HB0311 EngrossedLRB100 05356 RPS 15367 b

1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 1. Short title. This Act may be cited as the
5Network Adequacy and Transparency Act.
6    Section 3. Applicability of Act.This Act applies to an
7individual or group policy of accident and health insurance
8with a network plan amended, delivered, issued, or renewed in
9this State on or after January 1, 2019.
10    Section 5. Definitions. In this Act:
11    "Authorized representative" means a person to whom a
12beneficiary has given express written consent to represent the
13beneficiary; a person authorized by law to provide substituted
14consent for a beneficiary; or the beneficiary's treating
15provider only when the beneficiary or his or her family member
16is unable to provide consent.
17    "Beneficiary" means an individual, an enrollee, an
18insured, a participant, or any other person entitled to
19reimbursement for covered expenses of or the discounting of
20provider fees for health care services under a program in which
21the beneficiary has an incentive to utilize the services of a
22provider that has entered into an agreement or arrangement with



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1an insurer.
2    "Department" means the Department of Insurance.
3    "Director" means the Director of Insurance.
4    "Insurer" means any entity that offers individual or group
5accident and health insurance, including, but not limited to,
6health maintenance organizations, preferred provider
7organizations, exclusive provider organizations, and other
8plan structures requiring network participation, excluding the
9medical assistance program under the Illinois Public Aid Code,
10the State employees group health insurance program, workers
11compensation insurance, and pharmacy benefit managers.
12    "Material change" means a significant reduction in the
13number of providers available in a network plan, including, but
14not limited to, a reduction of 10% or more in a specific type
15of providers, the removal of a major health system that causes
16a network to be significantly different from the network when
17the beneficiary purchased the network plan, or any change that
18would cause the network to no longer satisfy the requirements
19of this Act or the Department's rules for network adequacy and
21    "Network" means the group or groups of preferred providers
22providing services to a network plan.
23    "Network plan" means an individual or group policy of
24accident and health insurance that either requires a covered
25person to use or creates incentives, including financial
26incentives, for a covered person to use providers managed,



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1owned, under contract with, or employed by the insurer.
2    "Ongoing course of treatment" means (1) treatment for a
3life-threatening condition, which is a disease or condition for
4which likelihood of death is probable unless the course of the
5disease or condition is interrupted; (2) treatment for a
6serious acute condition, defined as a disease or condition
7requiring complex ongoing care that the covered person is
8currently receiving, such as chemotherapy, radiation therapy,
9or post-operative visits; (3) a course of treatment for a
10health condition that a treating provider attests that
11discontinuing care by that provider would worsen the condition
12or interfere with anticipated outcomes; or (4) the third
13trimester of pregnancy through the post-partum period.
14    "Preferred provider" means any provider who has entered,
15either directly or indirectly, into an agreement with an
16employer or risk-bearing entity relating to health care
17services that may be rendered to beneficiaries under a network
19    "Providers" means physicians licensed to practice medicine
20in all its branches, other health care professionals,
21hospitals, or other health care institutions that provide
22health care services.
23    "Telehealth" has the meaning given to that term in Section
24356z.22 of the Illinois Insurance Code.
25    "Telemedicine" has the meaning given to that term in
26Section 49.5 of the Medical Practice Act of 1987.



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1    "Tiered network" means a network that identifies and groups
2some or all types of provider and facilities into specific
3groups to which different provider reimbursement, covered
4person cost-sharing or provider access requirements, or any
5combination thereof, apply for the same services.
6    "Woman's principal health care provider" means a physician
7licensed to practice medicine in all of its branches
8specializing in obstetrics, gynecology, or family practice.
9    Section 10. Network adequacy.
10    (a) An insurer providing a network plan shall file a
11description of all of the following with the Director:
12        (1) The written policies and procedures for adding
13    providers to meet patient needs based on increases in the
14    number of beneficiaries, changes in the
15    patient-to-provider ratio, changes in medical and health
16    care capabilities, and increased demand for services.
17        (2) The written policies and procedures for making
18    referrals within and outside the network.
19        (3) The written policies and procedures on how the
20    network plan will provide 24-hour, 7-day per week access to
21    network-affiliated primary care, emergency services, and
22    woman's principal health care providers.
23    An insurer shall not prohibit a preferred provider from
24discussing any specific or all treatment options with
25beneficiaries irrespective of the insurer's position on those



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1treatment options or from advocating on behalf of beneficiaries
2within the utilization review, grievance, or appeals processes
3established by the insurer in accordance with any rights or
4remedies available under applicable State or federal law.
5    (b) Insurers must file for review a description of the
6services to be offered through a network plan. The description
7shall include all of the following:
8        (1) A geographic map of the area proposed to be served
9    by the plan by county service area and zip code, including
10    marked locations for preferred providers.
11        (2) As deemed necessary by the Department, the names,
12    addresses, phone numbers, and specialties of the providers
13    who have entered into preferred provider agreements under
14    the network plan.
15        (3) The number of beneficiaries anticipated to be
16    covered by the network plan.
17        (4) An Internet website and toll-free telephone number
18    for beneficiaries and prospective beneficiaries to access
19    current and accurate lists of preferred providers,
20    additional information about the plan, as well as any other
21    information required by Department rule.
22        (5) A description of how health care services to be
23    rendered under the network plan are reasonably accessible
24    and available to beneficiaries. The description shall
25    address all of the following:
26            (A) the type of health care services to be provided



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1        by the network plan;
2            (B) the ratio of physicians and other providers to
3        beneficiaries, by specialty and including primary care
4        physicians and facility-based physicians when
5        applicable under the contract, necessary to meet the
6        health care needs and service demands of the currently
7        enrolled population;
8            (C) the travel and distance standards for plan
9        beneficiaries in county service areas; and
10            (D) a description of how the use of telemedicine,
11        telehealth, or mobile care services may be used to
12        partially meet the network adequacy standards, if
13        applicable.
14        (6) A provision ensuring that whenever a beneficiary
15    has made a good faith effort, as evidenced by accessing the
16    provider directory, calling the network plan, and calling
17    the provider, to utilize preferred providers for a covered
18    service and it is determined the insurer does not have the
19    appropriate preferred providers due to insufficient
20    number, type, or unreasonable travel distance or delay, the
21    insurer shall ensure, directly or indirectly, by terms
22    contained in the payer contract, that the beneficiary will
23    be provided the covered service at no greater cost to the
24    beneficiary than if the service had been provided by a
25    preferred provider. This paragraph (6) does not apply to:
26    (A) a beneficiary who willfully chooses to access a



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1    non-preferred provider for health care services available
2    through the panel of preferred providers, or (B) a
3    beneficiary enrolled in a health maintenance organization.
4    In these circumstances, the contractual requirements for
5    non-preferred provider reimbursements shall apply.
6        (7) A provision that the beneficiary shall receive
7    emergency care coverage such that payment for this coverage
8    is not dependent upon whether the emergency services are
9    performed by a preferred or non-preferred provider and the
10    coverage shall be at the same benefit level as if the
11    service or treatment had been rendered by a preferred
12    provider. For purposes of this paragraph (7), "the same
13    benefit level" means that the beneficiary is provided the
14    covered service at no greater cost to the beneficiary than
15    if the service had been provided by a preferred provider.
16        (8) A limitation that, if the plan provides that the
17    beneficiary will incur a penalty for failing to pre-certify
18    inpatient hospital treatment, the penalty may not exceed
19    $1,000 per occurrence in addition to the plan cost sharing
20    provisions.
21    (c) The network plan shall demonstrate to the Director a
22minimum ratio of providers to plan beneficiaries as required by
23the Department.
24        (1) The ratio of physicians or other providers to plan
25    beneficiaries shall be established annually by the
26    Department in consultation with the Department of Public



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1    Health based upon the guidance from the federal Centers for
2    Medicare and Medicaid Services. The Department shall
3    consider establishing ratios for the following physicians
4    or other providers:
5            (A) Primary Care;
6            (B) Pediatrics;
7            (C) Cardiology;
8            (D) Gastroenterology;
9            (E) General Surgery;
10            (F) Neurology;
11            (G) OB/GYN;
12            (H) Oncology/Radiation;
13            (I) Ophthalmology;
14            (J) Urology;
15            (K) Behavioral Health;
16            (L) Allergy/Immunology;
17            (M) Chiropractic;
18            (N) Dermatology;
19            (O) Endocrinology;
20            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
21            (Q) Infectious Disease;
22            (R) Nephrology;
23            (S) Neurosurgery;
24            (T) Orthopedic Surgery;
25            (U) Physiatry/Rehabilitative;
26            (V) Plastic Surgery;



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1            (W) Pulmonary;
2            (X) Rheumatology;
3            (Y) Anesthesiology;
4            (Z) Pain Medicine;
5            (AA) Pediatric Specialty Services;
6            (BB) Outpatient Dialysis; and
7            (CC) HIV.
8        (2) The Director shall establish a process for the
9    review of the adequacy of these standards, along with an
10    assessment of additional specialties to be included in the
11    list under this subsection (c).
12    (d) The network plan shall demonstrate to the Director
13maximum travel and distance standards for plan beneficiaries,
14which shall be established annually by the Department in
15consultation with the Department of Public Health based upon
16the guidance from the federal Centers for Medicare and Medicaid
17Services. These standards shall consist of the maximum minutes
18or miles to be traveled by a plan beneficiary for each county
19type, such as large counties, metro counties, or rural counties
20as defined by Department rule.
21    The maximum travel time and distance standards must include
22standards for each physician and other provider category listed
23for which ratios have been established.
24    The Director shall establish a process for the review of
25the adequacy of these standards along with an assessment of
26additional specialties to be included in the list under this



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1subsection (d).
2    (e) Except for network plans solely offered as a group
3health plan, these ratio and time and distance standards apply
4to the lowest cost-sharing tier of any tiered network.
5    (f) The network plan shall demonstrate sufficient
6inpatient services, including, but not limited to, services of
7preferred providers who specialize in emergency medicine,
8anesthesiology, pathology, and radiology.
9    (g) The network plan may consider use of other health care
10service delivery options, such as telemedicine or telehealth,
11mobile clinics, and centers of excellence, or other ways of
12delivering care to partially meet the requirements set under
13this Section.
14    (h) Insurers who are not able to comply with the provider
15ratios and time and distance standards established by the
16Department may request an exception to these requirements from
17the Department. The Department may grant an exception in the
18following circumstances:
19        (1) if no providers or facilities meet the specific
20    time and distance standard in a specific service area and
21    the insurer (i) discloses information on the distance and
22    travel time points that beneficiaries would have to travel
23    beyond the required criterion to reach the next closest
24    contracted provider outside of the service area and (ii)
25    provides contact information, including names, addresses,
26    and phone numbers for the next closest contracted provider



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1    or facility;
2        (2) if patterns of care in the service area do not
3    support the need for the requested number of provider or
4    facility type and the insurer provides data on local
5    patterns of care, such as claims data, referral patterns,
6    or local provider interviews, indicating where the
7    beneficiaries currently seek this type of care or where the
8    physicians currently refer beneficiaries, or both; or
9        (3) other circumstances deemed appropriate by the
10    Department consistent with the requirements of this Act.
11    (i) Insurers are required to report to the Director any
12material change to an approved network plan within 15 days
13after the change occurs and any change that would result in
14failure to meet the requirements of this Act. Upon notice from
15the insurer, the Director shall reevaluate the network plan's
16compliance with the network adequacy and transparency
17standards of this Act.
18    Section 15. Notice of nonrenewal or termination.
19    (a) A network plan must give at least 60 days' notice of
20nonrenewal or termination of a provider to the provider and to
21the beneficiaries served by the provider. The notice shall
22include a name and address to which a beneficiary or provider
23may direct comments and concerns regarding the nonrenewal or
24termination and the telephone number maintained by the
25Department for consumer complaints. Immediate written notice



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1may be provided without 60 days' notice when a provider's
2license has been disciplined by a State licensing board or when
3the network plan reasonably believes direct imminent physical
4harm to patients under the providers care may occur.
5    (b) Primary care providers must notify active affected
6patients of nonrenewal or termination of the provider from the
7network plan, except in the case of incapacitation.
8    Section 20. Transition of services.
9    (a) A network plan shall provide for continuity of care for
10its beneficiaries as follows:
11        (1) If a beneficiary's physician or hospital provider
12    leaves the network plan's network of providers for reasons
13    other than termination of a contract in situations
14    involving imminent harm to a patient or a final
15    disciplinary action by a State licensing board and the
16    provider remains within the network plan's service area,
17    the network plan shall permit the beneficiary to continue
18    an ongoing course of treatment with that provider during a
19    transitional period for the following duration:
20            (A) 90 days from the date of the notice to the
21        beneficiary of the provider's disaffiliation from the
22        network plan if the beneficiary has an ongoing course
23        of treatment; or
24            (B) if the beneficiary has entered the third
25        trimester of pregnancy at the time of the provider's



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1        disaffiliation, a period that includes the provision
2        of post-partum care directly related to the delivery.
3        (2) Notwithstanding the provisions of paragraph (1) of
4    this subsection (a), such care shall be authorized by the
5    network plan during the transitional period in accordance
6    with the following:
7            (A) the provider receives continued reimbursement
8        from the network plan at the rates and terms and
9        conditions applicable under the terminated contract
10        prior to the start of the transitional period;
11            (B) the provider adheres to the network plan's
12        quality assurance requirements, including provision to
13        the network plan of necessary medical information
14        related to such care; and
15            (C) the provider otherwise adheres to the network
16        plan's policies and procedures, including, but not
17        limited to, procedures regarding referrals and
18        obtaining preauthorizations for treatment.
19        (3) The provisions of this Section governing health
20    care provided during the transition period do not apply if
21    the beneficiary has successfully transitioned to another
22    provider participating in the network plan, if the
23    beneficiary has already met or exceeded the benefit
24    limitations of the plan, or if the care provided is not
25    medically necessary.
26    (b) A network plan shall provide for continuity of care for



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1new beneficiaries as follows:
2        (1) If a new beneficiary whose provider is not a member
3    of the network plan's provider network, but is within the
4    network plan's service area, enrolls in the network plan,
5    the network plan shall permit the beneficiary to continue
6    an ongoing course of treatment with the beneficiary's
7    current physician during a transitional period:
8            (A) of 90 days from the effective date of
9        enrollment if the beneficiary has an ongoing course of
10        treatment; or
11            (B) if the beneficiary has entered the third
12        trimester of pregnancy at the effective date of
13        enrollment, that includes the provision of post-partum
14        care directly related to the delivery.
15        (2) If a beneficiary, or a beneficiary's authorized
16    representative, elects in writing to continue to receive
17    care from such provider pursuant to paragraph (1) of this
18    subsection (b), such care shall be authorized by the
19    network plan for the transitional period in accordance with
20    the following:
21            (A) the provider receives reimbursement from the
22        network plan at rates established by the network plan;
23            (B) the provider adheres to the network plan's
24        quality assurance requirements, including provision to
25        the network plan of necessary medical information
26        related to such care; and



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1            (C) the provider otherwise adheres to the network
2        plan's policies and procedures, including, but not
3        limited to, procedures regarding referrals and
4        obtaining preauthorization for treatment.
5        (3) The provisions of this Section governing health
6    care provided during the transition period do not apply if
7    the beneficiary has successfully transitioned to another
8    provider participating in the network plan, if the
9    beneficiary has already met or exceeded the benefit
10    limitations of the plan, or if the care provided is not
11    medically necessary.
12    (c) In no event shall this Section be construed to require
13a network plan to provide coverage for benefits not otherwise
14covered or to diminish or impair preexisting condition
15limitations contained in the beneficiary's contract.
16    Section 25. Network transparency.
17    (a) A network plan shall post electronically an up-to-date,
18accurate, and complete provider directory for each of its
19network plans, with the information and search functions, as
20described in this Section.
21        (1) In making the directory available electronically,
22    the network plans shall ensure that the general public is
23    able to view all of the current providers for a plan
24    through a clearly identifiable link or tab and without
25    creating or accessing an account or entering a policy or



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1    contract number.
2        (2) The network plan shall update the online provider
3    directory at least monthly. Providers shall notify the
4    network plan electronically or in writing of any changes to
5    their information as listed in the provider directory. The
6    network plan shall update its online provider directory in
7    a manner consistent with the information provided by the
8    provider within 10 business days after being notified of
9    the change by the provider. Nothing in this paragraph (2)
10    shall void any contractual relationship between the
11    provider and the plan.
12        (3) The network plan shall audit periodically at least
13    25% of its provider directories for accuracy, make any
14    corrections necessary, and retain documentation of the
15    audit. The network plan shall submit the audit to the
16    Director upon request. As part of these audits, the network
17    plan shall contact any provider in its network that has not
18    submitted a claim to the plan or otherwise communicated his
19    or her intent to continue participation in the plan's
20    network.
21        (4) A network plan shall provide a print copy of a
22    current provider directory or a print copy of the requested
23    directory information upon request of a beneficiary or a
24    prospective beneficiary. Print copies must be updated
25    quarterly and an errata that reflects changes in the
26    provider network must be updated quarterly.



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1        (5) For each network plan, a network plan shall
2    include, in plain language in both the electronic and print
3    directory, the following general information:
4            (A) in plain language, a description of the
5        criteria the plan has used to build its provider
6        network;
7            (B) if applicable, in plain language, a
8        description of the criteria the insurer or network plan
9        has used to create tiered networks;
10            (C) if applicable, in plain language, how the
11        network plan designates the different provider tiers
12        or levels in the network and identifies for each
13        specific provider, hospital, or other type of facility
14        in the network which tier each is placed, for example,
15        by name, symbols, or grouping, in order for a
16        beneficiary-covered person or a prospective
17        beneficiary-covered person to be able to identify the
18        provider tier; and
19            (D) if applicable, a notation that authorization
20        or referral may be required to access some providers.
21        (6) A network plan shall make it clear for both its
22    electronic and print directories what provider directory
23    applies to which network plan, such as including the
24    specific name of the network plan as marketed and issued in
25    this State. The network plan shall include in both its
26    electronic and print directories a customer service email



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1    address and telephone number or electronic link that
2    beneficiaries or the general public may use to notify the
3    network plan of inaccurate provider directory information
4    and contact information for the Department's Office of
5    Consumer Health Insurance.
6        (7) A provider directory, whether in electronic or
7    print format, shall accommodate the communication needs of
8    individuals with disabilities, and include a link to or
9    information regarding available assistance for persons
10    with limited English proficiency.
11    (b) For each network plan, a network plan shall make
12available through an electronic provider directory the
13following information in a searchable format:
14        (1) for health care professionals:
15            (A) name;
16            (B) gender;
17            (C) participating office locations;
18            (D) specialty, if applicable;
19            (E) medical group affiliations, if applicable;
20            (F) facility affiliations, if applicable;
21            (G) participating facility affiliations, if
22        applicable;
23            (H) languages spoken other than English, if
24        applicable;
25            (I) whether accepting new patients; and
26            (J) board certifications, if applicable.



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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);
5            (C) participating hospital location; and
6            (D) hospital accreditation status; 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    (c) For the electronic provider directories, for each
13network plan, a network plan shall make available all of the
14following information in addition to the searchable
15information required in this Section:
16        (1) for health care professionals:
17            (A) contact information; and
18            (B) languages spoken other than English by
19        clinical staff, if applicable;
20        (2) for hospitals, telephone number; and
21        (3) for facilities other than hospitals, telephone
22    number.
23    (d) The insurer or network plan shall make available in
24print, upon request, the following provider directory
25information for the applicable network plan:
26        (1) for health care professionals:



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1            (A) name;
2            (B) contact information;
3            (C) participating office location or locations;
4            (D) specialty, if applicable;
5            (E) languages spoken other than English, if
6        applicable; and
7            (F) whether accepting new patients.
8        (2) for hospitals:
9            (A) hospital name;
10            (B) hospital type (such as acute, rehabilitation,
11        children's, or cancer); and
12            (C) participating hospital location and telephone
13        number; and
14        (3) for facilities, other than hospitals, by type:
15            (A) facility name;
16            (B) facility type;
17            (C) types of services performed; and
18            (D) participating facility location or locations
19        and telephone numbers.
20    (e) The network plan shall include a disclosure in the
21print format provider directory that the information included
22in the directory is accurate as of the date of printing and
23that beneficiaries or prospective beneficiaries should consult
24the insurer's electronic provider directory on its website and
25contact the provider. The network plan shall also include a
26telephone number in the print format provider directory for a



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1customer service representative where the beneficiary can
2obtain current provider directory information.
3    (f) The Director may conduct periodic audits of the
4accuracy of provider directories.
5    Section 30. Facility nonparticipating provider
6transparency.Prior to providing a non-emergency outpatient
7procedure to a beneficiary in an in-network facility or during
8the admission or as soon as practicable thereafter, the
9hospital must provide an insured patient with written notice
11        (1) the patient may receive separate bills for services
12    provided by health care professionals affiliated with the
13    hospital;
14        (2) if applicable, some hospital staff members may not
15    be participating providers in the same insurance plans and
16    networks as the hospital;
17        (3) if applicable, the patient may have a greater
18    financial responsibility for services provided by health
19    care professionals at the hospital who are not under
20    contract with the patient's health care plan; and
21        (4) questions about coverage or benefit levels should
22    be directed to the patient's health care plan and the
23    patient's certificate of coverage.
24    Section 35. Administration and enforcement.



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1    (a) Insurers, as defined in this Act, have a continuing
2obligation to comply with the requirements of this Act. Other
3than the duties specifically created in this Act, nothing in
4this Act is intended to preclude, prevent, or require the
5adoption, modification, or termination of any utilization
6management, quality management, or claims processing
7methodologies of an insurer.
8    (b) Nothing in this Act precludes, prevents, or requires
9the adoption, modification, or termination of any network plan
10term, benefit, coverage or eligibility provision, or payment
12    (c) The Director shall enforce the provisions of this Act
13pursuant to the enforcement powers granted to it by law.
14    (d) The Department shall adopt rules to enforce compliance
15with this Act to the extent necessary.
16    Section 99. Effective date. This Act takes effect upon
17becoming law.