Public Act 102-0092
 
SB0332 EnrolledLRB102 13548 BMS 18895 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 5 and 25 as follows:
 
    (215 ILCS 124/5)

    Sec. 5. Definitions.  In this Act:
    "Authorized representative" means a person to whom a 
beneficiary has given express written consent to represent the 
beneficiary; a person authorized by law to provide substituted 
consent for a beneficiary; or the beneficiary's treating 
provider only when the beneficiary or his or her family member 
is unable to provide consent.
    "Beneficiary" means an individual, an enrollee, an 
insured, a participant, or any other person entitled to 
reimbursement for covered expenses of or the discounting of 
provider fees for health care services under a program in 
which the beneficiary has an incentive to utilize the services 
of a provider that has entered into an agreement or 
arrangement with an insurer.
    "Department" means the Department of Insurance.
    "Director" means the Director  of Insurance.
    "Family caregiver" means a relative, partner, friend, or 
neighbor who has a significant relationship with the patient 
and administers or assists them with activities of daily 
living, instrumental activities of daily living, or other 
medical or nursing tasks for the quality and welfare of that 
patient. 
    "Insurer" means any entity that offers individual or group 
accident and health insurance, including, but not limited to, 
health maintenance organizations, preferred provider 
organizations, exclusive provider organizations, and other 
plan structures requiring network participation, excluding the 
medical assistance program under the Illinois Public Aid Code, 
the State employees group health insurance program, workers 
compensation insurance, and pharmacy benefit managers.
    "Material change" means a significant reduction in the 
number of providers available in a network plan, including, 
but not limited to, a reduction of 10% or more in a specific 
type of providers, the removal of a major health system that 
causes a network to be significantly different from the 
network when the beneficiary purchased the network plan, or 
any change that would cause the network to no longer satisfy 
the requirements of this Act or the Department's rules for 
network adequacy and transparency.
    "Network" means the group or groups of preferred providers 
providing services to a network plan.
    "Network plan" means an individual or group policy of 
accident and health insurance that either requires a covered 
person to use or creates incentives, including financial 
incentives, for a covered person to use providers managed, 
owned, under contract with, or employed by the insurer.
    "Ongoing course of treatment" means (1) treatment for a 
life-threatening condition, which is a disease or condition 
for which likelihood of death is probable unless the course of 
the disease or condition is interrupted; (2) treatment for a 
serious acute condition, defined as a disease or condition 
requiring complex ongoing care that the covered person is 
currently receiving, such as chemotherapy, radiation therapy, 
or post-operative visits; (3) a course of treatment for a 
health condition that a treating provider attests that 
discontinuing care by that provider would worsen the condition 
or interfere with anticipated outcomes; or (4) the third 
trimester of pregnancy through the post-partum period.
    "Preferred provider" means any provider who has entered, 
either directly or indirectly, into an agreement with an 
employer or risk-bearing entity relating to health care 
services that may be rendered to beneficiaries under a network 
plan.
    "Providers" means physicians licensed to practice medicine 
in all its branches, other health care professionals, 
hospitals, or other health care institutions that provide 
health care services.
    "Telehealth" has the meaning given to that term in Section 
356z.22 of the Illinois Insurance Code.
    "Telemedicine" has the  meaning given to that term in 
Section 49.5 of the Medical Practice Act of 1987.
    "Tiered network" means a network that identifies and 
groups some or all types of provider and facilities into 
specific groups to which different provider reimbursement, 
covered person cost-sharing or provider access requirements, 
or any combination thereof, apply for the same services.
    "Woman's principal health care provider" means a physician 
licensed to practice medicine in all of its branches 
specializing in obstetrics, gynecology, or family practice.

(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, 
    including the information required in subparagraph (K) of 
    paragraph (1) of subsection (b).  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; and .
            (K) use of telehealth or telemedicine, including, 
        but not limited to:
                (i) whether the provider offers the use of 
            telehealth or telemedicine to deliver services to 
            patients for whom it would be clinically 
            appropriate;
                (ii) what modalities are used and what types 
            of services may be provided via telehealth or 
            telemedicine; and
                (iii) whether the provider has the ability and 
            willingness to include in a telehealth or 
            telemedicine encounter a family caregiver who is 
            in a separate location than the patient if the 
            patient wishes and provides his or her consent; 
        (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; and .
            (G) use of telehealth or telemedicine, including, 
        but not limited to:
                (i) whether the provider offers the use of 
            telehealth or telemedicine to deliver services to 
            patients for whom it would be clinically 
            appropriate;
                (ii) what modalities are used and what types 
            of services may be provided via telehealth or 
            telemedicine; and
                (iii) whether the provider has the ability and 
            willingness to include in a telehealth or 
            telemedicine encounter a family caregiver who is 
            in a separate location than the patient if the 
            patient wishes and provides his or her consent; 
        (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; 100-601, eff. 6-29-18.)
 
 
    Section 99. Effective date. This Act takes effect upon 
becoming law.