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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Network Adequacy and Transparency Act is | |||||||||||||||||||||
5 | amended by changing Sections 5 and 25 as follows: | |||||||||||||||||||||
6 | (215 ILCS 124/5)
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7 | Sec. 5. Definitions. In this Act: | |||||||||||||||||||||
8 | "Authorized representative" means a person to whom a | |||||||||||||||||||||
9 | beneficiary has given express written consent to represent the | |||||||||||||||||||||
10 | beneficiary; a person authorized by law to provide substituted | |||||||||||||||||||||
11 | consent for a beneficiary; or the beneficiary's treating | |||||||||||||||||||||
12 | provider only when the beneficiary or his or her family member | |||||||||||||||||||||
13 | is unable to provide consent. | |||||||||||||||||||||
14 | "Beneficiary" means an individual, an enrollee, an | |||||||||||||||||||||
15 | insured, a participant, or any other person entitled to | |||||||||||||||||||||
16 | reimbursement for covered expenses of or the discounting of | |||||||||||||||||||||
17 | provider fees for health care services under a program in which | |||||||||||||||||||||
18 | the beneficiary has an incentive to utilize the services of a | |||||||||||||||||||||
19 | provider that has entered into an agreement or arrangement with | |||||||||||||||||||||
20 | an insurer. | |||||||||||||||||||||
21 | "Department" means the Department of Insurance. | |||||||||||||||||||||
22 | "Director" means the Director of Insurance. | |||||||||||||||||||||
23 | "Family caregiver" means a relative, partner, friend, or |
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1 | neighbor who has a significant relationship with the patient | ||||||
2 | and administers or assists them with activities of daily | ||||||
3 | living, instrumental activities of daily living, or other | ||||||
4 | medical or nursing tasks for the quality and welfare of that | ||||||
5 | patient. | ||||||
6 | "Insurer" means any entity that offers individual or group | ||||||
7 | accident and health insurance, including, but not limited to, | ||||||
8 | health maintenance organizations, preferred provider | ||||||
9 | organizations, exclusive provider organizations, and other | ||||||
10 | plan structures requiring network participation, excluding the | ||||||
11 | medical assistance program under the Illinois Public Aid Code, | ||||||
12 | the State employees group health insurance program, workers | ||||||
13 | compensation insurance, and pharmacy benefit managers. | ||||||
14 | "Material change" means a significant reduction in the | ||||||
15 | number of providers available in a network plan, including, but | ||||||
16 | not limited to, a reduction of 10% or more in a specific type | ||||||
17 | of providers, the removal of a major health system that causes | ||||||
18 | a network to be significantly different from the network when | ||||||
19 | the beneficiary purchased the network plan, or any change that | ||||||
20 | would cause the network to no longer satisfy the requirements | ||||||
21 | of this Act or the Department's rules for network adequacy and | ||||||
22 | transparency. | ||||||
23 | "Network" means the group or groups of preferred providers | ||||||
24 | providing services to a network plan. | ||||||
25 | "Network plan" means an individual or group policy of | ||||||
26 | accident and health insurance that either requires a covered |
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1 | person to use or creates incentives, including financial | ||||||
2 | incentives, for a covered person to use providers managed, | ||||||
3 | owned, under contract with, or employed by the insurer. | ||||||
4 | "Ongoing course of treatment" means (1) treatment for a | ||||||
5 | life-threatening condition, which is a disease or condition for | ||||||
6 | which likelihood of death is probable unless the course of the | ||||||
7 | disease or condition is interrupted; (2) treatment for a | ||||||
8 | serious acute condition, defined as a disease or condition | ||||||
9 | requiring complex ongoing care that the covered person is | ||||||
10 | currently receiving, such as chemotherapy, radiation therapy, | ||||||
11 | or post-operative visits; (3) a course of treatment for a | ||||||
12 | health condition that a treating provider attests that | ||||||
13 | discontinuing care by that provider would worsen the condition | ||||||
14 | or interfere with anticipated outcomes; or (4) the third | ||||||
15 | trimester of pregnancy through the post-partum period. | ||||||
16 | "Preferred provider" means any provider who has entered, | ||||||
17 | either directly or indirectly, into an agreement with an | ||||||
18 | employer or risk-bearing entity relating to health care | ||||||
19 | services that may be rendered to beneficiaries under a network | ||||||
20 | plan. | ||||||
21 | "Providers" means physicians licensed to practice medicine | ||||||
22 | in all its branches, other health care professionals, | ||||||
23 | hospitals, or other health care institutions that provide | ||||||
24 | health care services. | ||||||
25 | "Telehealth" has the meaning given to that term in Section | ||||||
26 | 356z.22 of the Illinois Insurance Code. |
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1 | "Telemedicine" has the meaning given to that term in | ||||||
2 | Section 49.5 of the Medical Practice Act of 1987. | ||||||
3 | "Tiered network" means a network that identifies and groups | ||||||
4 | some or all types of provider and facilities into specific | ||||||
5 | groups to which different provider reimbursement, covered | ||||||
6 | person cost-sharing or provider access requirements, or any | ||||||
7 | combination thereof, apply for the same services. | ||||||
8 | "Woman's principal health care provider" means a physician | ||||||
9 | licensed to practice medicine in all of its branches | ||||||
10 | specializing in obstetrics, gynecology, or family practice.
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11 | (Source: P.A. 100-502, eff. 9-15-17.) | ||||||
12 | (215 ILCS 124/25)
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13 | Sec. 25. Network transparency. | ||||||
14 | (a) A network plan shall post electronically an up-to-date, | ||||||
15 | accurate, and complete provider directory for each of its | ||||||
16 | network plans, with the information and search functions, as | ||||||
17 | described in this Section. | ||||||
18 | (1) In making the directory available electronically, | ||||||
19 | the network plans shall ensure that the general public is | ||||||
20 | able to view all of the current providers for a plan | ||||||
21 | through a clearly identifiable link or tab and without | ||||||
22 | creating or accessing an account or entering a policy or | ||||||
23 | contract number. | ||||||
24 | (2) The network plan shall update the online provider | ||||||
25 | directory at least monthly. Providers shall notify the |
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1 | network plan electronically or in writing of any changes to | ||||||
2 | their information as listed in the provider directory. The | ||||||
3 | network plan shall update its online provider directory in | ||||||
4 | a manner consistent with the information provided by the | ||||||
5 | provider within 10 business days after being notified of | ||||||
6 | the change by the provider. Nothing in this paragraph (2) | ||||||
7 | shall void any contractual relationship between the | ||||||
8 | provider and the plan. | ||||||
9 | (3) The network plan shall audit periodically at least | ||||||
10 | 25% of its provider directories for accuracy, make any | ||||||
11 | corrections necessary, and retain documentation of the | ||||||
12 | audit. The network plan shall submit the audit to the | ||||||
13 | Director upon request. As part of these audits, the network | ||||||
14 | plan shall contact any provider in its network that has not | ||||||
15 | submitted a claim to the plan or otherwise communicated his | ||||||
16 | or her intent to continue participation in the plan's | ||||||
17 | network. | ||||||
18 | (4) A network plan shall provide a print copy of a | ||||||
19 | current provider directory or a print copy of the requested | ||||||
20 | directory information upon request of a beneficiary or a | ||||||
21 | prospective beneficiary. Print copies must be updated | ||||||
22 | quarterly and an errata that reflects changes in the | ||||||
23 | provider network must be updated quarterly. | ||||||
24 | (5) For each network plan, a network plan shall | ||||||
25 | include, in plain language in both the electronic and print | ||||||
26 | directory, the following general information: |
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1 | (A) in plain language, a description of the | ||||||
2 | criteria the plan has used to build its provider | ||||||
3 | network; | ||||||
4 | (B) if applicable, in plain language, a | ||||||
5 | description of the criteria the insurer or network plan | ||||||
6 | has used to create tiered networks; | ||||||
7 | (C) if applicable, in plain language, how the | ||||||
8 | network plan designates the different provider tiers | ||||||
9 | or levels in the network and identifies for each | ||||||
10 | specific provider, hospital, or other type of facility | ||||||
11 | in the network which tier each is placed, for example, | ||||||
12 | by name, symbols, or grouping, in order for a | ||||||
13 | beneficiary-covered person or a prospective | ||||||
14 | beneficiary-covered person to be able to identify the | ||||||
15 | provider tier; and | ||||||
16 | (D) if applicable, a notation that authorization | ||||||
17 | or referral may be required to access some providers. | ||||||
18 | (6) A network plan shall make it clear for both its | ||||||
19 | electronic and print directories what provider directory | ||||||
20 | applies to which network plan, such as including the | ||||||
21 | specific name of the network plan as marketed and issued in | ||||||
22 | this State. The network plan shall include in both its | ||||||
23 | electronic and print directories a customer service email | ||||||
24 | address and telephone number or electronic link that | ||||||
25 | beneficiaries or the general public may use to notify the | ||||||
26 | network plan of inaccurate provider directory information |
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1 | and contact information for the Department's Office of | ||||||
2 | Consumer Health Insurance. | ||||||
3 | (7) A provider directory, whether in electronic or | ||||||
4 | print format, shall accommodate the communication needs of | ||||||
5 | individuals with disabilities, and include a link to or | ||||||
6 | information regarding available assistance for persons | ||||||
7 | with limited English proficiency. | ||||||
8 | (b) For each network plan, a network plan shall make | ||||||
9 | available through an electronic provider directory the | ||||||
10 | following information in a searchable format: | ||||||
11 | (1) for health care professionals: | ||||||
12 | (A) name; | ||||||
13 | (B) gender; | ||||||
14 | (C) participating office locations; | ||||||
15 | (D) specialty, if applicable; | ||||||
16 | (E) medical group affiliations, if applicable; | ||||||
17 | (F) facility affiliations, if applicable; | ||||||
18 | (G) participating facility affiliations, if | ||||||
19 | applicable; | ||||||
20 | (H) languages spoken other than English, if | ||||||
21 | applicable; | ||||||
22 | (I) whether accepting new patients; and | ||||||
23 | (J) board certifications, if applicable ; and . | ||||||
24 | (K) use of telehealth or telemedicine, including: | ||||||
25 | (i) whether the provider offers the use of | ||||||
26 | telehealth or telemedicine to deliver services; |
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1 | (ii) what modalities are used and what | ||||||
2 | services via telehealth or telemedicine are | ||||||
3 | provided; and | ||||||
4 | (iii) whether the provider has the ability and | ||||||
5 | willingness to include in a telehealth or | ||||||
6 | telemedicine encounter a family caregiver who is | ||||||
7 | in a separate location than the patient if the | ||||||
8 | patient wishes and provides his or her consent; | ||||||
9 | (2) for hospitals: | ||||||
10 | (A) hospital name; | ||||||
11 | (B) hospital type (such as acute, rehabilitation, | ||||||
12 | children's, or cancer); | ||||||
13 | (C) participating hospital location; and | ||||||
14 | (D) hospital accreditation status; and | ||||||
15 | (3) for facilities, other than hospitals, by type: | ||||||
16 | (A) facility name; | ||||||
17 | (B) facility type; | ||||||
18 | (C) types of services performed; and | ||||||
19 | (D) participating facility location or locations. | ||||||
20 | (c) For the electronic provider directories, for each | ||||||
21 | network plan, a network plan shall make available all of the | ||||||
22 | following information in addition to the searchable | ||||||
23 | information required in this Section: | ||||||
24 | (1) for health care professionals: | ||||||
25 | (A) contact information; and | ||||||
26 | (B) languages spoken other than English by |
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1 | clinical staff, if applicable; | ||||||
2 | (2) for hospitals, telephone number; and | ||||||
3 | (3) for facilities other than hospitals, telephone | ||||||
4 | number. | ||||||
5 | (d) The insurer or network plan shall make available in | ||||||
6 | print, upon request, the following provider directory | ||||||
7 | information for the applicable network plan: | ||||||
8 | (1) for health care professionals: | ||||||
9 | (A) name; | ||||||
10 | (B) contact information; | ||||||
11 | (C) participating office location or locations; | ||||||
12 | (D) specialty, if applicable; | ||||||
13 | (E) languages spoken other than English, if | ||||||
14 | applicable; and | ||||||
15 | (F) whether accepting new patients ; and . | ||||||
16 | (G) use of telehealth or telemedicine, including: | ||||||
17 | (i) whether the provider offers the use of | ||||||
18 | telehealth or telemedicine to deliver services; | ||||||
19 | (ii) what modalities are used and what | ||||||
20 | services via telehealth or telemedicine are | ||||||
21 | provided; and | ||||||
22 | (iii) whether the provider has the ability and | ||||||
23 | willingness to include in a telehealth or | ||||||
24 | telemedicine encounter a family caregiver who is | ||||||
25 | in a separate location than the patient if the | ||||||
26 | patient wishes and provides his or her consent; |
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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. A network plan shall not be | ||||||
24 | subject to any fines or penalties for information required in | ||||||
25 | this Section that a provider submits that is inaccurate or | ||||||
26 | incomplete.
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1 | (Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
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2 | Section 99. Effective date. This Act takes effect upon | ||||||
3 | becoming law.
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