HB5313 103RD GENERAL ASSEMBLY

LRB103 38443 RPS 68579 b

103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5313

Introduced 2/9/2024, by Rep. Margaret Croke

SYNOPSIS AS INTRODUCED:

215 ILCS 124/25
215 ILCS 124/35 new

Amends the Network Adequacy and Transparency Act. Provides that a network plan shall, at least annually, audit (instead of audit periodically) at least 25% of its provider directories for accuracy, make any corrections necessary, and retain documentation of the audit. Provides that the network plan shall submit the audit to the Department of Insurance (instead of to the Director of Insurance upon request). Provides that the Department shall make the audit publicly available. Provides that a network plan shall include in the print format provider directory (i) a detailed description of the process to dispute charges for out-of-network providers or facilities that were incorrectly listed as in-network prior to the provision of care and (ii) a telephone number and email address to dispute those charges. Makes changes to the information that must be provided in a network plan's electronic and print directory. Requires the Director to conduct random audits of the accuracy of provider directories for at least 10% of plans each year. Provides that a consumer who incurs a cost for inappropriate out-of-network charges for a provider, facility, or hospital that was listed as in-network prior to the provision of services may file a verified complaint with the Department, and the Department shall conduct an investigation of the verified complaint and determine whether the complaint is sufficient. Provides that, upon a finding of sufficiency, the Director shall have the authority to levy a fine for not less than the cost incurred by the consumer for inappropriate out-of-network charges for a provider, facility, or hospital that was listed in-network. Provides that the fines collected by the Director shall be remitted to the consumer.

A BILL FOR

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 Section 25 and by adding Section 35 as follows:

(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, at least annually, 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 Department, and the Department shall make the audit publicly available 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 printed print copy of a current provider directory or a printed print copy of the requested directory information upon request of a beneficiary or a prospective beneficiary. Printed 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; .

(E) a telephone number and email address for a customer service representative to whom directory inaccuracies may be reported; and

(F) a detailed description of the process to dispute charges for out-of-network providers or facilities that were incorrectly listed as in-network prior to the provision of care and a telephone number and email address to dispute such charges.

(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) patient population served (such as pediatric, adult, elderly, or women) and specialty or subspecialty, 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;

(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; and

(L) the anticipated date the provider will leave the network, if applicable, which shall be included not more than 10 days after the network provides notice in accordance with Section 15 of this Act; and

(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; and .

(E) the anticipated date the facility will leave the network, if applicable, which shall be included not more than 10 days after the network confirms the facility is scheduled to leave the network.

(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) patient population (such as pediatric, adult, elderly, or women) and specialty or subspecialty, if applicable;

(E) languages spoken other than English, if applicable;

(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 and email address in the print format provider directory for a customer service representative where the beneficiary can obtain current provider directory information or report directory inaccuracies. The network plan shall include in the print format provider directory a detailed description of the process to dispute charges for out-of-network providers or facilities that were incorrectly listed as in-network prior to the provision of care and a telephone number and email address to dispute those charges.

(f) The Director may conduct periodic audits of the accuracy of provider directories and shall conduct random audits of at least 10% of plans each year. 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. 102-92, eff. 7-9-21; revised 9-26-23.)

(215 ILCS 124/35 new)

Sec. 35. Complaint of incorrect charges.

(a) A consumer who incurs a cost for inappropriate out-of-network charges for a provider, facility, or hospital that was listed as in-network prior to the provision of services may file a verified complaint with the Department. The Department shall conduct an investigation of any verified complaint and determine whether the complaint is sufficient.

(b) Upon a finding of sufficiency, the Director shall have the authority to levy a fine for not less than the cost incurred by the consumer for inappropriate out-of-network charges for a provider, facility, or hospital that was listed as in-network. The fines collected by the Director shall be remitted to the consumer.