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1 | | accident and health insurance, including, but not limited to, |
2 | | health maintenance organizations, preferred provider |
3 | | organizations, exclusive provider organizations, and other |
4 | | plan structures requiring network participation, excluding the |
5 | | medical assistance program under the Illinois Public Aid Code, |
6 | | the State employees group health insurance program, workers |
7 | | compensation insurance, and pharmacy benefit managers. |
8 | | "Material change" means a significant reduction in the |
9 | | number of providers available in a network plan, including, but |
10 | | not limited to, a reduction of 10% or more in a specific type |
11 | | of providers, the removal of a major health system that causes |
12 | | a network to be significantly different from the network when |
13 | | the beneficiary purchased the network plan, or any change that |
14 | | would cause the network to no longer satisfy the requirements |
15 | | of this Act or the Department's rules for network adequacy and |
16 | | transparency. |
17 | | "Network" means the group or groups of preferred providers |
18 | | providing services to a network plan. |
19 | | "Network plan" means an individual or group policy of |
20 | | accident and health insurance that either requires a covered |
21 | | person to use or creates incentives, including financial |
22 | | incentives, for a covered person to use providers managed, |
23 | | owned, under contract with, or employed by the insurer. |
24 | | "Ongoing course of treatment" means (1) treatment for a |
25 | | life-threatening condition, which is a disease or condition for |
26 | | which likelihood of death is probable unless the course of the |
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1 | | disease or condition is interrupted; (2) treatment for a |
2 | | serious acute condition, defined as a disease or condition |
3 | | requiring complex ongoing care that the covered person is |
4 | | currently receiving, such as chemotherapy, radiation therapy, |
5 | | or post-operative visits; (3) a course of treatment for a |
6 | | health condition that a treating provider attests that |
7 | | discontinuing care by that provider would worsen the condition |
8 | | or interfere with anticipated outcomes; or (4) the third |
9 | | trimester of pregnancy through the post-partum period. |
10 | | "Preferred provider" means any provider who has entered, |
11 | | either directly or indirectly, into an agreement with an |
12 | | employer or risk-bearing entity relating to health care |
13 | | services that may be rendered to beneficiaries under a network |
14 | | plan. |
15 | | "Providers" means physicians licensed to practice medicine |
16 | | in all its branches, other health care professionals, |
17 | | hospitals, or other health care institutions that provide |
18 | | health care services. |
19 | | "Telehealth" has the meaning given to that term in Section |
20 | | 256z.22 of the Insurance Code. |
21 | | "Telemedicine" has the meaning given to that term in |
22 | | Section 49.5 of the Medical Practice Act of 1987. |
23 | | "Tiered network" means a network that identifies and groups |
24 | | some or all types of provider and facilities into specific |
25 | | groups to which different provider reimbursement, covered |
26 | | person cost-sharing or provider access requirements, or any |
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1 | | combination thereof, apply for the same services. |
2 | | "Woman's principal health care provider" means a physician |
3 | | licensed to practice medicine in all of its branches |
4 | | specializing in obstetrics, gynecology, or family practice. |
5 | | Section 10. Network adequacy. |
6 | | (a) An insurer providing a network plan shall file a |
7 | | description of all of the following with the Director: |
8 | | (1) The written policies and procedures for adding |
9 | | providers to meet patient needs based on increases in the |
10 | | number of beneficiaries, changes in the |
11 | | patient-to-provider ratio, changes in medical and health |
12 | | care capabilities, and increased demand for services. |
13 | | (2) The written policies and procedures for making |
14 | | referrals within and outside the network. |
15 | | (3) The written policies and procedures on how the |
16 | | network plan will provide 24-hour, 7-day per week access to |
17 | | network-affiliated primary care, emergency services, and |
18 | | woman's principal health care providers. |
19 | | An insurer shall not prohibit a preferred provider from |
20 | | discussing any specific or all treatment options with |
21 | | beneficiaries irrespective of the insurer's position on those |
22 | | treatment options or from advocating on behalf of beneficiaries |
23 | | within the utilization review, grievance, or appeals processes |
24 | | established by the insurer in accordance with any rights or |
25 | | remedies available under applicable State or federal law. |
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1 | | (b) Prior to going to market, insurers must file with the |
2 | | Director for review and approval a description of the services |
3 | | to be offered through a network plan. The description shall |
4 | | include all of the following: |
5 | | (1) A geographic map of the area proposed to be served |
6 | | by the plan by county service area and zip code, including |
7 | | marked locations for preferred providers. |
8 | | (2) As deemed necessary by the Department, the names, |
9 | | addresses, phone numbers, and specialties of the providers |
10 | | who have entered into preferred provider agreements under |
11 | | the network plan. |
12 | | (3) The number of beneficiaries anticipated to be |
13 | | covered by the network plan. |
14 | | (4) An Internet website and toll-free telephone number |
15 | | for beneficiaries and prospective beneficiaries to access |
16 | | current and accurate lists of preferred providers, |
17 | | additional information about the plan, as well as any other |
18 | | information required by Department rule. |
19 | | (5) A description of how health care services to be |
20 | | rendered under the network plan are reasonably accessible |
21 | | and available to beneficiaries. The description shall |
22 | | address all of the following: |
23 | | (A) the type of health care services to be provided |
24 | | by the network plan; |
25 | | (B) the ratio of full-time equivalent physicians |
26 | | and other providers to beneficiaries, by specialty and |
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1 | | including primary care physicians and facility-based |
2 | | physicians when applicable under the contract, |
3 | | necessary to meet the health care needs and service |
4 | | demands of the currently enrolled population; |
5 | | (C) the travel and distance standards for plan |
6 | | beneficiaries in county service areas; and |
7 | | (D) a description of how the use of telemedicine, |
8 | | telehealth, or mobile care services may be used to |
9 | | partially meet the network adequacy standards, if |
10 | | applicable. |
11 | | (6) A provision ensuring that whenever a beneficiary |
12 | | has made a good faith effort, as evidenced by accessing the |
13 | | provider directory, calling the network plan, and calling |
14 | | the provider, to utilize preferred providers for a covered |
15 | | service and it is determined the insurer does not have the |
16 | | appropriate preferred providers due to insufficient |
17 | | number, type, or unreasonable travel distance or delay, the |
18 | | insurer shall ensure, directly or indirectly, by terms |
19 | | contained in the payer contract, that the beneficiary will |
20 | | be provided the covered service at no greater cost to the |
21 | | beneficiary than if the service had been provided by a |
22 | | preferred provider. This paragraph (6) does not apply to a |
23 | | beneficiary who willfully chooses to access a |
24 | | non-preferred provider for health care services available |
25 | | through the panel of preferred providers. In these |
26 | | circumstances, the contractual requirements for |
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1 | | non-preferred provider reimbursements shall apply. |
2 | | (7) A provision that the beneficiary shall receive |
3 | | emergency care coverage such that payment for this coverage |
4 | | is not dependent upon whether the emergency services are |
5 | | performed by a preferred or non-preferred provider and the |
6 | | coverage shall be at the same benefit level as if the |
7 | | service or treatment had been rendered by a preferred |
8 | | provider. For purposes of this paragraph (7), "the same |
9 | | benefit level" means that the beneficiary is provided the |
10 | | covered service at no greater cost to the beneficiary than |
11 | | if the service had been provided by a preferred provider. |
12 | | (8) A limitation that, if the plan provides that the |
13 | | beneficiary will incur a penalty for failing to pre-certify |
14 | | inpatient hospital treatment, the penalty may not exceed |
15 | | $1,000 per occurrence in addition to the plan cost sharing |
16 | | provisions. |
17 | | (c) The network plan shall demonstrate to the Director, |
18 | | prior to approval, a minimum ratio of full-time equivalent |
19 | | providers to plan beneficiaries as required by the Department. |
20 | | (1) The ratio of full-time equivalent physicians or |
21 | | other providers to plan beneficiaries shall be established |
22 | | annually by the Department in consultation with the |
23 | | Department of Public Health based upon the guidance from |
24 | | the federal Centers for Medicare and Medicaid Services |
25 | | concerning exchange plans or Medicare Advantage Plans. The |
26 | | Department shall consider establishing ratios for the |
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1 | | (Z) Pain Medicine; |
2 | | (AA) Pediatric Specialty Services; |
3 | | (BB) Outpatient Dialysis; and |
4 | | (CC) HIV. |
5 | | (2) The Director shall establish a process for the |
6 | | annual review of the adequacy of these standards, along |
7 | | with an assessment of additional specialties to be included |
8 | | in the list under this subsection (c). |
9 | | (d) The network plan shall demonstrate to the Director, |
10 | | prior to approval, maximum travel and distance standards for |
11 | | plan beneficiaries, which shall be established annually by the |
12 | | Department in consultation with the Department of Public Health |
13 | | based upon the guidance from the federal Centers for Medicare |
14 | | and Medicaid Services concerning exchange plans or Medicare |
15 | | Advantage Plans. These standards shall consist of the maximum |
16 | | minutes or miles to be traveled by a plan beneficiary for each |
17 | | county type, such as large counties, metro counties, or rural |
18 | | counties as defined by Department rule. |
19 | | The maximum travel time and distance standards must include |
20 | | standards for each physician and other provider category listed |
21 | | for which ratios have been established. |
22 | | The Director shall establish a process for the annual |
23 | | review of the adequacy of these standards along with an |
24 | | assessment of additional specialties to be included in the list |
25 | | under this subsection (d). |
26 | | (e) These ratio and time and distance standards apply to |
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1 | | the lowest cost-sharing tier of any tiered network. |
2 | | (f) The network plan shall demonstrate sufficient |
3 | | inpatient services, including, but not limited to, services of |
4 | | preferred providers who specialize in emergency medicine, |
5 | | anesthesiology, pathology, and radiology. |
6 | | (g) The network plan may consider use of other health care |
7 | | service delivery options, such as telemedicine or telehealth, |
8 | | mobile clinics, and centers of excellence, or other ways of |
9 | | delivering care to partially meet the requirements set under |
10 | | this Section. |
11 | | (h) Insurers who are not able to comply with the provider |
12 | | ratios and time and distance standards established by the |
13 | | Department may request an exception to these requirements from |
14 | | the Department. The Department may grant an exception in the |
15 | | following circumstances: |
16 | | (1) if no providers or facilities meet the specific |
17 | | time and distance standard in a specific service area and |
18 | | the insurer (i) discloses information on the distance and |
19 | | travel time points that beneficiaries would have to travel |
20 | | beyond the required criterion to reach the next closest |
21 | | contracted provider outside of the service area and (ii) |
22 | | provides contact information, including names, addresses, |
23 | | and phone numbers for the next closest contracted provider |
24 | | or facility; |
25 | | (2) if patterns of care in the service area do not |
26 | | support the need for the requested number of provider or |
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1 | | facility type and the insurer provides data on local |
2 | | patterns of care, such as claims data, referral patterns, |
3 | | or local provider interviews, indicating where the |
4 | | beneficiaries currently seek this type of care or where the |
5 | | physicians currently refer beneficiaries, or both; or |
6 | | (3) other circumstances deemed appropriate by the |
7 | | Department consistent with the requirements of this Act. |
8 | | (i) Insurers are required to report to the Director any |
9 | | material change to an approved network plan within 15 days |
10 | | after the change occurs and any change that would result in |
11 | | failure to meet the requirements of this Act. Upon notice from |
12 | | the insurer, the Director shall reevaluate the network plan's |
13 | | compliance with the network adequacy and transparency |
14 | | standards of this Act. |
15 | | Section 15. Notice of nonrenewal or termination. A network |
16 | | plan must give at least 60 days' notice of nonrenewal or |
17 | | termination of a provider to the provider and to the |
18 | | beneficiaries served by the provider. The notice shall include |
19 | | a name and address to which a beneficiary or provider may |
20 | | direct comments and concerns regarding the nonrenewal or |
21 | | termination and the telephone number maintained by the |
22 | | Department for consumer complaints. Immediate written notice |
23 | | may be provided without 60 days' notice when a provider's |
24 | | license has been disciplined by a State licensing board or when |
25 | | the network plan reasonably believes direct imminent physical |
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1 | | harm to patients under the providers care may occur. |
2 | | Section 20. Transition of services. |
3 | | (a) A network plan shall provide for continuity of care for |
4 | | its beneficiaries as follows: |
5 | | (1) If a beneficiary's physician or hospital provider |
6 | | leaves the network plan's network of providers for reasons |
7 | | other than termination of a contract in situations |
8 | | involving imminent harm to a patient or a final |
9 | | disciplinary action by a State licensing board and the |
10 | | provider remains within the network plan's service area, |
11 | | the network plan shall permit the beneficiary to continue |
12 | | an ongoing course of treatment with that provider during a |
13 | | transitional period for the following duration: |
14 | | (A) 90 days from the date of the notice to the |
15 | | beneficiary of the provider's disaffiliation from the |
16 | | network plan if the beneficiary has an ongoing course |
17 | | of treatment; or |
18 | | (B) if the beneficiary has entered the third |
19 | | trimester of pregnancy at the time of the provider's |
20 | | disaffiliation, a period that includes the provision |
21 | | of post-partum care directly related to the delivery. |
22 | | (2) Notwithstanding the provisions of paragraph (1) of |
23 | | this subsection (a), such care shall be authorized by the |
24 | | network plan during the transitional period in accordance |
25 | | with the following: |
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1 | | (A) the provider receives continued reimbursement |
2 | | from the network plan at the rates and terms and |
3 | | conditions applicable under the terminated contract |
4 | | prior to the start of the transitional period; |
5 | | (B) the provider adheres to the network plan's |
6 | | quality assurance requirements, including provision to |
7 | | the network plan of necessary medical information |
8 | | related to such care; and |
9 | | (C) the provider otherwise adheres to the network |
10 | | plan's policies and procedures, including, but not |
11 | | limited to, procedures regarding referrals and |
12 | | obtaining preauthorizations for treatment. |
13 | | (3) The provisions of this Section governing health |
14 | | care provided during the transition period do not apply if |
15 | | the beneficiary has successfully transitioned to another |
16 | | provider participating in the network plan, if the |
17 | | beneficiary has already met or exceeded the benefit |
18 | | limitations of the plan, or if the care provided is not |
19 | | medically necessary. |
20 | | (b) A network plan shall provide for continuity of care for |
21 | | new beneficiaries as follows: |
22 | | (1) If a new beneficiary whose provider is not a member |
23 | | of the network plan's provider network, but is within the |
24 | | network plan's service area, enrolls in the network plan, |
25 | | the network plan shall permit the beneficiary to continue |
26 | | an ongoing course of treatment with the beneficiary's |
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1 | | current physician during a transitional period: |
2 | | (A) of 90 days from the effective date of |
3 | | enrollment if the beneficiary has an ongoing course of |
4 | | treatment; or |
5 | | (B) if the beneficiary has entered the third |
6 | | trimester of pregnancy at the effective date of |
7 | | enrollment, that includes the provision of post-partum |
8 | | care directly related to the delivery. |
9 | | (2) If a beneficiary elects to continue to receive care |
10 | | from such provider pursuant to paragraph (1) of this |
11 | | subsection (b), such care shall be authorized by the |
12 | | network plan for the transitional period in accordance with |
13 | | the following: |
14 | | (A) the provider receives reimbursement from the |
15 | | network plan at rates established by the network plan; |
16 | | (B) the provider adheres to the network plan's |
17 | | quality assurance requirements, including provision to |
18 | | the network plan of necessary medical information |
19 | | related to such care; and |
20 | | (C) the provider otherwise adheres to the network |
21 | | plan's policies and procedures, including, but not |
22 | | limited to, procedures regarding referrals and |
23 | | obtaining preauthorization for treatment. |
24 | | (3) The provisions of this Section governing health |
25 | | care provided during the transition period do not apply if |
26 | | the beneficiary has successfully transitioned to another |
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1 | | provider participating in the network plan, if the |
2 | | beneficiary has already met or exceeded the benefit |
3 | | limitations of the plan, or if the care provided is not |
4 | | medically necessary. |
5 | | (c) In no event shall this Section be construed to require |
6 | | a network plan to provide coverage for benefits not otherwise |
7 | | covered or to diminish or impair preexisting condition |
8 | | limitations contained in the beneficiary's contract. |
9 | | Section 25. Network transparency. |
10 | | (a) A network plan shall post electronically an up-to-date, |
11 | | accurate, and complete provider directory for each of its |
12 | | network plans, with the information and search functions, as |
13 | | described in this Section. |
14 | | (1) In making the directory available electronically, |
15 | | the network plans shall ensure that the general public is |
16 | | able to view all of the current providers for a plan |
17 | | through a clearly identifiable link or tab and without |
18 | | creating or accessing an account or entering a policy or |
19 | | contract number. |
20 | | (2) The network plan shall update the online provider |
21 | | directory at least monthly. Providers shall notify the |
22 | | network plan electronically or in writing of any changes to |
23 | | their information as listed in the provider directory. The |
24 | | network plan shall update its online provider directory in |
25 | | a manner consistent with the information provided by the |
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1 | | provider within 10 business days after being notified of |
2 | | the change by the provider. Nothing in this paragraph (2) |
3 | | shall void any contractual relationship between the |
4 | | provider and the plan. |
5 | | (3) The network plan shall audit periodically at least |
6 | | 25% of its provider directories for accuracy, make any |
7 | | corrections necessary, and retain documentation of the |
8 | | audit. The network plan shall submit the audit annually to |
9 | | the Director. As part of these audits, the network plan |
10 | | shall contact any provider in its network that has not |
11 | | submitted a claim to the plan or otherwise communicated his |
12 | | or her intent to continue participation in the plan's |
13 | | network. |
14 | | (4) A network plan shall provide a print copy of a |
15 | | current provider directory or a print copy of the requested |
16 | | directory information upon request of a beneficiary or a |
17 | | prospective beneficiary. Print copies must be updated |
18 | | quarterly and an errata that reflects changes in the |
19 | | provider network must be updated quarterly. |
20 | | (5) For each network plan, a network plan shall |
21 | | include, in plain language in both the electronic and print |
22 | | directory, the following general information: |
23 | | (A) in plain language, a description of the |
24 | | criteria the plan has used to build its provider |
25 | | network; |
26 | | (B) if applicable, in plain language, a |
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1 | | description of the criteria the insurer or network plan |
2 | | has used to create tiered networks; |
3 | | (C) if applicable, in plain language, how the |
4 | | network plan designates the different provider tiers |
5 | | or levels in the network and identifies for each |
6 | | specific provider, hospital, or other type of facility |
7 | | in the network which tier each is placed, for example, |
8 | | by name, symbols, or grouping, in order for a |
9 | | beneficiary-covered person or a prospective |
10 | | beneficiary-covered person to be able to identify the |
11 | | provider tier; and |
12 | | (D) if applicable, a notation that authorization |
13 | | or referral may be required to access some providers. |
14 | | (6) A network plan shall make it clear for both its |
15 | | electronic and print directories what provider directory |
16 | | applies to which network plan, such as including the |
17 | | specific name of the network plan as marketed and issued in |
18 | | this State. The network plan shall include in both its |
19 | | electronic and print directories a customer service email |
20 | | address and telephone number or electronic link that |
21 | | beneficiaries or the general public may use to notify the |
22 | | network plan of inaccurate provider directory information |
23 | | and contact information for the Department's Office of |
24 | | Consumer Health Insurance. |
25 | | (7) A provider directory, whether in electronic or |
26 | | print format, shall accommodate the communication needs of |
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1 | | individuals with disabilities, and include a link to or |
2 | | information regarding available assistance for persons |
3 | | with limited English proficiency. |
4 | | (b) For each network plan, a network plan shall make |
5 | | available through an electronic provider directory the |
6 | | following information in a searchable format: |
7 | | (1) for health care professionals: |
8 | | (A) name; |
9 | | (B) gender; |
10 | | (C) participating office locations; |
11 | | (D) specialty, if applicable; |
12 | | (E) medical group affiliations, if applicable; |
13 | | (F) facility affiliations, if applicable; |
14 | | (G) participating facility affiliations, if |
15 | | applicable; |
16 | | (H) languages spoken other than English, if |
17 | | applicable; |
18 | | (I) whether accepting new patients; and |
19 | | (J) board certifications, if applicable. |
20 | | (2) for hospitals: |
21 | | (A) hospital name; |
22 | | (B) hospital type (such as acute, rehabilitation, |
23 | | children's, or cancer); |
24 | | (C) participating hospital location; and |
25 | | (D) hospital accreditation status; and |
26 | | (3) for facilities, other than hospitals, by type: |
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1 | | (A) facility name; |
2 | | (B) facility type; |
3 | | (C) types of services performed; and |
4 | | (D) participating facility location or locations. |
5 | | (c) For the electronic provider directories, for each |
6 | | network plan, a network plan shall make available all of the |
7 | | following information in addition to the searchable |
8 | | information required in this Section: |
9 | | (1) for health care professionals: |
10 | | (A) contact information; and |
11 | | (B) languages spoken other than English by |
12 | | clinical staff, if applicable; |
13 | | (2) for hospitals, telephone number; and |
14 | | (3) for facilities other than hospitals, telephone |
15 | | number. |
16 | | (d) The insurer or network plan shall make available in |
17 | | print, upon request, the following provider directory |
18 | | information for the applicable network plan: |
19 | | (1) for health care professionals: |
20 | | (A) name; |
21 | | (B) contact information; |
22 | | (C) participating office location or locations; |
23 | | (D) specialty, if applicable; |
24 | | (E) languages spoken other than English, if |
25 | | applicable; and |
26 | | (F) whether accepting new patients. |
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1 | | (2) for hospitals: |
2 | | (A) hospital name; |
3 | | (B) hospital type (such as acute, rehabilitation, |
4 | | children's, or cancer); and |
5 | | (C) participating hospital location and telephone |
6 | | number; and |
7 | | (3) for facilities, other than hospitals, by type: |
8 | | (A) facility name; |
9 | | (B) facility type; |
10 | | (C) types of services performed; and |
11 | | (D) participating facility location or locations |
12 | | and telephone numbers. |
13 | | (e) The network plan shall include a disclosure in the |
14 | | print format provider directory that the information included |
15 | | in the directory is accurate as of the date of printing and |
16 | | that beneficiaries or prospective beneficiaries should consult |
17 | | the insurer's electronic provider directory on its website and |
18 | | contact the provider. The network plan shall also include a |
19 | | telephone number in the print format provider directory for a |
20 | | customer service representative where the beneficiary can |
21 | | obtain current provider directory information. |
22 | | (f) The Director may conduct periodic audits of the |
23 | | accuracy of provider directories. |
24 | | Section 30. Administration and enforcement.
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25 | | (a) Insurers, as defined in this Act, have a continuing |
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1 | | obligation to comply with the requirements of this Act. Other |
2 | | than the duties specifically created in this Act, nothing in |
3 | | this Act is intended to preclude, prevent, or require the |
4 | | adoption, modification, or termination of any utilization |
5 | | management, quality management, or claims processing |
6 | | methodologies of an insurer. |
7 | | (b) Nothing in this Act precludes, prevents, or requires |
8 | | the adoption, modification, or termination of any network plan |
9 | | term, benefit, coverage or eligibility provision, or payment |
10 | | methodology. |
11 | | (c) The Director shall enforce the provisions of this Act |
12 | | pursuant to the enforcement powers granted to it by law, |
13 | | including, but not limited to, compliance audits, such as |
14 | | market conduct examinations, and issuance of cease and desist |
15 | | orders, fines, or other penalties for violations of any |
16 | | provision of this Act. |
17 | | (d) The Department shall adopt rules to enforce compliance |
18 | | with this Act to the extent necessary.
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19 | | Section 99. Effective date. This Act takes effect January |
20 | | 1, 2018.".
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