requirements set under 
this Section.
    (g)  Insurers who are not able to comply with the provider 
ratios and time and distance standards established by the 
Department may request an exception to these requirements from 
the Department.  The Department may grant an exception in the 
following circumstances:
        (1) if no providers or facilities meet the specific 
    time and distance standard in a specific service area and 
    the insurer (i) discloses information on the distance and 
    travel time points that beneficiaries would have to travel 
    beyond the required criterion to reach the next closest 
    contracted provider outside of the service area and (ii) 
    provides contact information, including names, addresses, 
    and phone numbers for the next closest contracted provider 
    or facility;
        (2) if patterns of care in the service area do not 
    support the need for the requested number of provider or 
    facility type and the  insurer provides data on local 
    patterns of care, such as claims data, referral patterns, 
    or local provider interviews, indicating where the 
    beneficiaries currently seek this type of care or  where the 
    physicians currently refer beneficiaries, or both; or
        (3) other circumstances deemed appropriate by the 
    Department consistent with the requirements of this Act.
    (h)  Insurers are required to report to the Director any 
material change to an approved network plan within 15 days 
after the change occurs and any change that would result in 
failure to meet the requirements of this Act. Upon notice from 
the insurer, the Director shall reevaluate the network plan's 
compliance with the network adequacy and transparency 
standards of this Act.

(Source: P.A. 100-502, eff. 9-15-17.)
 
    (215 ILCS 124/25)

    Sec. 25. Network transparency.
    (a)  A network plan shall post electronically an up-to-date, 
accurate, and complete provider directory for each of its 
network plans, with the information and search functions, as 
described in this Section.
        (1) In making the directory available electronically, 
    the network plans shall ensure that the general public is 
    able to view all of the current providers for a plan 
    through a clearly identifiable link or tab and without 
    creating or accessing an account or entering a policy or 
    contract number.
        (2) The network plan shall update the online provider 
    directory at least monthly. Providers shall notify the 
    network plan electronically or in writing of any changes to 
    their information as listed in the provider directory.  The 
    network plan shall update its online provider directory in 
    a manner consistent with the information provided by the 
    provider within 10 business days after being notified of 
    the change by the provider.  Nothing in this paragraph (2) 
    shall void any contractual relationship between the 
    provider and the plan.
        (3) The network plan shall audit periodically at least 
    25% of its provider directories for accuracy, make any 
    corrections necessary, and retain documentation of the 
    audit. The network plan shall submit the audit to the 
    Director upon request.  As part of these audits, the network 
    plan shall contact any provider in its network that has not 
    submitted a claim to the plan or otherwise communicated his 
    or her intent to continue participation in the plan's 
    network.
        (4) A network plan shall provide a print copy of a 
    current provider directory or a print copy of the requested 
    directory information upon request of a beneficiary or a 
    prospective beneficiary. Print copies must be updated 
    quarterly and an errata that reflects changes in the 
    provider network must be updated quarterly.
        (5) For each network plan, a network plan shall 
    include, in plain language in both the electronic and print 
    directory, the following general information:
            (A)  in plain language, a description of the 
        criteria the plan has used to build its provider 
        network;
            (B)  if applicable, in plain language, a 
        description of the criteria the insurer or network plan 
        has used to create tiered networks;
            (C)  if applicable, in plain language, how the 
        network plan designates the different provider tiers 
        or levels in the network and identifies for each 
        specific provider, hospital, or other type of facility 
        in the network which tier each is placed, for example, 
        by name, symbols, or grouping, in order for a 
        beneficiary-covered person or a prospective 
        beneficiary-covered person to be able to identify the 
        provider tier; and
            (D)  if applicable, a notation that authorization 
        or referral may be required to access some providers.
        (6) A network plan shall make it clear for both its 
    electronic and print directories what provider directory 
    applies to which network plan, such as including the 
    specific name of the network plan as marketed and issued in 
    this State.  The network plan shall include in both its 
    electronic and print directories a customer service email 
    address and telephone number or electronic link that 
    beneficiaries or the general public may use to notify the 
    network plan of inaccurate provider directory information 
    and contact information for the Department's Office of 
    Consumer Health Insurance.
        (7) A provider directory, whether in electronic or 
    print format, shall accommodate the communication needs of 
    individuals with disabilities, and include a link to or 
    information regarding available assistance for persons 
    with limited English proficiency.
    (b)  For each network plan, a network plan shall make 
available through an electronic provider directory the 
following information in a searchable format:
        (1)  for health care professionals:
            (A)  name;
            (B)  gender;
            (C)  participating office locations;
            (D)  specialty, if applicable;
            (E)  medical group affiliations, if applicable;
            (F)  facility affiliations, if applicable;
            (G)  participating facility affiliations, if 
        applicable;
            (H)  languages spoken other than English, if 
        applicable;
            (I)  whether accepting new patients; and
            (J)  board certifications, if applicable.
        (2)  for hospitals:
            (A)  hospital name;
            (B)  hospital type (such as acute, rehabilitation, 
        children's, or cancer);
            (C)  participating hospital location; and
            (D) hospital accreditation status; and
        (3)  for facilities, other than hospitals, by type:
            (A)  facility name;
            (B)  facility type;
            (C)  types of services performed; and
            (D)  participating facility location or locations.
    (c)  For the electronic provider directories, for each 
network plan, a network plan shall make available all of the 
following information in addition to the searchable 
information required in this Section:
        (1)  for health care professionals:
            (A)  contact information; and
            (B)  languages spoken other than English by 
        clinical staff, if applicable;
        (2)  for hospitals,  telephone number; and
        (3)  for facilities other than hospitals,  telephone 
    number.
    (d)  The insurer or network plan shall make available in 
print, upon request, the following provider directory 
information for the applicable network plan:
        (1)  for health care professionals:
            (A)  name;
            (B)  contact information;
            (C)  participating office location or locations;
            (D)  specialty, if applicable;
            (E)  languages spoken other than English, if 
        applicable; and
            (F)  whether accepting new patients.
        (2)  for hospitals:
            (A)  hospital name;
            (B)  hospital type (such as acute, rehabilitation, 
        children's, or cancer); and
            (C)  participating hospital location and telephone 
        number; and
        (3)  for facilities, other than hospitals, by type:
            (A)  facility name;
            (B)  facility type;
            (C)  types of services performed; and
            (D)  participating facility location or locations 
        and telephone numbers.
    (e)  The network plan shall include a disclosure in the 
print format provider directory that the information included 
in the directory is accurate as of the date of printing and 
that beneficiaries or prospective beneficiaries should consult 
the insurer's  electronic provider directory on its website and 
contact the provider.  The network plan shall also include a 
telephone number in the print format provider directory for a 
customer service representative where the beneficiary can 
obtain current provider directory information.
    (f)  The Director may conduct periodic audits of the 
accuracy of provider directories. A network plan shall not be 
subject to any fines or penalties for information required in 
this Section that a provider submits that is inaccurate or 
incomplete. 

(Source: P.A. 100-502, eff. 9-15-17.)
 
 
    Section 99. Effective date. This Act takes effect upon 
becoming law.