Rep. Gregory Harris

Filed: 3/10/2017





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2    AMENDMENT NO. ______. Amend House Bill 311 by replacing
3everything after the enacting clause with the following:
4    "Section 1. Short title. This Act may be cited as the
5Network Adequacy and Transparency Act.
6    Section 5. Definitions. In this Act:
7    "Beneficiary" means an individual, an enrollee, an
8insured, a participant, or any other person entitled to
9reimbursement for covered expenses of or the discounting of
10provider fees for health care services under a program in which
11the beneficiary has an incentive to utilize the services of a
12provider that has entered into an agreement or arrangement with
13an insurer.
14    "Department" means the Department of Insurance.
15    "Director" means the Director of Insurance.
16    "Insurer" means any entity that offers individual or group



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1accident and health insurance, including, but not limited to,
2health maintenance organizations, preferred provider
3organizations, exclusive provider organizations, and other
4plan structures requiring network participation, excluding the
5medical assistance program under the Illinois Public Aid Code,
6the State employees group health insurance program, workers
7compensation insurance, and pharmacy benefit managers.
8    "Material change" means a significant reduction in the
9number of providers available in a network plan, including, but
10not limited to, a reduction of 10% or more in a specific type
11of providers, the removal of a major health system that causes
12a network to be significantly different from the network when
13the beneficiary purchased the network plan, or any change that
14would cause the network to no longer satisfy the requirements
15of this Act or the Department's rules for network adequacy and
17    "Network" means the group or groups of preferred providers
18providing services to a network plan.
19    "Network plan" means an individual or group policy of
20accident and health insurance that either requires a covered
21person to use or creates incentives, including financial
22incentives, for a covered person to use providers managed,
23owned, under contract with, or employed by the insurer.
24    "Ongoing course of treatment" means (1) treatment for a
25life-threatening condition, which is a disease or condition for
26which likelihood of death is probable unless the course of the



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1disease or condition is interrupted; (2) treatment for a
2serious acute condition, defined as a disease or condition
3requiring complex ongoing care that the covered person is
4currently receiving, such as chemotherapy, radiation therapy,
5or post-operative visits; (3) a course of treatment for a
6health condition that a treating provider attests that
7discontinuing care by that provider would worsen the condition
8or interfere with anticipated outcomes; or (4) the third
9trimester of pregnancy through the post-partum period.
10    "Preferred provider" means any provider who has entered,
11either directly or indirectly, into an agreement with an
12employer or risk-bearing entity relating to health care
13services that may be rendered to beneficiaries under a network
15    "Providers" means physicians licensed to practice medicine
16in all its branches, other health care professionals,
17hospitals, or other health care institutions that provide
18health care services.
19    "Telehealth" has the meaning given to that term in Section
20256z.22 of the Insurance Code.
21    "Telemedicine" has the meaning given to that term in
22Section 49.5 of the Medical Practice Act of 1987.
23    "Tiered network" means a network that identifies and groups
24some or all types of provider and facilities into specific
25groups to which different provider reimbursement, covered
26person cost-sharing or provider access requirements, or any



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1combination thereof, apply for the same services.
2    "Woman's principal health care provider" means a physician
3licensed to practice medicine in all of its branches
4specializing in obstetrics, gynecology, or family practice.
5    Section 10. Network adequacy.
6    (a) An insurer providing a network plan shall file a
7description 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
20discussing any specific or all treatment options with
21beneficiaries irrespective of the insurer's position on those
22treatment options or from advocating on behalf of beneficiaries
23within the utilization review, grievance, or appeals processes
24established by the insurer in accordance with any rights or
25remedies available under applicable State or federal law.



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1    (b) Prior to going to market, insurers must file with the
2Director for review and approval a description of the services
3to be offered through a network plan. The description shall
4include 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,
18prior to approval, a minimum ratio of full-time equivalent
19providers 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    following physicians or other providers:
2            (A) Primary Care;
3            (B) Pediatrics;
4            (C) Cardiology;
5            (D) Gastroenterology;
6            (E) General Surgery;
7            (F) Neurology;
8            (G) OB/GYN;
9            (H) Oncology/Radiation;
10            (I) Ophthalmology;
11            (J) Urology;
12            (K) Behavioral Health;
13            (L) Allergy/Immunology;
14            (M) Chiropractic;
15            (N) Dermatology;
16            (O) Endocrinology;
17            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
18            (Q) Infectious Disease;
19            (R) Nephrology;
20            (S) Neurosurgery;
21            (T) Orthopedic Surgery;
22            (U) Physiatry/Rehabilitative;
23            (V) Plastic Surgery;
24            (W) Pulmonary;
25            (X) Rheumatology;
26            (Y) Anesthesiology;



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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,
10prior to approval, maximum travel and distance standards for
11plan beneficiaries, which shall be established annually by the
12Department in consultation with the Department of Public Health
13based upon the guidance from the federal Centers for Medicare
14and Medicaid Services concerning exchange plans or Medicare
15Advantage Plans. These standards shall consist of the maximum
16minutes or miles to be traveled by a plan beneficiary for each
17county type, such as large counties, metro counties, or rural
18counties as defined by Department rule.
19    The maximum travel time and distance standards must include
20standards for each physician and other provider category listed
21for which ratios have been established.
22    The Director shall establish a process for the annual
23review of the adequacy of these standards along with an
24assessment of additional specialties to be included in the list
25under this subsection (d).
26    (e) These ratio and time and distance standards apply to



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1the lowest cost-sharing tier of any tiered network.
2    (f) The network plan shall demonstrate sufficient
3inpatient services, including, but not limited to, services of
4preferred providers who specialize in emergency medicine,
5anesthesiology, pathology, and radiology.
6    (g) The network plan may consider use of other health care
7service delivery options, such as telemedicine or telehealth,
8mobile clinics, and centers of excellence, or other ways of
9delivering care to partially meet the requirements set under
10this Section.
11    (h) Insurers who are not able to comply with the provider
12ratios and time and distance standards established by the
13Department may request an exception to these requirements from
14the Department. The Department may grant an exception in the
15following 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
9material change to an approved network plan within 15 days
10after the change occurs and any change that would result in
11failure to meet the requirements of this Act. Upon notice from
12the insurer, the Director shall reevaluate the network plan's
13compliance with the network adequacy and transparency
14standards of this Act.
15    Section 15. Notice of nonrenewal or termination. A network
16plan must give at least 60 days' notice of nonrenewal or
17termination of a provider to the provider and to the
18beneficiaries served by the provider. The notice shall include
19a name and address to which a beneficiary or provider may
20direct comments and concerns regarding the nonrenewal or
21termination and the telephone number maintained by the
22Department for consumer complaints. Immediate written notice
23may be provided without 60 days' notice when a provider's
24license has been disciplined by a State licensing board or when
25the network plan reasonably believes direct imminent physical



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1harm 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
4its 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
21new 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
6a network plan to provide coverage for benefits not otherwise
7covered or to diminish or impair preexisting condition
8limitations contained in the beneficiary's contract.
9    Section 25. Network transparency.
10    (a) A network plan shall post electronically an up-to-date,
11accurate, and complete provider directory for each of its
12network plans, with the information and search functions, as
13described 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
5available through an electronic provider directory the
6following 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
6network plan, a network plan shall make available all of the
7following information in addition to the searchable
8information 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
17print, upon request, the following provider directory
18information 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
14print format provider directory that the information included
15in the directory is accurate as of the date of printing and
16that beneficiaries or prospective beneficiaries should consult
17the insurer's electronic provider directory on its website and
18contact the provider. The network plan shall also include a
19telephone number in the print format provider directory for a
20customer service representative where the beneficiary can
21obtain current provider directory information.
22    (f) The Director may conduct periodic audits of the
23accuracy of provider directories.
24    Section 30. Administration and enforcement.
25    (a) Insurers, as defined in this Act, have a continuing



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1obligation to comply with the requirements of this Act. Other
2than the duties specifically created in this Act, nothing in
3this Act is intended to preclude, prevent, or require the
4adoption, modification, or termination of any utilization
5management, quality management, or claims processing
6methodologies of an insurer.
7    (b) Nothing in this Act precludes, prevents, or requires
8the adoption, modification, or termination of any network plan
9term, benefit, coverage or eligibility provision, or payment
11    (c) The Director shall enforce the provisions of this Act
12pursuant to the enforcement powers granted to it by law,
13including, but not limited to, compliance audits, such as
14market conduct examinations, and issuance of cease and desist
15orders, fines, or other penalties for violations of any
16provision of this Act.
17    (d) The Department shall adopt rules to enforce compliance
18with this Act to the extent necessary.
19    Section 99. Effective date. This Act takes effect January
201, 2018.".