Rep. Sue Scherer
Filed: 3/30/2022
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1 | AMENDMENT TO HOUSE BILL 1463
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2 | AMENDMENT NO. ______. Amend House Bill 1463 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Illinois Administrative Procedure Act is | ||||||
5 | amended by adding Section 5-45.21 as follows: | ||||||
6 | (5 ILCS 100/5-45.21 new) | ||||||
7 | Sec. 5-45.21. Emergency rulemaking; Network Adequacy and | ||||||
8 | Transparency Act. To provide for the expeditious and timely | ||||||
9 | implementation of the Network Adequacy and Transparency Act, | ||||||
10 | emergency rules implementing federal standards for provider | ||||||
11 | ratios, travel time and distance, and appointment wait times | ||||||
12 | if such standards apply to health insurance coverage regulated | ||||||
13 | by the Department of Insurance and are more stringent than the | ||||||
14 | State standards extant at the time the final federal standards | ||||||
15 | are published may be adopted in accordance with Section 5-45 | ||||||
16 | by the Department of Insurance. The adoption of emergency |
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1 | rules authorized by Section 5-45 and this Section is deemed to | ||||||
2 | be necessary for the public interest, safety, and welfare. | ||||||
3 | Section 10. The Illinois Insurance Code is amended by | ||||||
4 | changing Sections 132, 132.5, 155.35, 402, 408, 511.109, | ||||||
5 | 512-3, 512-5, and 513b3 and by adding Section 512-11 as | ||||||
6 | follows:
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7 | (215 ILCS 5/132) (from Ch. 73, par. 744)
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8 | Sec. 132. Market conduct and non-financial examinations.
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9 | (a) Definitions. | ||||||
10 | As used in this Section: | ||||||
11 | "Desk examination" means an examination conducted by | ||||||
12 | market conduct surveillance personnel at a location other than | ||||||
13 | the regulated person's premises. A "desk examination" is | ||||||
14 | usually performed at the Department's offices with the insurer | ||||||
15 | providing requested documents by hard copy, microfiche, discs, | ||||||
16 | or other electronic media for review without an on-site | ||||||
17 | examination. | ||||||
18 | "Market analysis" means a process whereby market conduct | ||||||
19 | surveillance personnel collect and analyze information from | ||||||
20 | filed schedules, surveys, data calls, required reports, and | ||||||
21 | other sources in order to develop a baseline understanding of | ||||||
22 | the marketplace and to identify patterns or practices of | ||||||
23 | regulated persons that deviate significantly from the norm or | ||||||
24 | that may pose a potential risk to the insurance consumer. |
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1 | "Market conduct action" means any of the full range of | ||||||
2 | activities that the Director may initiate to assess and | ||||||
3 | address the market practices of regulated persons, including, | ||||||
4 | but not limited to, market analysis and market conduct | ||||||
5 | examinations. "Market conduct action" does not include the | ||||||
6 | Department's consumer complaint process outlined in 50 Ill. | ||||||
7 | Adm. Code 926; however, the Department may initiate market | ||||||
8 | conduct actions based on information gathered during that | ||||||
9 | process. Examples of "market conduct action" include, but are | ||||||
10 | not limited to: | ||||||
11 | (1) correspondence with the company or person; | ||||||
12 | (2) interviews with the company or person; | ||||||
13 | (3) information gathering; | ||||||
14 | (4) reviews of policies and procedures; | ||||||
15 | (5) interrogatories; | ||||||
16 | (6) reviews of self-evaluations and voluntary | ||||||
17 | compliance programs of the person or company; | ||||||
18 | (7) self-audits; and | ||||||
19 | (8) market conduct examinations. | ||||||
20 | "Market conduct examination" or "examination" means any | ||||||
21 | type of examination described in the NAIC Market Regulation | ||||||
22 | Handbook that may be used to assess a regulated person's | ||||||
23 | compliance with the laws, rules, and regulations applicable to | ||||||
24 | the examinee. "Market conduct examination" includes | ||||||
25 | comprehensive examinations, targeted examinations, and | ||||||
26 | follow-up examinations. Market conduct examinations may be |
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1 | conducted as desk examinations, on-site examinations, or a | ||||||
2 | combination of those 2 types of examinations. | ||||||
3 | "Market conduct surveillance" means market analysis or a | ||||||
4 | market conduct action. | ||||||
5 | "Market conduct surveillance personnel" means those | ||||||
6 | individuals employed or retained by the Department and | ||||||
7 | designated by the Director to collect, analyze, review, or act | ||||||
8 | on information in the insurance marketplace that identifies | ||||||
9 | patterns or practices of insurers. "Market conduct | ||||||
10 | surveillance personnel" includes all persons identified as an | ||||||
11 | examiner in the insurance laws or rules of this State if the | ||||||
12 | Director has designated those persons to assist the Director | ||||||
13 | in ascertaining the non-financial business practices, | ||||||
14 | performance, and operations of a company or person subject to | ||||||
15 | the Director's jurisdiction. | ||||||
16 | "NAIC" means the National Association of Insurance | ||||||
17 | Commissioners. | ||||||
18 | "On-site examination" means an examination conducted at | ||||||
19 | the insurer's home office or the location where the records | ||||||
20 | under review are stored. | ||||||
21 | (b) Examinations. (1) | ||||||
22 | The Director, for the purposes of ascertaining the
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23 | non-financial business practices, performance, and operations | ||||||
24 | of any
company, may make
examinations of:
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25 | (1) (a) any company transacting or being organized to | ||||||
26 | transact business
in this State;
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1 | (2) (b) any person engaged in or proposing to be | ||||||
2 | engaged in the
organization, promotion, or solicitation of | ||||||
3 | shares or capital
contributions to or aiding in the | ||||||
4 | formation of a company;
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5 | (3) (c) any person having a contract, written or oral, | ||||||
6 | pertaining to the
management or control of a company as | ||||||
7 | general agent, managing agent, or
attorney-in-fact;
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8 | (4) (d) any licensed or registered
producer, firm, or | ||||||
9 | administrator, or any person,
organization, or corporation | ||||||
10 | making application for any
licenses or registration;
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11 | (5) (e) any person engaged in the business of | ||||||
12 | adjusting losses or
financing premiums; or
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13 | (6) (f) any person, organization, trust, or | ||||||
14 | corporation having custody or
control of information | ||||||
15 | reasonably related to the operation, performance, or
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16 | conduct of a company or person subject to the jurisdiction | ||||||
17 | of the Director.
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18 | (c) Market analysis and market conduct actions. | ||||||
19 | (1) The Director may perform market analysis by | ||||||
20 | gathering and analyzing information from data currently | ||||||
21 | available to the Director, information from surveys or | ||||||
22 | reports that are submitted regularly to the Director or | ||||||
23 | required in a data call, information collected by the | ||||||
24 | NAIC, and information from a variety of other sources in | ||||||
25 | both the public and private domain in order to develop a | ||||||
26 | baseline understanding of the marketplace and to identify |
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1 | for further review practices that deviate from the norm or | ||||||
2 | that may pose a potential risk to the insurance consumer. | ||||||
3 | The Director shall use the NAIC Market Regulation Handbook | ||||||
4 | as a guide in performing market analysis. | ||||||
5 | (2) If the Director determines that further inquiry | ||||||
6 | into a particular person or practice is needed, the | ||||||
7 | Director may consider one or more market conduct actions. | ||||||
8 | The Director shall inform the examinee in writing of the | ||||||
9 | type of market conduct action selected and shall use the | ||||||
10 | NAIC Market Regulation Handbook as a guide in performing | ||||||
11 | the market conduct action. The Director may coordinate a | ||||||
12 | market conduct action and findings of this State with | ||||||
13 | market conduct actions and findings of other states. | ||||||
14 | (3) Nothing in this Section requires the Director to | ||||||
15 | conduct market analysis prior to initiating any market | ||||||
16 | conduct action. | ||||||
17 | (4) Nothing in this Section restricts the Director to | ||||||
18 | the type of market conduct action initially selected. The | ||||||
19 | Director shall inform the examinee in writing of any | ||||||
20 | change in the type of market conduct action being | ||||||
21 | conducted. | ||||||
22 | (d) Access to books and records; oaths and examinations. | ||||||
23 | (2) Every examinee company or person being examined and | ||||||
24 | its officers, directors,
and agents must provide to the | ||||||
25 | Director convenient and free access at
all reasonable hours at | ||||||
26 | its office or location to all books, records,
documents, |
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1 | including consumer communications, and any or all papers | ||||||
2 | relating to the
business, performance, operations, and affairs | ||||||
3 | of the examinee company . The
officers, directors, and
agents | ||||||
4 | of the examinee company or person must facilitate the market | ||||||
5 | conduct action examination and aid
in the action examination | ||||||
6 | so far as it is in their power to do so.
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7 | The Director and any authorized market conduct | ||||||
8 | surveillance personnel examiner have the power to administer
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9 | oaths and examine under oath
any person relative to the | ||||||
10 | business of the examinee company being examined . Any delay of | ||||||
11 | more than 5 business days in the transmission of requested | ||||||
12 | documents without an extension approved by the Director or | ||||||
13 | designated market conduct surveillance personnel is a | ||||||
14 | violation of this Section.
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15 | (e) Examination report. | ||||||
16 | (3) The market conduct surveillance personnel examiners | ||||||
17 | designated by the Director under Section 402 must
make a full | ||||||
18 | and true report of every examination made by them, which
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19 | contains only facts ascertained from the books, papers, | ||||||
20 | records, or documents,
and other evidence obtained by | ||||||
21 | investigation
and examined by them or ascertained from the | ||||||
22 | testimony of officers or
agents or other persons examined | ||||||
23 | under oath concerning the business,
affairs, conduct, and | ||||||
24 | performance of the examinee
company or person . The report of
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25 | examination must be verified by the oath of the examiner in | ||||||
26 | charge
thereof, and when so verified is prima facie evidence |
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1 | in any action or
proceeding in the
name of the State against | ||||||
2 | the company, its officers, or agents upon the
facts stated | ||||||
3 | therein.
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4 | (f) Examinee acceptance of examination report. | ||||||
5 | The Department and the examinee shall adhere to the | ||||||
6 | following timeline, unless a mutual agreement is reached to | ||||||
7 | modify the timeline: | ||||||
8 | (1) The Department shall deliver the draft report to | ||||||
9 | the examinee within 60 days after completion of the | ||||||
10 | examination. "Completion of the examination" means the | ||||||
11 | date the Department confirms in writing that the | ||||||
12 | examination is completed. Nothing in this Section prevents | ||||||
13 | the Department from sharing an earlier draft of the report | ||||||
14 | with the examinee before confirming that the examination | ||||||
15 | is completed. | ||||||
16 | (2) If the examinee chooses to respond with written | ||||||
17 | submissions or rebuttals, the examinee must do so within | ||||||
18 | 30 days after receipt of any draft report delivered after | ||||||
19 | the completion of the examination. | ||||||
20 | (3) After receipt of any written submissions or | ||||||
21 | rebuttals, the Department shall issue a final report. At | ||||||
22 | any time, the Department may share draft corrections or | ||||||
23 | changes to the report with the examinee before issuing a | ||||||
24 | final report, and the examinee shall have 30 days to | ||||||
25 | respond to the draft. | ||||||
26 | (4) The examinee shall, within 10 days after the |
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1 | issuance of the final report, accept the final report or | ||||||
2 | request a hearing in writing. Failure to take either | ||||||
3 | action within 10 days shall be deemed an acceptance of the | ||||||
4 | final report. If the examinee accepts the examination | ||||||
5 | report, the Director shall continue to hold the content of | ||||||
6 | the examination report as private and confidential for a | ||||||
7 | period of 30 days, except to the extent provided for in | ||||||
8 | subsection (h) and in paragraph (10) of subsection (g). | ||||||
9 | Thereafter, the Director shall open the report for public | ||||||
10 | inspection if no court of competent jurisdiction has | ||||||
11 | stayed its publication. | ||||||
12 | (g) Written hearing. | ||||||
13 | Notwithstanding anything to the contrary in this Code or | ||||||
14 | Department rules, if the examinee requests a hearing, the | ||||||
15 | following procedures apply: | ||||||
16 | (1) The examinee shall request the hearing in writing | ||||||
17 | and shall specify the issues in the final report that the | ||||||
18 | examinee is challenging. The examinee is limited to | ||||||
19 | challenging the issues that were previously challenged in | ||||||
20 | the examinee's written submission and rebuttal or | ||||||
21 | supplemental submission and rebuttal as provided pursuant | ||||||
22 | to paragraphs (2) and (3) of subsection (f). | ||||||
23 | (2) The hearing shall be conducted by written | ||||||
24 | arguments submitted to the Director. | ||||||
25 | (3) Discovery is limited to the market conduct | ||||||
26 | surveillance personnel's work papers that are relevant to |
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1 | the issues the examinee is challenging. The relevant | ||||||
2 | market conduct surveillance personnel's work papers shall | ||||||
3 | be deemed admitted into and included in the record. No | ||||||
4 | other forms of discovery, including depositions and | ||||||
5 | interrogatories, are allowed, except upon written | ||||||
6 | agreement of the examinee and the Department's counsel. | ||||||
7 | (4) Only the examinee and the Department's counsel may | ||||||
8 | submit written arguments. | ||||||
9 | (5) The examinee shall submit its written argument | ||||||
10 | within 30 days after the Department's counsel serves a | ||||||
11 | formal notice of hearing. | ||||||
12 | (6) The Department's counsel shall submit its written | ||||||
13 | response within 30 days after the examinee submits its | ||||||
14 | written argument. | ||||||
15 | (7) The Director shall issue a decision accompanied by | ||||||
16 | findings and conclusions resulting from the Director's | ||||||
17 | consideration and review of the written arguments, the | ||||||
18 | final report, relevant market conduct surveillance | ||||||
19 | personnel work papers, and any written submissions or | ||||||
20 | rebuttals. The Director's order is a final agency action | ||||||
21 | and shall be served upon the examinee by electronic mail | ||||||
22 | together with a copy of the final report pursuant to | ||||||
23 | Section 10-75 of the Illinois Administrative Procedure | ||||||
24 | Act. | ||||||
25 | (8) Any portion of the final examination report that | ||||||
26 | was not challenged by the examinee is incorporated into |
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1 | the decision of the Director. | ||||||
2 | (9) Findings of fact and conclusions of law in the | ||||||
3 | Director's final agency action are prima facie evidence in | ||||||
4 | any legal or regulatory action. | ||||||
5 | (10) If an examinee has requested a hearing, the | ||||||
6 | Director shall continue to hold the content of any | ||||||
7 | examination report or other final agency action of a | ||||||
8 | market conduct examination as private and confidential for | ||||||
9 | a period of 49 days after the final agency action. After | ||||||
10 | the 49-day period expires, the Director shall open the | ||||||
11 | final agency action for public inspection if a court of | ||||||
12 | competent jurisdiction has not stayed its publication. | ||||||
13 | (h) Nothing in this Section prevents the Director from | ||||||
14 | disclosing at any time the content of an examination report, | ||||||
15 | preliminary examination report, or results, or any matter | ||||||
16 | relating to a report or results, to the division or to the | ||||||
17 | insurance division of any other state or agency or office of | ||||||
18 | the federal government at any time if the division, agency, or | ||||||
19 | office receiving the report or related matters agrees and has | ||||||
20 | the legal authority to hold it confidential in a manner | ||||||
21 | consistent with this Section. | ||||||
22 | (i) Confidentiality. | ||||||
23 | (1) The Director and any other person in the course of | ||||||
24 | market conduct surveillance shall keep confidential all | ||||||
25 | documents pertaining to the market conduct surveillance, | ||||||
26 | including working papers, third-party models, or products, |
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1 | complaint logs, and copies of any documents created by, | ||||||
2 | produced by, obtained by, or disclosed to the Director, | ||||||
3 | market conduct surveillance personnel, or any other person | ||||||
4 | in the course of market conduct surveillance conducted | ||||||
5 | pursuant to this Section, and all documents obtained by | ||||||
6 | the NAIC as a result of this Section. The documents shall | ||||||
7 | remain confidential after termination of the market | ||||||
8 | conduct surveillance, are not subject to subpoena, are not | ||||||
9 | subject to discovery or admissible as evidence in private | ||||||
10 | civil litigation, are not subject to disclosure under the | ||||||
11 | Freedom of Information Act, and shall not be made public | ||||||
12 | at any time or used by the Director or any other person, | ||||||
13 | except as provided in paragraphs (3), (4), and (6) of this | ||||||
14 | subsection and in subsection (l). | ||||||
15 | (2) The Director, the Department, and any other person | ||||||
16 | in the course of market conduct surveillance shall keep | ||||||
17 | confidential any self-evaluation or voluntary compliance | ||||||
18 | program documents disclosed to the Director or other | ||||||
19 | person by an examinee and the data collected via the NAIC | ||||||
20 | market conduct annual statement. The documents are not | ||||||
21 | subject to subpoena, are not subject to discovery or | ||||||
22 | admissible as evidence in private civil litigation, are | ||||||
23 | not subject to disclosure under the Freedom of Information | ||||||
24 | Act, and shall not be made public or used by the Director | ||||||
25 | or any other person, except as provided in paragraphs (3), | ||||||
26 | (4), and (6) of this subsection, in subsection (l), or in |
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1 | Section 155.35 of this Code. | ||||||
2 | (3) Notwithstanding paragraphs (1) and (2), and | ||||||
3 | consistent with paragraph (5), in order to assist in the | ||||||
4 | performance of the Director's duties, the Director may: | ||||||
5 | (A) share documents, materials, communications, or | ||||||
6 | other information, including the confidential and | ||||||
7 | privileged documents, materials, or information | ||||||
8 | described in this subsection, with other State, | ||||||
9 | federal, alien, and international regulatory agencies | ||||||
10 | and law enforcement authorities and the NAIC, its | ||||||
11 | affiliates, and subsidiaries, if the recipient agrees | ||||||
12 | to and has the legal authority to maintain the | ||||||
13 | confidentiality and privileged status of the document, | ||||||
14 | material, communication, or other information; | ||||||
15 | (B) receive documents, materials, communications, | ||||||
16 | or information, including otherwise confidential and | ||||||
17 | privileged documents, materials, or information, from | ||||||
18 | the NAIC and its affiliates or subsidiaries, and from | ||||||
19 | regulatory and law enforcement officials of other | ||||||
20 | domestic, alien, or international jurisdictions, | ||||||
21 | authorities, and agencies, and shall maintain as | ||||||
22 | confidential or privileged any document, material, | ||||||
23 | communication, or information received with notice or | ||||||
24 | the understanding that it is confidential or | ||||||
25 | privileged under the laws of the jurisdiction that is | ||||||
26 | the source of the document, material, communication, |
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1 | or information; | ||||||
2 | (C) enter into agreements governing the sharing | ||||||
3 | and use of information consistent with this Section; | ||||||
4 | and | ||||||
5 | (D) when the Director performs any type of market | ||||||
6 | conduct surveillance that does not rise to the level | ||||||
7 | of a market conduct examination, make the final | ||||||
8 | results of the market conduct surveillance, in an | ||||||
9 | aggregated format, available for public inspection in | ||||||
10 | a manner deemed appropriate by the Director. | ||||||
11 | (4) Nothing in this Section limits: | ||||||
12 | (A) the Director's authority to use, if consistent | ||||||
13 | with subsection (5) of Section 188.1, any final or | ||||||
14 | preliminary examination report, any market conduct | ||||||
15 | surveillance or examinee work papers or other | ||||||
16 | documents, or any other information discovered or | ||||||
17 | developed during the course of any market conduct | ||||||
18 | surveillance, in the furtherance of any legal or | ||||||
19 | regulatory action initiated by the Director that the | ||||||
20 | Director may, in the Director's sole discretion, deem | ||||||
21 | appropriate; or | ||||||
22 | (B) the ability of an examinee to conduct | ||||||
23 | discovery in accordance with paragraph (3) of | ||||||
24 | subsection (g). | ||||||
25 | (5) Disclosure to the Director of documents, | ||||||
26 | materials, communications, or information required as part |
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1 | of any type of market conduct surveillance does not waive | ||||||
2 | any applicable privilege or claim of confidentiality in | ||||||
3 | the documents, materials, communications, or information. | ||||||
4 | (6) If the Director deems fit, the Director may | ||||||
5 | publicly acknowledge the existence of an ongoing | ||||||
6 | examination before filing the examination report but shall | ||||||
7 | not disclose any other information protected under this | ||||||
8 | subsection. | ||||||
9 | (j) Corrective actions; sanctions. | ||||||
10 | (1) As a result of any market conduct action other | ||||||
11 | than market analysis, the Director may order the examinee | ||||||
12 | to take any action the Director considers necessary or | ||||||
13 | appropriate in accordance with the report of examination | ||||||
14 | or any hearing thereon, including, but not limited to, | ||||||
15 | requiring the regulated person to undertake corrective | ||||||
16 | actions to cease and desist an identified violation or | ||||||
17 | institute processes and practices to comply with | ||||||
18 | applicable standards, requiring reimbursement or | ||||||
19 | restitution to persons harmed by the regulated person's | ||||||
20 | violation, or imposing civil penalties, for acts in | ||||||
21 | violation of any law, rule, or prior lawful order of the | ||||||
22 | Director. Civil penalties imposed as a result of a market | ||||||
23 | conduct action shall be consistent, reasonable, and | ||||||
24 | justifiable. | ||||||
25 | (2) If any other provision of this Code or any other | ||||||
26 | law or rule under the Director's jurisdiction prescribes |
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1 | an amount or range of penalties for a violation of a | ||||||
2 | particular statute, that provision shall apply. If no | ||||||
3 | penalty is already provided by law or rule for a violation | ||||||
4 | and the violation is quantifiable, then the Director may | ||||||
5 | order a penalty of up to $3,000 for every act in violation | ||||||
6 | of any law, rule, or prior lawful order of the Director. If | ||||||
7 | the examination report finds a violation by the examinee | ||||||
8 | that the report is unable to quantify, such as, an | ||||||
9 | operational policy or procedure that conflicts with | ||||||
10 | applicable law, then the Director may order a penalty of | ||||||
11 | up to $10,000 for that violation. A violation of | ||||||
12 | subsection (d) is punishable by a fine of $2,000 per day up | ||||||
13 | to a maximum of $500,000. | ||||||
14 | (k) Participation in national market conduct databases. | ||||||
15 | The Director shall collect and report market data to the | ||||||
16 | NAIC's market information systems, including, but not limited | ||||||
17 | to, the Complaint Database System, the Examination Tracking | ||||||
18 | System, and the Regulatory Information Retrieval System, or | ||||||
19 | other successor NAIC products as determined by the Director. | ||||||
20 | Information collected and maintained by the Department for | ||||||
21 | inclusion in these NAIC market information systems shall be | ||||||
22 | compiled in a manner that meets the requirements of the NAIC. | ||||||
23 | (4) The Director must notify the company or person made | ||||||
24 | the subject of
any examination hereunder of the
contents of | ||||||
25 | the verified examination report before filing it and making | ||||||
26 | the
report public of any matters relating thereto, and must |
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1 | afford the
company or person an opportunity to demand a | ||||||
2 | hearing with reference to
the facts and other evidence therein | ||||||
3 | contained.
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4 | The company or person may request a hearing within 10 days | ||||||
5 | after
receipt of the examination report by giving the Director | ||||||
6 | written notice
of that request, together with a statement of | ||||||
7 | its objections. The
Director must then conduct a hearing in | ||||||
8 | accordance with Sections 402 and
403. He must issue a written | ||||||
9 | order based upon the examination report and
upon the hearing | ||||||
10 | within 90 days after the report is filed or within 90
days | ||||||
11 | after the hearing.
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12 | If the examination reveals that the company is operating | ||||||
13 | in violation
of any law, regulation, or prior order, the | ||||||
14 | Director in the written
order may require the company or | ||||||
15 | person to take any action he considers
necessary or | ||||||
16 | appropriate in accordance with the report of examination
or | ||||||
17 | any hearing thereon. The order is subject to judicial review | ||||||
18 | under
the Administrative Review Law.
The Director may withhold | ||||||
19 | any report from public
inspection for such time as he may deem | ||||||
20 | proper and may, after filing the
same, publish any part or all | ||||||
21 | of the report as he considers to be in the
interest of the | ||||||
22 | public, in one or more newspapers in this State, without
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23 | expense to the company.
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24 | (5) Any company which or person who violates or aids and | ||||||
25 | abets any
violation of a written order issued under this | ||||||
26 | Section shall be guilty
of a business offense and may be fined |
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1 | not more than $5,000. The penalty
shall be paid into the | ||||||
2 | General Revenue fund of the State of Illinois.
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3 | (Source: P.A. 87-108.)
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4 | (215 ILCS 5/132.5) (from Ch. 73, par. 744.5)
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5 | Sec. 132.5. Examination reports.
| ||||||
6 | (a) General description. All examination reports shall be | ||||||
7 | comprised of
only facts appearing upon the books, records, or | ||||||
8 | other documents of the
company, its agents, or other persons | ||||||
9 | examined or as ascertained from the
testimony of its officers, | ||||||
10 | agents, or other persons examined concerning its
affairs and | ||||||
11 | the conclusions and recommendations as the examiners find
| ||||||
12 | reasonably warranted from those facts.
| ||||||
13 | (b) Filing of examination report. No later than 60 days | ||||||
14 | following
completion of the examination, the examiner in | ||||||
15 | charge shall file with the
Department a verified written | ||||||
16 | report of examination under oath. Upon
receipt of the verified | ||||||
17 | report, the Department shall transmit the report to
the | ||||||
18 | company examined, together with a notice that affords the | ||||||
19 | company examined
a reasonable opportunity of not more than 30 | ||||||
20 | days to make a written
submission or rebuttal with respect to | ||||||
21 | any matters contained in the examination report.
| ||||||
22 | (c) Adoption of the report on examination. Within 30 days | ||||||
23 | of the end of the
period allowed for the receipt of written | ||||||
24 | submissions or rebuttals, the
Director shall fully consider | ||||||
25 | and review the report, together with any
written submissions |
| |||||||
| |||||||
1 | or rebuttals and any relevant portions of the examiners
work | ||||||
2 | papers and enter an order:
| ||||||
3 | (1) Adopting the examination report as filed or with | ||||||
4 | modification or
corrections. If the examination report | ||||||
5 | reveals that the company is
operating in violation of any | ||||||
6 | law, regulation, or prior order of the
Director, the | ||||||
7 | Director may order the company to take any action the
| ||||||
8 | Director considers necessary and appropriate to cure the | ||||||
9 | violation.
| ||||||
10 | (2) Rejecting the examination report with directions | ||||||
11 | to the examiners
to reopen the examination for purposes of | ||||||
12 | obtaining additional data,
documentation, or information | ||||||
13 | and refiling under subsection (b).
| ||||||
14 | (3) Calling for an investigatory hearing with no less | ||||||
15 | than 20 days
notice to the company for purposes of | ||||||
16 | obtaining additional documentation,
data, information, and | ||||||
17 | testimony.
| ||||||
18 | (d) Order and procedures. All orders entered under | ||||||
19 | paragraph (1) of
subsection (c) shall be accompanied by | ||||||
20 | findings and conclusions resulting
from the Director's | ||||||
21 | consideration and review of the examination report,
relevant | ||||||
22 | examiner work papers, and any written submissions or | ||||||
23 | rebuttals.
The order shall be considered a final | ||||||
24 | administrative decision and may be
appealed in accordance with | ||||||
25 | the Administrative Review Law. The order shall
be served upon | ||||||
26 | the company by certified mail, together with a copy of the
|
| |||||||
| |||||||
1 | adopted examination report. Within 30 days of the issuance of | ||||||
2 | the adopted
report, the company shall file affidavits executed | ||||||
3 | by each of its directors
stating under oath that they have | ||||||
4 | received a copy of the adopted report and
related orders.
| ||||||
5 | Any hearing conducted under paragraph (3) of subsection | ||||||
6 | (c) by the
Director or an authorized representative shall be | ||||||
7 | conducted as a
nonadversarial confidential investigatory | ||||||
8 | proceeding as necessary for the
resolution of any | ||||||
9 | inconsistencies, discrepancies, or disputed issues
apparent | ||||||
10 | upon the face of the filed examination report or raised by or | ||||||
11 | as a
result of the Director's review of relevant work papers or | ||||||
12 | by the written
submission or rebuttal of the company.
Within | ||||||
13 | 20 days of the conclusion of any hearing, the Director shall | ||||||
14 | enter
an order under paragraph (1) of subsection (c).
| ||||||
15 | The Director shall not appoint an examiner as an | ||||||
16 | authorized
representative to conduct the hearing. The hearing | ||||||
17 | shall proceed
expeditiously with discovery by the company | ||||||
18 | limited to the examiner's work
papers that tend to | ||||||
19 | substantiate any assertions set forth in any written
| ||||||
20 | submission or rebuttal. The Director or his representative may | ||||||
21 | issue
subpoenas for the attendance of any witnesses or the | ||||||
22 | production of any
documents deemed relevant to the | ||||||
23 | investigation, whether under the control
of the Department, | ||||||
24 | the company, or other persons. The documents produced
shall be | ||||||
25 | included in the record, and testimony taken by the Director or | ||||||
26 | his
representative shall be under oath and preserved for the |
| |||||||
| |||||||
1 | record. Nothing
contained in this Section shall require the | ||||||
2 | Department to disclose any
information or records that would | ||||||
3 | indicate or show the existence or content
of any investigation | ||||||
4 | or activity of a criminal justice agency.
| ||||||
5 | The hearing shall proceed with the Director or his | ||||||
6 | representative
posing questions to the persons subpoenaed. | ||||||
7 | Thereafter the company and the
Department may present | ||||||
8 | testimony relevant to the investigation.
Cross-examination | ||||||
9 | shall be conducted only by the Director or his representative.
| ||||||
10 | The company and the Department shall be permitted to make | ||||||
11 | closing
statements and may be represented by counsel of their | ||||||
12 | choice.
| ||||||
13 | (e) Publication and use. Upon the adoption of the | ||||||
14 | examination report
under paragraph (1) of subsection (c), the | ||||||
15 | Director shall continue to hold
the content of the examination | ||||||
16 | report as private and confidential
information for a period of | ||||||
17 | 35 days, except to the extent provided in
subsection (b). | ||||||
18 | Thereafter, the Director may open the report for public
| ||||||
19 | inspection so long as no court of competent jurisdiction has | ||||||
20 | stayed its publication.
| ||||||
21 | Nothing contained in this Code shall prevent or be | ||||||
22 | construed as
prohibiting the Director from disclosing the | ||||||
23 | content of an examination
report, preliminary examination | ||||||
24 | report or results, or any matter relating
thereto, to the | ||||||
25 | insurance department of any other state or country or to law
| ||||||
26 | enforcement officials of this or any other state or agency of |
| |||||||
| |||||||
1 | the federal
government at any time, so long as the agency or | ||||||
2 | office receiving the
report or matters relating thereto agrees | ||||||
3 | in writing to hold it
confidential and in a manner consistent | ||||||
4 | with this Code.
| ||||||
5 | In the event the Director determines that regulatory | ||||||
6 | action is
appropriate as a result of any examination, he may | ||||||
7 | initiate any
proceedings or actions as provided by law.
| ||||||
8 | (f) Confidentiality of ancillary information. All working | ||||||
9 | papers,
recorded information, documents, and copies
thereof | ||||||
10 | produced by, obtained by, or disclosed to the Director or any | ||||||
11 | other
person in the course of any examination must be given | ||||||
12 | confidential
treatment, are not subject to subpoena, and may | ||||||
13 | not be made public by the
Director or any other persons, except | ||||||
14 | to the extent provided in subsection
(e). Access may also be | ||||||
15 | granted to the National Association of Insurance | ||||||
16 | Commissioners.
Those parties must agree in writing before | ||||||
17 | receiving the information to
provide to it the same | ||||||
18 | confidential treatment as required by this Section,
unless the | ||||||
19 | prior written consent of the company to which it pertains has | ||||||
20 | been obtained.
| ||||||
21 | This subsection (f) applies to market conduct examinations | ||||||
22 | described in Section 132 of this Code. | ||||||
23 | (Source: P.A. 100-475, eff. 1-1-18 .)
| ||||||
24 | (215 ILCS 5/155.35)
| ||||||
25 | Sec. 155.35. Insurance compliance self-evaluative |
| |||||||
| |||||||
1 | privilege.
| ||||||
2 | (a) To encourage insurance companies and persons | ||||||
3 | conducting activities
regulated under this Code, both to | ||||||
4 | conduct voluntary internal audits of their
compliance programs | ||||||
5 | and management systems and to assess and improve compliance
| ||||||
6 | with State and federal statutes, rules, and orders, an | ||||||
7 | insurance compliance
self-evaluative privilege is recognized | ||||||
8 | to protect the confidentiality of
communications relating to | ||||||
9 | voluntary internal compliance audits. The General
Assembly | ||||||
10 | hereby finds and declares that protection of insurance | ||||||
11 | consumers is
enhanced by companies' voluntary compliance with | ||||||
12 | this State's insurance and
other laws and that the public will | ||||||
13 | benefit from incentives to identify and
remedy insurance and | ||||||
14 | other compliance issues. It is further declared that
limited | ||||||
15 | expansion of the protection against disclosure will encourage | ||||||
16 | voluntary
compliance and improve insurance market conduct | ||||||
17 | quality and that the voluntary
provisions of this Section will | ||||||
18 | not inhibit the exercise of the regulatory
authority by those | ||||||
19 | entrusted with protecting insurance consumers.
| ||||||
20 | (b)(1) An insurance compliance self-evaluative audit | ||||||
21 | document is privileged
information and is not admissible as | ||||||
22 | evidence in any legal action in any
civil, criminal, or | ||||||
23 | administrative proceeding, except as provided in
subsections | ||||||
24 | (c) and (d) of this Section. Documents, communications, data,
| ||||||
25 | reports, or other information created as a result of a claim | ||||||
26 | involving personal
injury or workers' compensation made |
| |||||||
| |||||||
1 | against an insurance policy are not
insurance compliance | ||||||
2 | self-evaluative audit documents and are admissible as
evidence | ||||||
3 | in civil proceedings as otherwise provided by applicable rules | ||||||
4 | of
evidence or civil procedure, subject to any applicable | ||||||
5 | statutory or common law
privilege, including but not limited | ||||||
6 | to the work product doctrine, the
attorney-client privilege, | ||||||
7 | or the subsequent remedial measures exclusion.
| ||||||
8 | (2) If any company, person, or entity performs or directs | ||||||
9 | the performance
of an insurance compliance audit, an officer | ||||||
10 | or employee involved with the
insurance compliance audit, or | ||||||
11 | any consultant who is hired for the purpose of
performing the | ||||||
12 | insurance compliance audit, may not be examined in any civil,
| ||||||
13 | criminal, or administrative proceeding as to the insurance | ||||||
14 | compliance audit or
any insurance compliance self-evaluative | ||||||
15 | audit document, as defined in this
Section. This subsection | ||||||
16 | (b)(2) does not apply if the privilege set forth in
subsection | ||||||
17 | (b)(1) of this Section is determined under subsection (c) or | ||||||
18 | (d) not
to apply.
| ||||||
19 | (3) A company may voluntarily submit, in connection with | ||||||
20 | examinations
conducted under this Article, an insurance | ||||||
21 | compliance self-evaluative audit
document to the Director, or | ||||||
22 | his or her designee, as a confidential document
under | ||||||
23 | subsection (i) of Section 132 or subsection (f) of Section | ||||||
24 | 132.5 of this Code , as applicable, without waiving the
| ||||||
25 | privilege set forth in this Section to which the company would | ||||||
26 | otherwise be
entitled;
provided, however, that the provisions |
| |||||||
| |||||||
1 | in Sections 132 and subsection (f) of Section 132.5
permitting | ||||||
2 | the Director to make confidential documents public pursuant to
| ||||||
3 | subsection (e) of Section 132.5 and grant access to the | ||||||
4 | National Association of
Insurance Commissioners shall not | ||||||
5 | apply to the insurance compliance
self-evaluative audit
| ||||||
6 | document so voluntarily submitted. Nothing contained in this | ||||||
7 | subsection shall
give the Director any authority to compel a | ||||||
8 | company to disclose involuntarily
or otherwise provide an | ||||||
9 | insurance compliance self-evaluative audit document.
| ||||||
10 | (c)(1) The privilege set forth in subsection (b) of this | ||||||
11 | Section does not
apply to the extent that it is expressly | ||||||
12 | waived by the company that prepared
or caused to be prepared | ||||||
13 | the insurance compliance self-evaluative audit
document.
| ||||||
14 | (2) In a civil or administrative proceeding, a court of | ||||||
15 | record may, after
an in camera review, require disclosure of | ||||||
16 | material for which the privilege set
forth in subsection (b) | ||||||
17 | of this Section is asserted, if the court determines
one of the | ||||||
18 | following:
| ||||||
19 | (A) the privilege is asserted for a fraudulent | ||||||
20 | purpose;
| ||||||
21 | (B) the material is not subject to the privilege; or
| ||||||
22 | (C) even if subject to the privilege, the material | ||||||
23 | shows evidence of
noncompliance with State and federal | ||||||
24 | statutes, rules and orders and the company
failed to | ||||||
25 | undertake reasonable
corrective action or eliminate the | ||||||
26 | noncompliance within a reasonable time.
|
| |||||||
| |||||||
1 | (3) In a criminal proceeding, a court of record may, after | ||||||
2 | an in camera
review, require disclosure of material for which | ||||||
3 | the privilege described in
subsection (b) of this Section is | ||||||
4 | asserted, if the court determines one of the
following:
| ||||||
5 | (A) the privilege is asserted for a fraudulent | ||||||
6 | purpose;
| ||||||
7 | (B) the material is not subject to the privilege;
| ||||||
8 | (C) even if subject to the privilege, the material | ||||||
9 | shows evidence
of noncompliance with State and federal | ||||||
10 | statutes, rules and orders and the
company failed to | ||||||
11 | undertake reasonable
corrective action or eliminate such | ||||||
12 | noncompliance within a reasonable time; or
| ||||||
13 | (D) the material contains evidence relevant to | ||||||
14 | commission of a criminal
offense under this Code, and all | ||||||
15 | of the following factors are present:
| ||||||
16 | (i) the Director, State's Attorney, or Attorney | ||||||
17 | General has a compelling
need for the information;
| ||||||
18 | (ii) the information is not otherwise available; | ||||||
19 | and
| ||||||
20 | (iii) the Director, State's Attorney, or Attorney | ||||||
21 | General is unable to
obtain the substantial equivalent | ||||||
22 | of the information by any means without
incurring | ||||||
23 | unreasonable cost and delay.
| ||||||
24 | (d)(1) Within 30 days after the Director, State's | ||||||
25 | Attorney, or Attorney
General makes a written request by | ||||||
26 | certified mail for disclosure of an
insurance compliance |
| |||||||
| |||||||
1 | self-evaluative audit document under this subsection, the
| ||||||
2 | company that
prepared or caused the document to be prepared | ||||||
3 | may file with the appropriate
court a petition requesting an | ||||||
4 | in camera hearing on whether the insurance
compliance | ||||||
5 | self-evaluative audit document or portions of the document are
| ||||||
6 | privileged under this Section or subject to disclosure. The | ||||||
7 | court has
jurisdiction over a petition filed by a company | ||||||
8 | under this subsection
requesting an in camera hearing on | ||||||
9 | whether the insurance compliance
self-evaluative audit | ||||||
10 | document or portions of the document are privileged or
subject
| ||||||
11 | to disclosure. Failure by the company to file a petition | ||||||
12 | waives the privilege.
| ||||||
13 | (2) A company asserting the insurance compliance | ||||||
14 | self-evaluative privilege
in response to a request for | ||||||
15 | disclosure under this subsection shall include in
its request | ||||||
16 | for an in camera hearing all of the information set forth in
| ||||||
17 | subsection (d)(5) of this Section.
| ||||||
18 | (3) Upon the filing of a petition under this subsection, | ||||||
19 | the court shall
issue an order scheduling, within 45 days | ||||||
20 | after the filing of the petition, an
in camera hearing to | ||||||
21 | determine whether the insurance compliance self-evaluative
| ||||||
22 | audit document or portions of the document are privileged | ||||||
23 | under this Section or
subject to disclosure.
| ||||||
24 | (4) The court, after an in camera review, may require | ||||||
25 | disclosure of
material for which the privilege in subsection | ||||||
26 | (b) of this Section is asserted
if the court determines, based |
| |||||||
| |||||||
1 | upon its in camera review, that any one of the
conditions set | ||||||
2 | forth in subsection (c)(2)(A) through (C) is applicable as to | ||||||
3 | a
civil or administrative proceeding or that any one of the | ||||||
4 | conditions set forth
in subsection (c)(3)(A) through (D) is | ||||||
5 | applicable as to a criminal proceeding.
Upon making such a | ||||||
6 | determination, the court may only compel the disclosure of
| ||||||
7 | those portions of an insurance compliance self-evaluative | ||||||
8 | audit document
relevant to issues in dispute in the underlying | ||||||
9 | proceeding.
Any compelled disclosure will not be considered to | ||||||
10 | be a public document or be
deemed to be a waiver of the | ||||||
11 | privilege for any other civil, criminal, or
administrative | ||||||
12 | proceeding. A party unsuccessfully opposing disclosure may
| ||||||
13 | apply to the court for an appropriate order protecting the | ||||||
14 | document from
further disclosure.
| ||||||
15 | (5) A company asserting the insurance compliance | ||||||
16 | self-evaluative privilege
in response to a request for | ||||||
17 | disclosure under this subsection (d) shall provide
to the | ||||||
18 | Director, State's Attorney, or Attorney General, as the case | ||||||
19 | may be, at
the time of
filing any objection to the disclosure, | ||||||
20 | all of the following information:
| ||||||
21 | (A) The date of the insurance compliance | ||||||
22 | self-evaluative audit document.
| ||||||
23 | (B) The identity of the entity conducting the audit.
| ||||||
24 | (C) The general nature of the activities covered by | ||||||
25 | the insurance
compliance audit.
| ||||||
26 | (D) An identification of the portions of the insurance |
| |||||||
| |||||||
1 | compliance
self-evaluative audit document for which the | ||||||
2 | privilege is being asserted.
| ||||||
3 | (e) (1) A company asserting the insurance compliance | ||||||
4 | self-evaluative
privilege set forth in subsection (b) of this | ||||||
5 | Section has the burden of
demonstrating the applicability of | ||||||
6 | the privilege. Once a company has
established the | ||||||
7 | applicability of the privilege, a party
seeking disclosure | ||||||
8 | under subsections (c)(2)(A) or (C) of this Section has the
| ||||||
9 | burden of proving that the privilege is asserted for
a | ||||||
10 | fraudulent purpose or that the company failed to
undertake | ||||||
11 | reasonable corrective action or eliminate the noncompliance | ||||||
12 | with a
reasonable time. The Director, State's Attorney, or | ||||||
13 | Attorney General seeking
disclosure under subsection (c)(3) of | ||||||
14 | this Section has the burden of proving
the elements set forth | ||||||
15 | in subsection (c)(3) of this Section.
| ||||||
16 | (2) The parties may at any time stipulate in proceedings | ||||||
17 | under subsections
(c) or (d) of this Section to entry of an | ||||||
18 | order directing that specific
information contained in an | ||||||
19 | insurance compliance self-evaluative audit document
is or is | ||||||
20 | not subject to the privilege provided under subsection (b) of | ||||||
21 | this
Section.
| ||||||
22 | (f) The privilege set forth in subsection (b) of this | ||||||
23 | Section shall not
extend to any of the following:
| ||||||
24 | (1) documents, communications, data, reports, or other | ||||||
25 | information
required
to be collected, developed, | ||||||
26 | maintained, reported, or otherwise made available
to
a |
| |||||||
| |||||||
1 | regulatory agency pursuant to this Code, or other federal | ||||||
2 | or State law, rule,
or order;
| ||||||
3 | (2) information obtained by observation or monitoring | ||||||
4 | by any regulatory
agency; or
| ||||||
5 | (3) information obtained from a source independent of | ||||||
6 | the insurance
compliance audit.
| ||||||
7 | (g) As used in this Section:
| ||||||
8 | (1) "Insurance compliance audit" means a voluntary, | ||||||
9 | internal evaluation,
review, assessment, or audit not | ||||||
10 | otherwise expressly required by law of a
company
or an | ||||||
11 | activity regulated under this Code, or other State or | ||||||
12 | federal law
applicable to a company, or of management | ||||||
13 | systems related to the company or
activity, that is | ||||||
14 | designed to identify and prevent noncompliance and to | ||||||
15 | improve
compliance with those statutes, rules, or orders. | ||||||
16 | An insurance compliance
audit
may be conducted by the | ||||||
17 | company, its employees, or by independent contractors.
| ||||||
18 | (2) "Insurance compliance self-evaluative audit | ||||||
19 | document" means documents
prepared as a result of or in | ||||||
20 | connection with and not prior to an insurance
compliance | ||||||
21 | audit. An
insurance compliance self-evaluation audit
| ||||||
22 | document may include a written response to the findings of | ||||||
23 | an insurance
compliance audit. An insurance compliance | ||||||
24 | self-evaluative audit document may
include, but is not | ||||||
25 | limited to, as applicable, field notes and records of
| ||||||
26 | observations, findings, opinions, suggestions, |
| |||||||
| |||||||
1 | conclusions, drafts, memoranda,
drawings, photographs, | ||||||
2 | computer-generated or electronically recorded
| ||||||
3 | information, phone records, maps, charts, graphs, and | ||||||
4 | surveys, provided this
supporting information is collected | ||||||
5 | or developed for the primary purpose and in
the course of | ||||||
6 | an insurance compliance audit. An insurance compliance
| ||||||
7 | self-evaluative audit document may also include any of the | ||||||
8 | following:
| ||||||
9 | (A) an insurance compliance audit report prepared | ||||||
10 | by an auditor, who may
be
an employee of the company or | ||||||
11 | an independent contractor, which may include the
scope | ||||||
12 | of the audit, the information gained in the audit, and | ||||||
13 | conclusions and
recommendations, with exhibits and | ||||||
14 | appendices;
| ||||||
15 | (B) memoranda and documents analyzing portions or | ||||||
16 | all of the
insurance
compliance audit report and | ||||||
17 | discussing potential implementation issues;
| ||||||
18 | (C) an implementation plan that addresses | ||||||
19 | correcting past noncompliance,
improving current | ||||||
20 | compliance, and preventing future noncompliance; or
| ||||||
21 | (D) analytic data generated in the course of | ||||||
22 | conducting the insurance
compliance audit.
| ||||||
23 | (3) "Company" has the same meaning as provided in | ||||||
24 | Section 2 of this Code.
| ||||||
25 | (h) Nothing in this Section shall limit, waive, or | ||||||
26 | abrogate the scope or
nature of any statutory or common law |
| |||||||
| |||||||
1 | privilege including, but not limited to,
the work product | ||||||
2 | doctrine, the attorney-client privilege, or the subsequent
| ||||||
3 | remedial measures exclusion.
| ||||||
4 | (Source: P.A. 90-499, eff. 8-19-97; 90-655, eff. 7-30-98.)
| ||||||
5 | (215 ILCS 5/402) (from Ch. 73, par. 1014)
| ||||||
6 | Sec. 402. Examinations, investigations and hearings. (1) | ||||||
7 | All examinations, investigations and hearings provided for by | ||||||
8 | this
Code may be conducted either by the Director personally, | ||||||
9 | or by one or more
of the actuaries, technical advisors, | ||||||
10 | deputies, supervisors or examiners
employed or retained by the | ||||||
11 | Department and designated by the Director for
such purpose. | ||||||
12 | When necessary to supplement its examination procedures, the
| ||||||
13 | Department may retain independent actuaries deemed competent | ||||||
14 | by the
Director, independent certified public accountants, | ||||||
15 | attorneys, or qualified
examiners of insurance companies | ||||||
16 | deemed competent by the Director, or any
combination of the | ||||||
17 | foregoing, the cost of which shall be borne by the
company or | ||||||
18 | person being examined. The Director may compensate independent
| ||||||
19 | actuaries, certified public accountants and qualified | ||||||
20 | examiners retained
for supplementing examination procedures in | ||||||
21 | amounts not to exceed the
reasonable and customary charges for | ||||||
22 | such services. The Director
may also accept as a part of the | ||||||
23 | Department's examination of any company or
person (a) a report | ||||||
24 | by an independent actuary deemed competent by the
Director or | ||||||
25 | (b) a report of an audit made by an independent certified
|
| |||||||
| |||||||
1 | public accountant. Neither those persons so designated nor any | ||||||
2 | members of
their immediate families shall be officers of, | ||||||
3 | connected with, or
financially interested in any company other | ||||||
4 | than as policyholders, nor
shall they be financially | ||||||
5 | interested in any other corporation or person
affected by the | ||||||
6 | examination, investigation or hearing.
| ||||||
7 | (2) All hearings provided for in this Code shall, unless | ||||||
8 | otherwise
specially provided, be held at such time and place | ||||||
9 | as shall be designated
in a notice which shall be given by the | ||||||
10 | Director in writing to the person
or company whose interests | ||||||
11 | are affected, at least 10 days before the date
designated | ||||||
12 | therein. The notice shall state the subject of inquiry and the
| ||||||
13 | specific charges, if any. The hearings shall be held in the | ||||||
14 | City of
Springfield, the City of Chicago, or in the county | ||||||
15 | where the principal
business address of the person or company | ||||||
16 | affected is located.
| ||||||
17 | (Source: P.A. 87-757.)
| ||||||
18 | (215 ILCS 5/408) (from Ch. 73, par. 1020)
| ||||||
19 | Sec. 408. Fees and charges.
| ||||||
20 | (1) The Director shall charge, collect and
give proper | ||||||
21 | acquittances for the payment of the following fees and | ||||||
22 | charges:
| ||||||
23 | (a) For filing all documents submitted for the | ||||||
24 | incorporation or
organization or certification of a | ||||||
25 | domestic company, except for a fraternal
benefit society, |
| |||||||
| |||||||
1 | $2,000.
| ||||||
2 | (b) For filing all documents submitted for the | ||||||
3 | incorporation or
organization of a fraternal benefit | ||||||
4 | society, $500.
| ||||||
5 | (c) For filing amendments to articles of incorporation | ||||||
6 | and amendments to
declaration of organization, except for | ||||||
7 | a fraternal benefit society, a
mutual benefit association, | ||||||
8 | a burial society or a farm mutual, $200.
| ||||||
9 | (d) For filing amendments to articles of incorporation | ||||||
10 | of a fraternal
benefit society, a mutual benefit | ||||||
11 | association or a burial society, $100.
| ||||||
12 | (e) For filing amendments to articles of incorporation | ||||||
13 | of a farm mutual,
$50.
| ||||||
14 | (f) For filing bylaws or amendments thereto, $50.
| ||||||
15 | (g) For filing agreement of merger or consolidation:
| ||||||
16 | (i) for a domestic company, except
for a fraternal | ||||||
17 | benefit society, a
mutual benefit association, a | ||||||
18 | burial society,
or a farm mutual, $2,000.
| ||||||
19 | (ii) for a foreign or
alien company, except for a | ||||||
20 | fraternal
benefit society, $600.
| ||||||
21 | (iii) for a fraternal benefit society,
a mutual | ||||||
22 | benefit association, a burial society,
or a farm | ||||||
23 | mutual, $200.
| ||||||
24 | (h) For filing agreements of reinsurance by a domestic | ||||||
25 | company, $200.
| ||||||
26 | (i) For filing all documents submitted by a foreign or |
| |||||||
| |||||||
1 | alien
company to be admitted to transact business or | ||||||
2 | accredited as a
reinsurer in this State, except for a
| ||||||
3 | fraternal benefit society, $5,000.
| ||||||
4 | (j) For filing all documents submitted by a foreign or | ||||||
5 | alien
fraternal benefit society to be admitted to transact | ||||||
6 | business
in this State, $500.
| ||||||
7 | (k) For filing declaration of withdrawal of a foreign | ||||||
8 | or
alien company, $50.
| ||||||
9 | (l) For filing annual statement by a domestic company, | ||||||
10 | except a fraternal benefit
society, a mutual benefit | ||||||
11 | association, a burial society, or
a farm mutual, $200.
| ||||||
12 | (m) For filing annual statement by a domestic | ||||||
13 | fraternal benefit
society, $100.
| ||||||
14 | (n) For filing annual statement by a farm mutual, a | ||||||
15 | mutual benefit
association, or a burial society, $50.
| ||||||
16 | (o) For issuing a certificate of authority or
renewal | ||||||
17 | thereof except to a foreign fraternal benefit society, | ||||||
18 | $400.
| ||||||
19 | (p) For issuing a certificate of authority or renewal | ||||||
20 | thereof to a foreign
fraternal benefit society, $200.
| ||||||
21 | (q) For issuing an amended certificate of authority, | ||||||
22 | $50.
| ||||||
23 | (r) For each certified copy of certificate of | ||||||
24 | authority, $20.
| ||||||
25 | (s) For each certificate of deposit, or valuation, or | ||||||
26 | compliance
or surety certificate, $20.
|
| |||||||
| |||||||
1 | (t) For copies of papers or records per page, $1.
| ||||||
2 | (u) For each certification to copies
of papers or | ||||||
3 | records, $10.
| ||||||
4 | (v) For multiple copies of documents or certificates | ||||||
5 | listed in
subparagraphs (r), (s), and (u) of paragraph (1) | ||||||
6 | of this Section, $10 for
the first copy of a certificate of | ||||||
7 | any type and $5 for each additional copy
of the same | ||||||
8 | certificate requested at the same time, unless, pursuant | ||||||
9 | to
paragraph (2) of this Section, the Director finds these | ||||||
10 | additional fees
excessive.
| ||||||
11 | (w) For issuing a permit to sell shares or increase | ||||||
12 | paid-up
capital:
| ||||||
13 | (i) in connection with a public stock offering, | ||||||
14 | $300;
| ||||||
15 | (ii) in any other case, $100.
| ||||||
16 | (x) For issuing any other certificate required or | ||||||
17 | permissible
under the law, $50.
| ||||||
18 | (y) For filing a plan of exchange of the stock of a | ||||||
19 | domestic
stock insurance company, a plan of | ||||||
20 | demutualization of a domestic
mutual company, or a plan of | ||||||
21 | reorganization under Article XII, $2,000.
| ||||||
22 | (z) For filing a statement of acquisition of a
| ||||||
23 | domestic company as defined in Section 131.4 of this Code, | ||||||
24 | $2,000.
| ||||||
25 | (aa) For filing an agreement to purchase the business | ||||||
26 | of an
organization authorized under the Dental Service |
| |||||||
| |||||||
1 | Plan Act
or the Voluntary Health Services Plans Act or
of a | ||||||
2 | health maintenance
organization or a limited health | ||||||
3 | service organization, $2,000.
| ||||||
4 | (bb) For filing a statement of acquisition of a | ||||||
5 | foreign or alien
insurance company as defined in Section | ||||||
6 | 131.12a of this Code, $1,000.
| ||||||
7 | (cc) For filing a registration statement as required | ||||||
8 | in Sections 131.13
and 131.14, the notification as | ||||||
9 | required by Sections 131.16,
131.20a, or 141.4, or an
| ||||||
10 | agreement or transaction required by Sections 124.2(2), | ||||||
11 | 141, 141a, or
141.1, $200.
| ||||||
12 | (dd) For filing an application for licensing of:
| ||||||
13 | (i) a religious or charitable risk pooling trust | ||||||
14 | or a workers'
compensation pool, $1,000;
| ||||||
15 | (ii) a workers' compensation service company, | ||||||
16 | $500;
| ||||||
17 | (iii) a self-insured automobile fleet, $200; or
| ||||||
18 | (iv) a renewal of or amendment of any license | ||||||
19 | issued pursuant to (i),
(ii), or (iii) above, $100.
| ||||||
20 | (ee) For filing articles of incorporation for a | ||||||
21 | syndicate to engage in
the business of insurance through | ||||||
22 | the Illinois Insurance Exchange, $2,000.
| ||||||
23 | (ff) For filing amended articles of incorporation for | ||||||
24 | a syndicate engaged
in the business of insurance through | ||||||
25 | the Illinois Insurance Exchange, $100.
| ||||||
26 | (gg) For filing articles of incorporation for a |
| |||||||
| |||||||
1 | limited syndicate to
join with other subscribers or | ||||||
2 | limited syndicates to do business through
the Illinois | ||||||
3 | Insurance Exchange, $1,000.
| ||||||
4 | (hh) For filing amended articles of incorporation for | ||||||
5 | a limited
syndicate to do business through the Illinois | ||||||
6 | Insurance Exchange, $100.
| ||||||
7 | (ii) For a permit to solicit subscriptions to a | ||||||
8 | syndicate
or limited syndicate, $100.
| ||||||
9 | (jj) For the filing of each form as required in | ||||||
10 | Section 143 of this
Code, $50 per form. The fee for | ||||||
11 | advisory and rating
organizations shall be $200 per form.
| ||||||
12 | (i) For the purposes of the form filing fee, | ||||||
13 | filings made on insert page
basis will be considered | ||||||
14 | one form at the time of its original submission.
| ||||||
15 | Changes made to a form subsequent to its approval | ||||||
16 | shall be considered a
new filing.
| ||||||
17 | (ii) Only one fee shall be charged for a form, | ||||||
18 | regardless of the number
of other forms or policies | ||||||
19 | with which it will be used.
| ||||||
20 | (iii) Fees charged for a policy filed as it will be | ||||||
21 | issued regardless of the number of forms comprising | ||||||
22 | that policy shall not exceed $1,500. For advisory or | ||||||
23 | rating organizations, fees charged for a policy filed | ||||||
24 | as it will be issued regardless of the number of forms | ||||||
25 | comprising that policy shall not exceed $2,500.
| ||||||
26 | (iv) The Director may by rule exempt forms from |
| |||||||
| |||||||
1 | such fees.
| ||||||
2 | (kk) For filing an application for licensing of a | ||||||
3 | reinsurance
intermediary, $500.
| ||||||
4 | (ll) For filing an application for renewal of a | ||||||
5 | license of a reinsurance
intermediary, $200.
| ||||||
6 | (mm) For a network adequacy filing required under the | ||||||
7 | Network Adequacy and Transparency Act, $500, except that | ||||||
8 | the fee for a filing required based on a material change is | ||||||
9 | $100. | ||||||
10 | (2) When printed copies or numerous copies of the same | ||||||
11 | paper or records
are furnished or certified, the Director may | ||||||
12 | reduce such fees for copies
if he finds them excessive. He may, | ||||||
13 | when he considers it in the public
interest, furnish without | ||||||
14 | charge to state insurance departments and persons
other than | ||||||
15 | companies, copies or certified copies of reports of | ||||||
16 | examinations
and of other papers and records.
| ||||||
17 | (3) The expenses incurred in any performance
examination | ||||||
18 | authorized by law shall be paid by the company or person being
| ||||||
19 | examined. The charge shall be reasonably related to the cost | ||||||
20 | of the
examination including but not limited to compensation | ||||||
21 | of examiners,
electronic data processing costs, supervision | ||||||
22 | and preparation of an
examination report and lodging and | ||||||
23 | travel expenses.
All lodging and travel expenses shall be in | ||||||
24 | accord
with the applicable travel regulations as published by | ||||||
25 | the Department of
Central Management Services and approved by | ||||||
26 | the Governor's Travel Control
Board, except that out-of-state |
| |||||||
| |||||||
1 | lodging and travel expenses related to
examinations authorized | ||||||
2 | under Section 132 shall be in accordance with
travel rates | ||||||
3 | prescribed under paragraph 301-7.2 of the Federal Travel
| ||||||
4 | Regulations, 41 C.F.R. 301-7.2, for reimbursement of | ||||||
5 | subsistence expenses
incurred during official travel. All | ||||||
6 | lodging and travel expenses may be reimbursed directly upon | ||||||
7 | authorization of the
Director. With the exception of the
| ||||||
8 | direct reimbursements authorized by the
Director, all | ||||||
9 | performance examination charges collected by the
Department | ||||||
10 | shall be paid
to the Insurance Producer Administration Fund,
| ||||||
11 | however, the electronic data processing costs
incurred by the | ||||||
12 | Department in the performance of any examination shall be
| ||||||
13 | billed directly to the company being examined for payment to | ||||||
14 | the Technology Management
Revolving Fund.
| ||||||
15 | (4) At the time of any service of process on the Director
| ||||||
16 | as attorney for such service, the Director shall charge and | ||||||
17 | collect the
sum of $20, which may be recovered as taxable costs | ||||||
18 | by
the party to the suit or action causing such service to be | ||||||
19 | made if he prevails
in such suit or action.
| ||||||
20 | (5) (a) The costs incurred by the Department of Insurance
| ||||||
21 | in conducting any hearing authorized by law shall be assessed | ||||||
22 | against the
parties to the hearing in such proportion as the | ||||||
23 | Director of Insurance may
determine upon consideration of all | ||||||
24 | relevant circumstances including: (1)
the nature of the | ||||||
25 | hearing; (2) whether the hearing was instigated by, or
for the | ||||||
26 | benefit of a particular party or parties; (3) whether there is |
| |||||||
| |||||||
1 | a
successful party on the merits of the proceeding; and (4) the | ||||||
2 | relative levels
of participation by the parties.
| ||||||
3 | (b) For purposes of this subsection (5) costs incurred | ||||||
4 | shall
mean the hearing officer fees, court reporter fees, and | ||||||
5 | travel expenses
of Department of Insurance officers and | ||||||
6 | employees; provided however, that
costs incurred shall not | ||||||
7 | include hearing officer fees or court reporter
fees unless the | ||||||
8 | Department has retained the services of independent
| ||||||
9 | contractors or outside experts to perform such functions.
| ||||||
10 | (c) The Director shall make the assessment of costs | ||||||
11 | incurred as part of
the final order or decision arising out of | ||||||
12 | the proceeding; provided, however,
that such order or decision | ||||||
13 | shall include findings and conclusions in support
of the | ||||||
14 | assessment of costs. This subsection (5) shall not be | ||||||
15 | construed as
permitting the payment of travel expenses unless | ||||||
16 | calculated in accordance
with the applicable travel | ||||||
17 | regulations of the Department
of Central Management Services, | ||||||
18 | as approved by the Governor's Travel Control
Board. The | ||||||
19 | Director as part of such order or decision shall require all
| ||||||
20 | assessments for hearing officer fees and court reporter fees, | ||||||
21 | if any, to
be paid directly to the hearing officer or court | ||||||
22 | reporter by the party(s)
assessed for such costs. The | ||||||
23 | assessments for travel expenses of Department
officers and | ||||||
24 | employees shall be reimbursable to the
Director of Insurance | ||||||
25 | for
deposit to the fund out of which those expenses had been | ||||||
26 | paid.
|
| |||||||
| |||||||
1 | (d) The provisions of this subsection (5) shall apply in | ||||||
2 | the case of any
hearing conducted by the Director of Insurance | ||||||
3 | not otherwise specifically
provided for by law.
| ||||||
4 | (6) The Director shall charge and collect an annual | ||||||
5 | financial
regulation fee from every domestic company for | ||||||
6 | examination and analysis of
its financial condition and to | ||||||
7 | fund the internal costs and expenses of the
Interstate | ||||||
8 | Insurance Receivership Commission as may be allocated to the | ||||||
9 | State
of Illinois and companies doing an insurance business in | ||||||
10 | this State pursuant to
Article X of the Interstate Insurance | ||||||
11 | Receivership Compact. The fee shall be
the greater fixed | ||||||
12 | amount based upon
the combination of nationwide direct premium | ||||||
13 | income and
nationwide reinsurance
assumed premium
income or | ||||||
14 | upon admitted assets calculated under this subsection as | ||||||
15 | follows:
| ||||||
16 | (a) Combination of nationwide direct premium income | ||||||
17 | and
nationwide reinsurance assumed premium.
| ||||||
18 | (i) $150, if the premium is less than $500,000 and | ||||||
19 | there is
no
reinsurance assumed premium;
| ||||||
20 | (ii) $750, if the premium is $500,000 or more, but | ||||||
21 | less
than $5,000,000
and there is no reinsurance | ||||||
22 | assumed premium; or if the premium is less than
| ||||||
23 | $5,000,000 and the reinsurance assumed premium is less | ||||||
24 | than $10,000,000;
| ||||||
25 | (iii) $3,750, if the premium is less than | ||||||
26 | $5,000,000 and
the reinsurance
assumed premium is |
| |||||||
| |||||||
1 | $10,000,000 or more;
| ||||||
2 | (iv) $7,500, if the premium is $5,000,000 or more, | ||||||
3 | but
less than
$10,000,000;
| ||||||
4 | (v) $18,000, if the premium is $10,000,000 or | ||||||
5 | more, but
less than $25,000,000;
| ||||||
6 | (vi) $22,500, if the premium is $25,000,000 or | ||||||
7 | more, but
less
than $50,000,000;
| ||||||
8 | (vii) $30,000, if the premium is $50,000,000 or | ||||||
9 | more,
but less than $100,000,000;
| ||||||
10 | (viii) $37,500, if the premium is $100,000,000 or | ||||||
11 | more.
| ||||||
12 | (b) Admitted assets.
| ||||||
13 | (i) $150, if admitted assets are less than | ||||||
14 | $1,000,000;
| ||||||
15 | (ii) $750, if admitted assets are $1,000,000 or | ||||||
16 | more, but
less than
$5,000,000;
| ||||||
17 | (iii) $3,750, if admitted assets are $5,000,000 or | ||||||
18 | more,
but less than
$25,000,000;
| ||||||
19 | (iv) $7,500, if admitted assets are $25,000,000 or | ||||||
20 | more,
but less than
$50,000,000;
| ||||||
21 | (v) $18,000, if admitted assets are $50,000,000 or | ||||||
22 | more,
but less than
$100,000,000;
| ||||||
23 | (vi) $22,500, if admitted assets are $100,000,000 | ||||||
24 | or
more, but less
than $500,000,000;
| ||||||
25 | (vii) $30,000, if admitted assets are $500,000,000 | ||||||
26 | or
more, but less
than $1,000,000,000;
|
| |||||||
| |||||||
1 | (viii) $37,500, if admitted assets are | ||||||
2 | $1,000,000,000
or more.
| ||||||
3 | (c) The sum of financial regulation fees charged to | ||||||
4 | the domestic
companies of the same affiliated group shall | ||||||
5 | not exceed $250,000
in the aggregate in any single year | ||||||
6 | and shall be billed by the Director to
the member company | ||||||
7 | designated by the
group.
| ||||||
8 | (7) The Director shall charge and collect an annual | ||||||
9 | financial regulation
fee from every foreign or alien company, | ||||||
10 | except fraternal benefit
societies, for the
examination and | ||||||
11 | analysis of its financial condition and to fund the internal
| ||||||
12 | costs and expenses of the Interstate Insurance Receivership | ||||||
13 | Commission as may
be allocated to the State of Illinois and | ||||||
14 | companies doing an insurance business
in this State pursuant | ||||||
15 | to Article X of the Interstate Insurance Receivership
Compact.
| ||||||
16 | The fee shall be a fixed amount based upon Illinois direct | ||||||
17 | premium income
and nationwide reinsurance assumed premium | ||||||
18 | income in accordance with the
following schedule:
| ||||||
19 | (a) $150, if the premium is less than $500,000 and | ||||||
20 | there is
no
reinsurance assumed premium;
| ||||||
21 | (b) $750, if the premium is $500,000 or more, but less | ||||||
22 | than
$5,000,000
and there is no reinsurance assumed | ||||||
23 | premium;
or if the premium is less than $5,000,000 and the | ||||||
24 | reinsurance assumed
premium is less than $10,000,000;
| ||||||
25 | (c) $3,750, if the premium is less than $5,000,000 and | ||||||
26 | the
reinsurance
assumed premium is $10,000,000 or more;
|
| |||||||
| |||||||
1 | (d) $7,500, if the premium is $5,000,000 or more, but | ||||||
2 | less
than
$10,000,000;
| ||||||
3 | (e) $18,000, if the premium is $10,000,000 or more, | ||||||
4 | but
less than
$25,000,000;
| ||||||
5 | (f) $22,500, if the premium is $25,000,000 or more, | ||||||
6 | but
less than
$50,000,000;
| ||||||
7 | (g) $30,000, if the premium is $50,000,000 or more, | ||||||
8 | but
less than
$100,000,000;
| ||||||
9 | (h) $37,500, if the premium is $100,000,000 or more.
| ||||||
10 | The sum of financial regulation fees under this subsection | ||||||
11 | (7)
charged to the foreign or alien companies within the same | ||||||
12 | affiliated group
shall not exceed $250,000 in the aggregate in | ||||||
13 | any single year
and shall be
billed by the Director to the | ||||||
14 | member company designated by the group.
| ||||||
15 | (8) Beginning January 1, 1992, the financial regulation | ||||||
16 | fees imposed
under subsections (6) and (7)
of this Section | ||||||
17 | shall be paid by each company or domestic affiliated group
| ||||||
18 | annually. After January
1, 1994, the fee shall be billed by | ||||||
19 | Department invoice
based upon the company's
premium income or | ||||||
20 | admitted assets as shown in its annual statement for the
| ||||||
21 | preceding calendar year. The invoice is due upon
receipt and | ||||||
22 | must be paid no later than June 30 of each calendar year. All
| ||||||
23 | financial
regulation fees collected by the Department shall be | ||||||
24 | paid to the Insurance
Financial Regulation Fund. The | ||||||
25 | Department may not collect financial
examiner per diem charges | ||||||
26 | from companies subject to subsections (6) and (7)
of this |
| |||||||
| |||||||
1 | Section undergoing financial examination
after June 30, 1992.
| ||||||
2 | (9) In addition to the financial regulation fee required | ||||||
3 | by this
Section, a company undergoing any financial | ||||||
4 | examination authorized by law
shall pay the following costs | ||||||
5 | and expenses incurred by the Department:
electronic data | ||||||
6 | processing costs, the expenses authorized under Section 131.21
| ||||||
7 | and
subsection (d) of Section 132.4 of this Code, and lodging | ||||||
8 | and travel expenses.
| ||||||
9 | Electronic data processing costs incurred by the | ||||||
10 | Department in the
performance of any examination shall be | ||||||
11 | billed directly to the company
undergoing examination for | ||||||
12 | payment to the Technology Management Revolving
Fund. Except | ||||||
13 | for direct reimbursements authorized by the Director or
direct | ||||||
14 | payments made under Section 131.21 or subsection (d) of | ||||||
15 | Section
132.4 of this Code, all financial regulation fees and | ||||||
16 | all financial
examination charges collected by the Department | ||||||
17 | shall be paid to the
Insurance Financial Regulation Fund.
| ||||||
18 | All lodging and travel expenses shall be in accordance | ||||||
19 | with applicable
travel regulations published by the Department | ||||||
20 | of Central Management
Services and approved by the Governor's | ||||||
21 | Travel Control Board, except that
out-of-state lodging and | ||||||
22 | travel expenses related to examinations authorized
under | ||||||
23 | Sections 132.1 through 132.7 shall be in accordance
with | ||||||
24 | travel rates prescribed
under paragraph 301-7.2 of the Federal | ||||||
25 | Travel Regulations, 41 C.F.R. 301-7.2,
for reimbursement of | ||||||
26 | subsistence expenses incurred during official travel.
All |
| |||||||
| |||||||
1 | lodging and travel expenses may be
reimbursed directly upon | ||||||
2 | the authorization of the Director.
| ||||||
3 | In the case of an organization or person not subject to the | ||||||
4 | financial
regulation fee, the expenses incurred in any | ||||||
5 | financial examination authorized
by law shall be paid by the | ||||||
6 | organization or person being examined. The charge
shall be | ||||||
7 | reasonably related to the cost of the examination including, | ||||||
8 | but not
limited to, compensation of examiners and other costs | ||||||
9 | described in this
subsection.
| ||||||
10 | (10) Any company, person, or entity failing to make any | ||||||
11 | payment of $150
or more as required under this Section shall be | ||||||
12 | subject to the penalty and
interest provisions provided for in | ||||||
13 | subsections (4) and (7)
of Section 412.
| ||||||
14 | (11) Unless otherwise specified, all of the fees collected | ||||||
15 | under this
Section shall be paid into the Insurance Financial | ||||||
16 | Regulation Fund.
| ||||||
17 | (12) For purposes of this Section:
| ||||||
18 | (a) "Domestic company" means a company as defined in | ||||||
19 | Section 2 of this
Code which is incorporated or organized | ||||||
20 | under the laws of this State, and in
addition includes a | ||||||
21 | not-for-profit corporation authorized under the Dental
| ||||||
22 | Service Plan Act or the Voluntary Health
Services Plans | ||||||
23 | Act, a health maintenance organization, and a
limited
| ||||||
24 | health service organization.
| ||||||
25 | (b) "Foreign company" means a company as defined in | ||||||
26 | Section 2 of this
Code which is incorporated or organized |
| |||||||
| |||||||
1 | under the laws of any state of the
United States other than | ||||||
2 | this State and in addition includes a health
maintenance | ||||||
3 | organization and a limited health service organization | ||||||
4 | which is
incorporated or organized under the laws
of any | ||||||
5 | state of the United States other than this State.
| ||||||
6 | (c) "Alien company" means a company as defined in | ||||||
7 | Section 2 of this Code
which is incorporated or organized | ||||||
8 | under the laws of any country other than
the United | ||||||
9 | States.
| ||||||
10 | (d) "Fraternal benefit society" means a corporation, | ||||||
11 | society, order,
lodge or voluntary association as defined | ||||||
12 | in Section 282.1 of this
Code.
| ||||||
13 | (e) "Mutual benefit association" means a company, | ||||||
14 | association or
corporation authorized by the Director to | ||||||
15 | do business in this State under
the provisions of Article | ||||||
16 | XVIII of this Code.
| ||||||
17 | (f) "Burial society" means a person, firm, | ||||||
18 | corporation, society or
association of individuals | ||||||
19 | authorized by the Director to do business in
this State | ||||||
20 | under the provisions of Article XIX of this Code.
| ||||||
21 | (g) "Farm mutual" means a district, county and | ||||||
22 | township mutual insurance
company authorized by the | ||||||
23 | Director to do business in this State under the
provisions | ||||||
24 | of the Farm Mutual Insurance Company Act of 1986.
| ||||||
25 | (Source: P.A. 100-23, eff. 7-6-17.)
|
| |||||||
| |||||||
1 | (215 ILCS 5/511.109) (from Ch. 73, par. 1065.58-109)
| ||||||
2 | (Section scheduled to be repealed on January 1, 2027)
| ||||||
3 | Sec. 511.109. Examination. | ||||||
4 | (a) The Director or the Director's his designee may | ||||||
5 | examine
any applicant for or holder of an administrator's | ||||||
6 | license in accordance with Sections 132 through 132.7 of this | ||||||
7 | Code. If the Director or the examiners find that the | ||||||
8 | administrator has violated this Article or any other | ||||||
9 | insurance-related laws or rules under the Director's | ||||||
10 | jurisdiction because of the manner in which the administrator | ||||||
11 | has conducted business on behalf of an insurer or plan | ||||||
12 | sponsor, then, unless the insurer or plan sponsor is included | ||||||
13 | in the examination and has been afforded the same opportunity | ||||||
14 | to request or participate in a hearing on the examination | ||||||
15 | report, the examination report shall not allege a violation by | ||||||
16 | the insurer or plan sponsor and the Director's order based on | ||||||
17 | the report shall not impose any requirements, prohibitions, or | ||||||
18 | penalties on the insurer or plan sponsor. Nothing in this | ||||||
19 | Section shall prevent the Director from using any information | ||||||
20 | obtained during the examination of an administrator to | ||||||
21 | examine, investigate, or take other appropriate regulatory or | ||||||
22 | legal action with respect to an insurer or plan sponsor .
| ||||||
23 | (b) (Blank). Any administrator being examined shall | ||||||
24 | provide to the Director or
his designee convenient and free | ||||||
25 | access, at all reasonable hours at their
offices, to all | ||||||
26 | books, records, documents and other papers relating to such
|
| |||||||
| |||||||
1 | administrator's business affairs.
| ||||||
2 | (c) (Blank). The Director or his designee may administer | ||||||
3 | oaths and thereafter examine
any individual about the business | ||||||
4 | of the administrator.
| ||||||
5 | (d) (Blank). The examiners designated by the Director | ||||||
6 | pursuant to this Section
may make reports to the Director. Any | ||||||
7 | report alleging substantive violations
of this Article, any | ||||||
8 | applicable provisions of the Illinois Insurance Code,
or any | ||||||
9 | applicable Part of Title 50 of the Illinois Administrative | ||||||
10 | Code shall
be in writing and be based upon facts obtained by | ||||||
11 | the examiners. The report
shall be verified by the examiners.
| ||||||
12 | (e) (Blank). If a report is made, the Director shall | ||||||
13 | either deliver a duplicate
thereof to the administrator being | ||||||
14 | examined or send such duplicate by certified
or registered | ||||||
15 | mail to the administrator's address specified in the records
| ||||||
16 | of the Department. The Director shall afford the administrator | ||||||
17 | an opportunity
to request a hearing to object to the report. | ||||||
18 | The administrator may request
a hearing within 30 days after | ||||||
19 | receipt of the duplicate of the examination
report by giving | ||||||
20 | the Director written notice of such request together with
| ||||||
21 | written objections to the report. Any hearing shall be | ||||||
22 | conducted in accordance
with Sections 402 and 403 of this | ||||||
23 | Code. The right to hearing is waived
if the delivery of the | ||||||
24 | report is refused or the report is otherwise
undeliverable or | ||||||
25 | the administrator does not timely request a hearing.
After the | ||||||
26 | hearing or upon expiration of the time period during which an
|
| |||||||
| |||||||
1 | administrator may request a hearing, if the examination | ||||||
2 | reveals that the
administrator is operating in violation of | ||||||
3 | any applicable provision of the
Illinois Insurance Code, any | ||||||
4 | applicable Part of Title 50 of the Illinois
Administrative | ||||||
5 | Code or prior order, the Director, in the written order, may
| ||||||
6 | require the administrator to take any action the Director | ||||||
7 | considers
necessary or appropriate in accordance with the | ||||||
8 | report or examination
hearing. If the Director issues an | ||||||
9 | order, it shall be issued within 90
days after the report is | ||||||
10 | filed, or if there is a hearing, within 90 days
after the | ||||||
11 | conclusion of the hearing. The order is subject to review | ||||||
12 | under
the Administrative Review Law.
| ||||||
13 | (Source: P.A. 84-887 .)
| ||||||
14 | (215 ILCS 5/512-3) (from Ch. 73, par. 1065.59-3)
| ||||||
15 | Sec. 512-3. Definitions. For the purposes of this Article, | ||||||
16 | unless the
context otherwise requires, the terms defined in | ||||||
17 | this Article have the meanings
ascribed
to them herein:
| ||||||
18 | (a) "Third party prescription program" or "program" means | ||||||
19 | any system of
providing for the reimbursement of | ||||||
20 | pharmaceutical services and prescription
drug products offered | ||||||
21 | or operated in this State under a contractual arrangement
or | ||||||
22 | agreement between a provider of such services and another | ||||||
23 | party who is
not the consumer of those services and products. | ||||||
24 | Such programs may include, but need not be limited to, | ||||||
25 | employee benefit
plans whereby a consumer receives |
| |||||||
| |||||||
1 | prescription drugs or other pharmaceutical
services and those | ||||||
2 | services are paid for by
an agent of the employer or others.
| ||||||
3 | (b) "Third party program administrator" or "administrator" | ||||||
4 | means any person,
partnership or corporation who issues or | ||||||
5 | causes to be issued any payment
or reimbursement to a provider | ||||||
6 | for services rendered pursuant to a third
party prescription | ||||||
7 | program, but does not include the Director of Healthcare and | ||||||
8 | Family Services or any agent authorized by
the Director to | ||||||
9 | reimburse a provider of services rendered pursuant to a
| ||||||
10 | program of which the Department of Healthcare and Family | ||||||
11 | Services is the third party.
| ||||||
12 | (c) "Health care payer" means an insurance company, health | ||||||
13 | maintenance organization, limited health service organization, | ||||||
14 | health services plan corporation, or dental service plan | ||||||
15 | corporation authorized to do business in this State. | ||||||
16 | (Source: P.A. 95-331, eff. 8-21-07.)
| ||||||
17 | (215 ILCS 5/512-5) (from Ch. 73, par. 1065.59-5)
| ||||||
18 | Sec. 512-5. Fiduciary and Bonding Requirements. A third | ||||||
19 | party prescription program administrator shall (1) establish | ||||||
20 | and
maintain a fiduciary account, separate and apart from any | ||||||
21 | and all other
accounts, for the receipt and disbursement of | ||||||
22 | funds for reimbursement of
providers of services under the | ||||||
23 | program, or (2) post,
or cause to be posted, a bond of | ||||||
24 | indemnity in an amount equal to not less
than 10% of the total | ||||||
25 | estimated annual reimbursements under the program.
|
| |||||||
| |||||||
1 | The establishment of such fiduciary accounts and bonds | ||||||
2 | shall be consistent
with applicable State law.
If a bond of | ||||||
3 | indemnity is posted, it shall be held by the Director of | ||||||
4 | Insurance
for the benefit and indemnification of the providers | ||||||
5 | of services under the
third party prescription program.
| ||||||
6 | An administrator who operates more than one third party | ||||||
7 | prescription program
may establish and maintain a separate | ||||||
8 | fiduciary account or bond of indemnity
for each such program, | ||||||
9 | or may operate and maintain a consolidated fiduciary
account | ||||||
10 | or bond of indemnity for all such programs.
| ||||||
11 | The requirements of this Section do not apply to any third | ||||||
12 | party prescription
program administered by or on behalf of any | ||||||
13 | health care payer insurance company, Health Care
Service Plan | ||||||
14 | Corporation or Pharmaceutical Service Plan Corporation | ||||||
15 | authorized
to do business in the State of Illinois .
| ||||||
16 | (Source: P.A. 82-1005.)
| ||||||
17 | (215 ILCS 5/512-11 new) | ||||||
18 | Sec. 512-11. Examination. The Director or the Director's | ||||||
19 | designee may examine any applicant for or holder of an | ||||||
20 | administrator's registration in accordance with Sections 132 | ||||||
21 | through 132.7 of this Code. If the Director or the examiners | ||||||
22 | find that the administrator has violated this Article or any | ||||||
23 | other insurance-related laws or rules under the Director's | ||||||
24 | jurisdiction because of the manner in which the administrator | ||||||
25 | has conducted business on behalf of a separately incorporated |
| |||||||
| |||||||
1 | health care payer, then, unless the health care payer is | ||||||
2 | included in the examination and has been afforded the same | ||||||
3 | opportunity to request or participate in a hearing on the | ||||||
4 | examination report, the examination report shall not allege a | ||||||
5 | violation by the health care payer and the Director's order | ||||||
6 | based on the report shall not impose any requirements, | ||||||
7 | prohibitions, or penalties on the health care payer. Nothing | ||||||
8 | in this Section shall prevent the Director from using any | ||||||
9 | information obtained during the examination of an | ||||||
10 | administrator to examine, investigate, or take other | ||||||
11 | appropriate regulatory or legal action with respect to a | ||||||
12 | health care payer. | ||||||
13 | (215 ILCS 5/513b3) | ||||||
14 | Sec. 513b3. Examination. | ||||||
15 | (a) The Director, or the Director's his or her designee, | ||||||
16 | may examine a registered pharmacy benefit manager in | ||||||
17 | accordance with Sections 132 through 132.7 of this Code. If | ||||||
18 | the Director or the examiners find that the pharmacy benefit | ||||||
19 | manager has violated this Article or any other | ||||||
20 | insurance-related laws or rules under the Director's | ||||||
21 | jurisdiction because of the manner in which the pharmacy | ||||||
22 | benefit manager has conducted business on behalf of a health | ||||||
23 | insurer or plan sponsor, then, unless the health insurer or | ||||||
24 | plan sponsor is included in the examination and has been | ||||||
25 | afforded the same opportunity to request or participate in a |
| |||||||
| |||||||
1 | hearing on the examination report, the examination report | ||||||
2 | shall not allege a violation by the health insurer or plan | ||||||
3 | sponsor and the Director's order based on the report shall not | ||||||
4 | impose any requirements, prohibitions, or penalties on the | ||||||
5 | health insurer or plan sponsor. Nothing in this Section shall | ||||||
6 | prevent the Director from using any information obtained | ||||||
7 | during the examination of an administrator to examine, | ||||||
8 | investigate, or take other appropriate regulatory or legal | ||||||
9 | action with respect to a health insurer or plan sponsor . | ||||||
10 | (b) (Blank). Any pharmacy benefit manager being examined | ||||||
11 | shall provide to the Director, or his or her designee, | ||||||
12 | convenient and free access to all books, records, documents, | ||||||
13 | and other papers relating to such pharmacy benefit manager's | ||||||
14 | business affairs at all reasonable hours at its offices. | ||||||
15 | (c) (Blank). The Director, or his or her designee, may | ||||||
16 | administer oaths and thereafter examine the pharmacy benefit | ||||||
17 | manager's designee, representative, or any officer or senior | ||||||
18 | manager as listed on the license or registration certificate | ||||||
19 | about the business of the pharmacy benefit manager. | ||||||
20 | (d) (Blank). The examiners designated by the Director | ||||||
21 | under this Section may make reports to the Director. Any | ||||||
22 | report alleging substantive violations of this Article, any | ||||||
23 | applicable provisions of this Code, or any applicable Part of | ||||||
24 | Title 50 of the Illinois Administrative Code shall be in | ||||||
25 | writing and be based upon facts obtained by the examiners. The | ||||||
26 | report shall be verified by the examiners. |
| |||||||
| |||||||
1 | (e) (Blank). If a report is made, the Director shall | ||||||
2 | either deliver a duplicate report to the pharmacy benefit | ||||||
3 | manager being examined or send such duplicate by certified or | ||||||
4 | registered mail to the pharmacy benefit manager's address | ||||||
5 | specified in the records of the Department. The Director shall | ||||||
6 | afford the pharmacy benefit manager an opportunity to request | ||||||
7 | a hearing to object to the report. The pharmacy benefit | ||||||
8 | manager may request a hearing within 30 days after receipt of | ||||||
9 | the duplicate report by giving the Director written notice of | ||||||
10 | such request together with written objections to the report. | ||||||
11 | Any hearing shall be conducted in accordance with Sections 402 | ||||||
12 | and 403 of this Code. The right to a hearing is waived if the | ||||||
13 | delivery of the report is refused or the report is otherwise | ||||||
14 | undeliverable or the pharmacy benefit manager does not timely | ||||||
15 | request a hearing. After the hearing or upon expiration of the | ||||||
16 | time period during which a pharmacy benefit manager may | ||||||
17 | request a hearing, if the examination reveals that the | ||||||
18 | pharmacy benefit manager is operating in violation of any | ||||||
19 | applicable provision of this Code, any applicable Part of | ||||||
20 | Title 50 of the Illinois Administrative Code, a provision of | ||||||
21 | this Article, or prior order, the Director, in the written | ||||||
22 | order, may require the pharmacy benefit manager to take any | ||||||
23 | action the Director considers necessary or appropriate in | ||||||
24 | accordance with the report or examination hearing. If the | ||||||
25 | Director issues an order, it shall be issued within 90 days | ||||||
26 | after the report is filed, or if there is a hearing, within 90 |
| |||||||
| |||||||
1 | days after the conclusion of the hearing. The order is subject | ||||||
2 | to review under the Administrative Review Law.
| ||||||
3 | (Source: P.A. 101-452, eff. 1-1-20 .) | ||||||
4 | Section 15. The Network Adequacy and Transparency Act is | ||||||
5 | amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and | ||||||
6 | by adding Sections 35 and 40 as follows: | ||||||
7 | (215 ILCS 124/3)
| ||||||
8 | Sec. 3. Applicability of Act. This Act applies to an | ||||||
9 | individual or group policy of accident and health insurance | ||||||
10 | coverage with a network plan amended, delivered, issued, or | ||||||
11 | renewed in this State on or after January 1, 2019. This Act | ||||||
12 | does not apply to an individual or group policy for excepted | ||||||
13 | benefits or short-term, limited-duration health insurance | ||||||
14 | coverage dental or vision insurance or a limited health | ||||||
15 | service organization with a network plan amended, delivered, | ||||||
16 | issued, or renewed in this State on or after January 1, 2019 , | ||||||
17 | except to the extent that federal law establishes network | ||||||
18 | adequacy and transparency standards for stand-alone dental | ||||||
19 | plans, which the Department shall enforce .
| ||||||
20 | (Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.) | ||||||
21 | (215 ILCS 124/5)
| ||||||
22 | Sec. 5. Definitions. In this Act: | ||||||
23 | "Authorized representative" means a person to whom a |
| |||||||
| |||||||
1 | beneficiary has given express written consent to represent the | ||||||
2 | beneficiary; a person authorized by law to provide substituted | ||||||
3 | consent for a beneficiary; or the beneficiary's treating | ||||||
4 | provider only when the beneficiary or his or her family member | ||||||
5 | is unable to provide consent. | ||||||
6 | "Beneficiary" means an individual, an enrollee, an | ||||||
7 | insured, a participant, or any other person entitled to | ||||||
8 | reimbursement for covered expenses of or the discounting of | ||||||
9 | provider fees for health care services under a program in | ||||||
10 | which the beneficiary has an incentive to utilize the services | ||||||
11 | of a provider that has entered into an agreement or | ||||||
12 | arrangement with an issuer insurer . | ||||||
13 | "Department" means the Department of Insurance. | ||||||
14 | "Director" means the Director of Insurance. | ||||||
15 | "Essential community provider" has the meaning ascribed to | ||||||
16 | that term in 45 CFR 156.235. | ||||||
17 | "Excepted benefits" has the meaning ascribed to that term | ||||||
18 | in 42 U.S.C. 300gg-91(c). | ||||||
19 | "Family caregiver" means a relative, partner, friend, or | ||||||
20 | neighbor who has a significant relationship with the patient | ||||||
21 | and administers or assists the patient them with activities of | ||||||
22 | daily living, instrumental activities of daily living, or | ||||||
23 | other medical or nursing tasks for the quality and welfare of | ||||||
24 | that patient. | ||||||
25 | "Group health plan" has the meaning ascribed to that term | ||||||
26 | in Section 5 of the Illinois Health Insurance Portability and |
| |||||||
| |||||||
1 | Accountability Act. | ||||||
2 | "Health insurance coverage" has the meaning ascribed to | ||||||
3 | that term in Section 5 of the Illinois Health Insurance | ||||||
4 | Portability and Accountability Act. "Health insurance | ||||||
5 | coverage" does not include any coverage or benefits under | ||||||
6 | Medicare or under the medical assistance program established | ||||||
7 | under Article V of the Illinois Public Aid Code. | ||||||
8 | "Issuer" means a "health insurance issuer" as defined in | ||||||
9 | Section 5 of the Illinois Health Insurance Portability and | ||||||
10 | Accountability Act. | ||||||
11 | "Insurer" means any entity that offers individual or group | ||||||
12 | accident and health insurance, including, but not limited to, | ||||||
13 | health maintenance organizations, preferred provider | ||||||
14 | organizations, exclusive provider organizations, and other | ||||||
15 | plan structures requiring network participation, excluding the | ||||||
16 | medical assistance program under the Illinois Public Aid Code, | ||||||
17 | the State employees group health insurance program, workers | ||||||
18 | compensation insurance, and pharmacy benefit managers. | ||||||
19 | "Material change" means a significant reduction in the | ||||||
20 | number of providers available in a network plan, including, | ||||||
21 | but not limited to, a reduction of 10% or more in a specific | ||||||
22 | type of providers within any county , the removal of a major | ||||||
23 | health system that causes a network to be significantly | ||||||
24 | different within any county from the network when the | ||||||
25 | beneficiary purchased the network plan, or any change that | ||||||
26 | would cause the network to no longer satisfy the requirements |
| |||||||
| |||||||
1 | of this Act or the Department's rules for network adequacy and | ||||||
2 | transparency. | ||||||
3 | "Network" means the group or groups of preferred providers | ||||||
4 | providing services to a network plan. | ||||||
5 | "Network plan" means an individual or group policy of | ||||||
6 | accident and health insurance coverage that either requires a | ||||||
7 | covered person to use or creates incentives, including | ||||||
8 | financial incentives, for a covered person to use providers | ||||||
9 | managed, owned, under contract with, or employed by the issuer | ||||||
10 | or by a third party contracted to arrange, contract for, or | ||||||
11 | administer such provider-related incentives for the issuer | ||||||
12 | insurer . | ||||||
13 | "Ongoing course of treatment" means (1) treatment for a | ||||||
14 | life-threatening condition, which is a disease or condition | ||||||
15 | for which likelihood of death is probable unless the course of | ||||||
16 | the disease or condition is interrupted; (2) treatment for a | ||||||
17 | serious acute condition, defined as a disease or condition | ||||||
18 | requiring complex ongoing care that the covered person is | ||||||
19 | currently receiving, such as chemotherapy, radiation therapy, | ||||||
20 | or post-operative visits , or a serious and complex condition | ||||||
21 | as defined under 42 U.S.C. 300gg-113(b)(2) ; (3) a course of | ||||||
22 | treatment for a health condition that a treating provider | ||||||
23 | attests that discontinuing care by that provider would worsen | ||||||
24 | the condition or interfere with anticipated outcomes; or (4) | ||||||
25 | the third trimester of pregnancy through the post-partum | ||||||
26 | period ; (5) undergoing a course of institutional or inpatient |
| |||||||
| |||||||
1 | care from the provider within the meaning of 42 U.S.C. | ||||||
2 | 300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective | ||||||
3 | surgery from the provider, including receipt of postoperative | ||||||
4 | care from such provider with respect to such a surgery; or (7) | ||||||
5 | being determined to be terminally ill, as determined under 42 | ||||||
6 | U.S.C. 1395x(dd)(3)(A), and receiving treatment for such | ||||||
7 | illness from such provider . | ||||||
8 | "Preferred provider" means any provider who has entered, | ||||||
9 | either directly or indirectly, into an agreement with an | ||||||
10 | employer or risk-bearing entity relating to health care | ||||||
11 | services that may be rendered to beneficiaries under a network | ||||||
12 | plan. | ||||||
13 | "Providers" means physicians licensed to practice medicine | ||||||
14 | in all its branches, other health care professionals, | ||||||
15 | hospitals, or other health care institutions or facilities | ||||||
16 | that provide health care services. | ||||||
17 | "Short-term, limited-duration health insurance coverage" | ||||||
18 | has the meaning ascribed to that term in Section 5 of the | ||||||
19 | Short-Term, Limited-Duration Health Insurance Coverage Act. | ||||||
20 | "Stand-alone dental plan" has the meaning ascribed to that | ||||||
21 | term in 45 CFR 156.400. | ||||||
22 | "Telehealth" has the meaning given to that term in Section | ||||||
23 | 356z.22 of the Illinois Insurance Code. | ||||||
24 | "Telemedicine" has the meaning given to that term in | ||||||
25 | Section 49.5 of the Medical Practice Act of 1987. | ||||||
26 | "Tiered network" means a network that identifies and |
| |||||||
| |||||||
1 | groups some or all types of provider and facilities into | ||||||
2 | specific groups to which different provider reimbursement, | ||||||
3 | covered person cost-sharing or provider access requirements, | ||||||
4 | or any combination thereof, apply for the same services. | ||||||
5 | "Woman's principal health care provider" means a physician | ||||||
6 | licensed to practice medicine in all of its branches | ||||||
7 | specializing in obstetrics, gynecology, or family practice.
| ||||||
8 | (Source: P.A. 102-92, eff. 7-9-21; revised 10-5-21.) | ||||||
9 | (215 ILCS 124/10) | ||||||
10 | Sec. 10. Network adequacy. | ||||||
11 | (a) Before issuing, delivering, or renewing a network | ||||||
12 | plan, an issuer An insurer providing a network plan shall file | ||||||
13 | a description of all of the following with the Director: | ||||||
14 | (1) The written policies and procedures for adding | ||||||
15 | providers to meet patient needs based on increases in the | ||||||
16 | number of beneficiaries, changes in the | ||||||
17 | patient-to-provider ratio, changes in medical and health | ||||||
18 | care capabilities, and increased demand for services. | ||||||
19 | (2) The written policies and procedures for making | ||||||
20 | referrals within and outside the network. | ||||||
21 | (3) The written policies and procedures on how the | ||||||
22 | network plan will provide 24-hour, 7-day per week access | ||||||
23 | to network-affiliated primary care, emergency services, | ||||||
24 | and woman's principal health care providers. | ||||||
25 | An issuer insurer shall not prohibit a preferred provider |
| |||||||
| |||||||
1 | from discussing any specific or all treatment options with | ||||||
2 | beneficiaries irrespective of the insurer's position on those | ||||||
3 | treatment options or from advocating on behalf of | ||||||
4 | beneficiaries within the utilization review, grievance, or | ||||||
5 | appeals processes established by the issuer insurer in | ||||||
6 | accordance with any rights or remedies available under | ||||||
7 | applicable State or federal law. | ||||||
8 | (b) Before issuing, delivering, or renewing a network | ||||||
9 | plan, an issuer Insurers must file for review a description of | ||||||
10 | the services to be offered through a network plan. The | ||||||
11 | description shall include all of the following: | ||||||
12 | (1) A geographic map of the area proposed to be served | ||||||
13 | by the plan by county service area and zip code, including | ||||||
14 | marked locations for preferred providers. | ||||||
15 | (2) As deemed necessary by the Department, the names, | ||||||
16 | addresses, phone numbers, and specialties of the providers | ||||||
17 | who have entered into preferred provider agreements under | ||||||
18 | the network plan. | ||||||
19 | (3) The number of beneficiaries anticipated to be | ||||||
20 | covered by the network plan. | ||||||
21 | (4) An Internet website and toll-free telephone number | ||||||
22 | for beneficiaries and prospective beneficiaries to access | ||||||
23 | current and accurate lists of preferred providers, | ||||||
24 | additional information about the plan, as well as any | ||||||
25 | other information required by Department rule. | ||||||
26 | (5) A description of how health care services to be |
| |||||||
| |||||||
1 | rendered under the network plan are reasonably accessible | ||||||
2 | and available to beneficiaries. The description shall | ||||||
3 | address all of the following: | ||||||
4 | (A) the type of health care services to be | ||||||
5 | provided by the network plan; | ||||||
6 | (B) the ratio of physicians and other providers to | ||||||
7 | beneficiaries, by specialty and including primary care | ||||||
8 | physicians and facility-based physicians when | ||||||
9 | applicable under the contract, necessary to meet the | ||||||
10 | health care needs and service demands of the currently | ||||||
11 | enrolled population; | ||||||
12 | (C) the travel and distance standards for plan | ||||||
13 | beneficiaries in county service areas; and | ||||||
14 | (D) a description of how the use of telemedicine, | ||||||
15 | telehealth, or mobile care services may be used to | ||||||
16 | partially meet the network adequacy standards, if | ||||||
17 | applicable. | ||||||
18 | (6) A provision ensuring that whenever a beneficiary | ||||||
19 | has made a good faith effort, as evidenced by accessing | ||||||
20 | the provider directory, calling the network plan, and | ||||||
21 | calling the provider, to utilize preferred providers for a | ||||||
22 | covered service and it is determined the insurer does not | ||||||
23 | have the appropriate preferred providers due to | ||||||
24 | insufficient number, type, or unreasonable travel distance | ||||||
25 | or delay, the issuer insurer shall ensure, directly or | ||||||
26 | indirectly, by terms contained in the payer contract, that |
| |||||||
| |||||||
1 | the beneficiary will be provided the covered service at no | ||||||
2 | greater cost to the beneficiary than if the service had | ||||||
3 | been provided by a preferred provider. This paragraph (6) | ||||||
4 | does not apply to: (A) a beneficiary who willfully chooses | ||||||
5 | to access a non-preferred provider for health care | ||||||
6 | services available through the panel of preferred | ||||||
7 | providers, or (B) a beneficiary enrolled in a health | ||||||
8 | maintenance organization. In these circumstances, the | ||||||
9 | contractual requirements for non-preferred provider | ||||||
10 | reimbursements shall apply. | ||||||
11 | (7) A provision that the beneficiary shall receive | ||||||
12 | emergency care coverage such that payment for this | ||||||
13 | coverage is not dependent upon whether the emergency | ||||||
14 | services are performed by a preferred or non-preferred | ||||||
15 | provider and the coverage shall be at the same benefit | ||||||
16 | level as if the service or treatment had been rendered by a | ||||||
17 | preferred provider. For purposes of this paragraph (7), | ||||||
18 | "the same benefit level" means that the beneficiary is | ||||||
19 | provided the covered service at no greater cost to the | ||||||
20 | beneficiary than if the service had been provided by a | ||||||
21 | preferred provider. | ||||||
22 | (8) A limitation that, if the plan provides that the | ||||||
23 | beneficiary will incur a penalty for failing to | ||||||
24 | pre-certify inpatient hospital treatment, the penalty may | ||||||
25 | not exceed $1,000 per occurrence in addition to the plan | ||||||
26 | cost sharing provisions. |
| |||||||
| |||||||
1 | (9) For a network plan in the individual or small | ||||||
2 | group market other than a grandfathered health plan, | ||||||
3 | evidence that the network plan: | ||||||
4 | (A) contracts with at least 35% of the essential | ||||||
5 | community providers in the service area of the network | ||||||
6 | plan that are available to participate in the provider | ||||||
7 | network of the network plan, as calculated using the | ||||||
8 | methodology contained in the most recent Letter to | ||||||
9 | Issuers in the Federally-facilitated Marketplaces | ||||||
10 | issued by the federal Centers for Medicare and | ||||||
11 | Medicaid Services. The Director may specify a | ||||||
12 | different percentage by rule. | ||||||
13 | (B) offers contracts in good faith to all | ||||||
14 | available Indian health care providers in the service | ||||||
15 | area of the network plan, including, without | ||||||
16 | limitation, the Indian Health Service, Indian tribes, | ||||||
17 | tribal organizations, and urban Indian organizations, | ||||||
18 | as defined in 25 U.S.C. 1603, which apply the special | ||||||
19 | terms and conditions necessitated by federal statutes | ||||||
20 | and regulations as referenced in the Model Qualified | ||||||
21 | Health Plan Addendum for Indian Health Care Providers | ||||||
22 | issued by the federal Centers for Medicare and
| ||||||
23 | Medicaid Services. | ||||||
24 | (C) offers contracts in good faith to at least one | ||||||
25 | essential community provider in each category of | ||||||
26 | essential community provider, as contained in the most |
| |||||||
| |||||||
1 | recent Letter to Issuers in the Federally-facilitated | ||||||
2 | Marketplaces, in each county in the service area of | ||||||
3 | the network plan, where an essential community | ||||||
4 | provider in that category is available and provides | ||||||
5 | medical or dental services that are covered by the | ||||||
6 | network plan. To offer a contract in good faith, a | ||||||
7 | network plan must offer contract terms comparable to | ||||||
8 | the terms that an issuer would offer to a similarly | ||||||
9 | situated provider that is not an essential community | ||||||
10 | provider, except for terms that would not be | ||||||
11 | applicable to an essential community provider, | ||||||
12 | including, without limitation, because of the type of | ||||||
13 | services that an essential community provider | ||||||
14 | provides. A network plan must be able to provide | ||||||
15 | verification of such offers if the Centers for | ||||||
16 | Medicare and Medicaid Services of the United States | ||||||
17 | Department of Health and Human Services requests to | ||||||
18 | verify compliance with this policy. | ||||||
19 | (c) The issuer network plan shall demonstrate to the | ||||||
20 | Director a minimum ratio of providers to plan beneficiaries as | ||||||
21 | required by the Department for each network plan . | ||||||
22 | (1) The minimum ratio of physicians or other providers | ||||||
23 | to plan beneficiaries shall be established annually by the | ||||||
24 | Department in consultation with the Department of Public | ||||||
25 | Health based upon the guidance from the federal Centers | ||||||
26 | for Medicare and Medicaid Services. The Department shall |
| |||||||
| |||||||
1 | not establish ratios for vision or dental providers who | ||||||
2 | provide services under dental-specific or vision-specific | ||||||
3 | benefits , except to the extent provided under federal law | ||||||
4 | for stand-alone dental plans . The Department shall | ||||||
5 | consider establishing ratios for the following physicians | ||||||
6 | or other providers: | ||||||
7 | (A) Primary Care; | ||||||
8 | (B) Pediatrics; | ||||||
9 | (C) Cardiology; | ||||||
10 | (D) Gastroenterology; | ||||||
11 | (E) General Surgery; | ||||||
12 | (F) Neurology; | ||||||
13 | (G) OB/GYN; | ||||||
14 | (H) Oncology/Radiation; | ||||||
15 | (I) Ophthalmology; | ||||||
16 | (J) Urology; | ||||||
17 | (K) Behavioral Health; | ||||||
18 | (L) Allergy/Immunology; | ||||||
19 | (M) Chiropractic; | ||||||
20 | (N) Dermatology; | ||||||
21 | (O) Endocrinology; | ||||||
22 | (P) Ears, Nose, and Throat (ENT)/Otolaryngology; | ||||||
23 | (Q) Infectious Disease; | ||||||
24 | (R) Nephrology; | ||||||
25 | (S) Neurosurgery; | ||||||
26 | (T) Orthopedic Surgery; |
| |||||||
| |||||||
1 | (U) Physiatry/Rehabilitative; | ||||||
2 | (V) Plastic Surgery; | ||||||
3 | (W) Pulmonary; | ||||||
4 | (X) Rheumatology; | ||||||
5 | (Y) Anesthesiology; | ||||||
6 | (Z) Pain Medicine; | ||||||
7 | (AA) Pediatric Specialty Services; | ||||||
8 | (BB) Outpatient Dialysis; and | ||||||
9 | (CC) HIV. | ||||||
10 | (2) The Director shall establish a process for the | ||||||
11 | review of the adequacy of these standards, along with an | ||||||
12 | assessment of additional specialties to be included in the | ||||||
13 | list under this subsection (c). | ||||||
14 | (3) Notwithstanding any other law or rule, the minimum | ||||||
15 | ratio for each provider type shall be no less than any such | ||||||
16 | ratio established for qualified health plans in | ||||||
17 | Federally-Facilitated Exchanges by federal law or by the | ||||||
18 | federal Centers for Medicare and Medicaid Services, even | ||||||
19 | if the network plan is issued in the large group market or | ||||||
20 | is otherwise not issued through an exchange. Federal | ||||||
21 | standards for stand-alone dental plans shall only apply to | ||||||
22 | such network plans. In the absence of an applicable | ||||||
23 | Department rule, the federal standards shall apply for the | ||||||
24 | time period specified in the federal law, regulation, or | ||||||
25 | guidance. If the Centers for Medicare and Medicaid | ||||||
26 | Services establish standards that are more stringent than |
| |||||||
| |||||||
1 | the standards in effect under any Department rule, the | ||||||
2 | Department may amend its rules to conform to the more | ||||||
3 | stringent federal standards. | ||||||
4 | (4) Prior to the enactment of an applicable Department | ||||||
5 | rule or the promulgation of federal standards for | ||||||
6 | qualified health plans or stand-alone dental plans, the | ||||||
7 | minimum ratios for any network plan issued, delivered, | ||||||
8 | amended, or renewed during 2023 shall be the following, | ||||||
9 | expressed in terms of providers to beneficiaries for | ||||||
10 | health care professionals and in terms of providers per | ||||||
11 | county for facilities: | ||||||
12 | (A) primary care physician, general practice, | ||||||
13 | family practice, internal medicine, pediatrician, | ||||||
14 | primary care physician assistant, or primary care | ||||||
15 | nurse practitioner - 1:500; | ||||||
16 | (B) allergy/immunology - 1:15,000; | ||||||
17 | (C) cardiology - 1:10,000; | ||||||
18 | (D) chiropractic - 1:10,000; | ||||||
19 | (E) dermatology - 1:10,000; | ||||||
20 | (F) endocrinology - 1:10,000; | ||||||
21 | (G) ENT/otolaryngology - 1:15,000; | ||||||
22 | (H) gastroenterology - 1:10,000; | ||||||
23 | (I) general surgery - 1:5,000; | ||||||
24 | (J) gynecology or OB/GYN - 1:2,500; | ||||||
25 | (K) infectious diseases - 1:15,000; | ||||||
26 | (L) nephrology - 1:10,000; |
| |||||||
| |||||||
1 | (M) neurology - 1:20,000; | ||||||
2 | (N) oncology/radiation - 1:15,000; | ||||||
3 | (O) ophthalmology - 1:10,000; | ||||||
4 | (P) orthopedic surgery - 1:10,000; | ||||||
5 | (Q) physiatry/rehabilitative medicine - 1:15,000; | ||||||
6 | (R) plastic surgery - 1:20,000; | ||||||
7 | (S) behavioral health - 1:5,000; | ||||||
8 | (T) pulmonology - 1:10,000; | ||||||
9 | (U) rheumatology - 1:10,000; | ||||||
10 | (V) urology - 1:10,000; | ||||||
11 | (W) acute inpatient hospital with emergency | ||||||
12 | services available 24 hours a day, 7 days a week - one | ||||||
13 | per county; and | ||||||
14 | (X) inpatient or residential behavioral health | ||||||
15 | facility - one per county. | ||||||
16 | (d) The network plan shall demonstrate to the Director | ||||||
17 | maximum travel and distance standards and appointment wait | ||||||
18 | time standards for plan beneficiaries, which shall be | ||||||
19 | established annually by the Department in consultation with | ||||||
20 | the Department of Public Health based upon the guidance from | ||||||
21 | the federal Centers for Medicare and Medicaid Services. These | ||||||
22 | standards shall consist of the maximum minutes or miles to be | ||||||
23 | traveled by a plan beneficiary for each county type, such as | ||||||
24 | large counties, metro counties, or rural counties as defined | ||||||
25 | by Department rule. | ||||||
26 | The maximum travel time and distance standards must |
| |||||||
| |||||||
1 | include standards for each physician and other provider | ||||||
2 | category listed for which ratios have been established. | ||||||
3 | The Director shall establish a process for the review of | ||||||
4 | the adequacy of these standards along with an assessment of | ||||||
5 | additional specialties to be included in the list under this | ||||||
6 | subsection (d). | ||||||
7 | Notwithstanding any other law or Department rule, the | ||||||
8 | maximum travel and distance standards and appointment wait | ||||||
9 | time standards shall be no greater than any such standards | ||||||
10 | established for qualified health plans in | ||||||
11 | Federally-Facilitated Exchanges by federal law or by the | ||||||
12 | federal Centers for Medicare and Medicaid Services, even if | ||||||
13 | the network plan is issued in the large group market or is | ||||||
14 | otherwise not issued through an exchange. Federal standards | ||||||
15 | for stand-alone dental plans shall only apply to such network | ||||||
16 | plans. In the absence of an applicable Department rule, the | ||||||
17 | federal standards shall apply for the time period specified in | ||||||
18 | the federal law, regulation, or guidance. If the Centers for | ||||||
19 | Medicare and Medicaid Services establish standards that are | ||||||
20 | more stringent than the standards in effect under any | ||||||
21 | Department rule, the Department may amend its rules to conform | ||||||
22 | to the more stringent federal standards. | ||||||
23 | If the federal area designations for the maximum time or | ||||||
24 | distance or appointment wait time standards required are | ||||||
25 | changed by the most recent Letter to Issuers in the | ||||||
26 | Federally-facilitated Marketplaces, the Department shall post |
| |||||||
| |||||||
1 | on its website notice of such changes and may amend its rules | ||||||
2 | to conform to those designations if the Director deems | ||||||
3 | appropriate. | ||||||
4 | (d-5)(1) Every issuer insurer shall ensure that | ||||||
5 | beneficiaries have timely and proximate access to treatment | ||||||
6 | for mental, emotional, nervous, or substance use disorders or | ||||||
7 | conditions in accordance with the provisions of paragraph (4) | ||||||
8 | of subsection (a) of Section 370c of the Illinois Insurance | ||||||
9 | Code. Issuers Insurers shall use a comparable process, | ||||||
10 | strategy, evidentiary standard, and other factors in the | ||||||
11 | development and application of the network adequacy standards | ||||||
12 | for timely and proximate access to treatment for mental, | ||||||
13 | emotional, nervous, or substance use disorders or conditions | ||||||
14 | and those for the access to treatment for medical and surgical | ||||||
15 | conditions. As such, the network adequacy standards for timely | ||||||
16 | and proximate access shall equally be applied to treatment | ||||||
17 | facilities and providers for mental, emotional, nervous, or | ||||||
18 | substance use disorders or conditions and specialists | ||||||
19 | providing medical or surgical benefits pursuant to the parity | ||||||
20 | requirements of Section 370c.1 of the Illinois Insurance Code | ||||||
21 | and the federal Paul Wellstone and Pete Domenici Mental Health | ||||||
22 | Parity and Addiction Equity Act of 2008. Notwithstanding the | ||||||
23 | foregoing, the network adequacy standards for timely and | ||||||
24 | proximate access to treatment for mental, emotional, nervous, | ||||||
25 | or substance use disorders or conditions shall, at a minimum, | ||||||
26 | satisfy the following requirements: |
| |||||||
| |||||||
1 | (A) For beneficiaries residing in the metropolitan | ||||||
2 | counties of Cook, DuPage, Kane, Lake, McHenry, and Will, | ||||||
3 | network adequacy standards for timely and proximate access | ||||||
4 | to treatment for mental, emotional, nervous, or substance | ||||||
5 | use disorders or conditions means a beneficiary shall not | ||||||
6 | have to travel longer than 30 minutes or 30 miles from the | ||||||
7 | beneficiary's residence to receive outpatient treatment | ||||||
8 | for mental, emotional, nervous, or substance use disorders | ||||||
9 | or conditions. Beneficiaries shall not be required to wait | ||||||
10 | longer than 10 business days between requesting an initial | ||||||
11 | appointment and being seen by the facility or provider of | ||||||
12 | mental, emotional, nervous, or substance use disorders or | ||||||
13 | conditions for outpatient treatment or to wait longer than | ||||||
14 | 20 business days between requesting a repeat or follow-up | ||||||
15 | appointment and being seen by the facility or provider of | ||||||
16 | mental, emotional, nervous, or substance use disorders or | ||||||
17 | conditions for outpatient treatment; however, subject to | ||||||
18 | the protections of paragraph (3) of this subsection, a | ||||||
19 | network plan shall not be held responsible if the | ||||||
20 | beneficiary or provider voluntarily chooses to schedule an | ||||||
21 | appointment outside of these required time frames. | ||||||
22 | (B) For beneficiaries residing in Illinois counties | ||||||
23 | other than those counties listed in subparagraph (A) of | ||||||
24 | this paragraph, network adequacy standards for timely and | ||||||
25 | proximate access to treatment for mental, emotional, | ||||||
26 | nervous, or substance use disorders or conditions means a |
| |||||||
| |||||||
1 | beneficiary shall not have to travel longer than 60 | ||||||
2 | minutes or 60 miles from the beneficiary's residence to | ||||||
3 | receive outpatient treatment for mental, emotional, | ||||||
4 | nervous, or substance use disorders or conditions. | ||||||
5 | Beneficiaries shall not be required to wait longer than 10 | ||||||
6 | business days between requesting an initial appointment | ||||||
7 | and being seen by the facility or provider of mental, | ||||||
8 | emotional, nervous, or substance use disorders or | ||||||
9 | conditions for outpatient treatment or to wait longer than | ||||||
10 | 20 business days between requesting a repeat or follow-up | ||||||
11 | appointment and being seen by the facility or provider of | ||||||
12 | mental, emotional, nervous, or substance use disorders or | ||||||
13 | conditions for outpatient treatment; however, subject to | ||||||
14 | the protections of paragraph (3) of this subsection, a | ||||||
15 | network plan shall not be held responsible if the | ||||||
16 | beneficiary or provider voluntarily chooses to schedule an | ||||||
17 | appointment outside of these required time frames. | ||||||
18 | (2) For beneficiaries residing in all Illinois counties, | ||||||
19 | network adequacy standards for timely and proximate access to | ||||||
20 | treatment for mental, emotional, nervous, or substance use | ||||||
21 | disorders or conditions means a beneficiary shall not have to | ||||||
22 | travel longer than 60 minutes or 60 miles from the | ||||||
23 | beneficiary's residence to receive inpatient or residential | ||||||
24 | treatment for mental, emotional, nervous, or substance use | ||||||
25 | disorders or conditions. | ||||||
26 | (3) If there is no in-network facility or provider |
| |||||||
| |||||||
1 | available for a beneficiary to receive timely and proximate | ||||||
2 | access to treatment for mental, emotional, nervous, or | ||||||
3 | substance use disorders or conditions in accordance with the | ||||||
4 | network adequacy standards outlined in this subsection, the | ||||||
5 | issuer insurer shall provide necessary exceptions to its | ||||||
6 | network to ensure admission and treatment with a provider or | ||||||
7 | at a treatment facility in accordance with the network | ||||||
8 | adequacy standards in this subsection. | ||||||
9 | (4) If the federal Centers for Medicare and Medicaid | ||||||
10 | Services establish or law requires more stringent standards | ||||||
11 | for qualified health plans in the Federally-Facilitated | ||||||
12 | Exchanges, the federal standards shall control for the time | ||||||
13 | period specified in the federal law, regulation, or guidance, | ||||||
14 | even if the network plan is issued in the large group market or | ||||||
15 | is otherwise not issued through an exchange. | ||||||
16 | (e) Except for network plans solely offered as a group | ||||||
17 | health plan, these ratio and time and distance standards apply | ||||||
18 | to the lowest cost-sharing tier of any tiered network. | ||||||
19 | (f) The network plan may consider use of other health care | ||||||
20 | service delivery options, such as telemedicine or telehealth, | ||||||
21 | mobile clinics, and centers of excellence, or other ways of | ||||||
22 | delivering care to partially meet the requirements set under | ||||||
23 | this Section. | ||||||
24 | (g) Except for the requirements set forth in subsection | ||||||
25 | (d-5), issuers insurers who are not able to comply with the | ||||||
26 | provider ratios and time and distance or appointment wait time |
| |||||||
| |||||||
1 | standards established under this Act by the Department may | ||||||
2 | request an exception to these requirements from the | ||||||
3 | Department. The Department may grant an exception in the | ||||||
4 | following circumstances: | ||||||
5 | (1) if no providers or facilities meet the specific | ||||||
6 | time and distance standard in a specific service area and | ||||||
7 | the issuer insurer (i) discloses information on the | ||||||
8 | distance and travel time points that beneficiaries would | ||||||
9 | have to travel beyond the required criterion to reach the | ||||||
10 | next closest contracted provider outside of the service | ||||||
11 | area and (ii) provides contact information, including | ||||||
12 | names, addresses, and phone numbers for the next closest | ||||||
13 | contracted provider or facility; | ||||||
14 | (2) if patterns of care in the service area do not | ||||||
15 | support the need for the requested number of provider or | ||||||
16 | facility type and the issuer insurer provides data on | ||||||
17 | local patterns of care, such as claims data, referral | ||||||
18 | patterns, or local provider interviews, indicating where | ||||||
19 | the beneficiaries currently seek this type of care or | ||||||
20 | where the physicians currently refer beneficiaries, or | ||||||
21 | both; or | ||||||
22 | (3) other circumstances deemed appropriate by the | ||||||
23 | Department consistent with the requirements of this Act. | ||||||
24 | (h) Issuers Insurers are required to report to the | ||||||
25 | Director any material change to an approved network plan | ||||||
26 | within 15 days after the change occurs and any change that |
| |||||||
| |||||||
1 | would result in failure to meet the requirements of this Act. | ||||||
2 | The issuer shall submit a revised version of the complete | ||||||
3 | network adequacy filing based on the material change, and the | ||||||
4 | issuer shall attach versions with the changes indicated for | ||||||
5 | each document that was revised from the previous version of | ||||||
6 | the filing. Upon notice from the issuer insurer , the Director | ||||||
7 | shall reevaluate the network plan's compliance with the | ||||||
8 | network adequacy and transparency standards of this Act. For | ||||||
9 | every day past 15 days that the issuer fails to submit a | ||||||
10 | revised network adequacy filing to the Director, the Director | ||||||
11 | shall order a fine of $1,000 per day.
| ||||||
12 | (i) If a network plan is inadequate under this Act with | ||||||
13 | respect to a provider type in a county, and if the network plan | ||||||
14 | does not have an approved exception for that provider type in | ||||||
15 | that county pursuant to subsection (g), an issuer shall | ||||||
16 | process out-of-network claims for covered health care services | ||||||
17 | received from that provider type within that county at the | ||||||
18 | in-network benefit level and shall retroactively adjudicate | ||||||
19 | and reimburse beneficiaries to achieve that objective if their | ||||||
20 | claims were processed at the out-of-network level contrary to | ||||||
21 | this subsection. | ||||||
22 | (j) If the Director determines that a network is | ||||||
23 | inadequate in any county and no exception has been granted | ||||||
24 | under subsection (g) and the issuer does not have a process in | ||||||
25 | place to comply with subsection (d-5), the Director may | ||||||
26 | prohibit the network plan from being issued or renewed within |
| |||||||
| |||||||
1 | that county until the Director determines that the network is | ||||||
2 | adequate apart from processes and exceptions described in | ||||||
3 | subsections (d-5) and (g). Nothing in this subsection shall be | ||||||
4 | construed to terminate any beneficiary's health insurance | ||||||
5 | coverage under a network plan before the expiration of the | ||||||
6 | beneficiary's policy period if the Director makes a | ||||||
7 | determination under this subsection after the issuance or | ||||||
8 | renewal of the beneficiary's policy or certificate because of | ||||||
9 | a material change. Policies or certificates issued or renewed | ||||||
10 | in violation of this subsection shall subject the issuer to a | ||||||
11 | civil penalty of $1,000 per policy. | ||||||
12 | (Source: P.A. 102-144, eff. 1-1-22 .) | ||||||
13 | (215 ILCS 124/15)
| ||||||
14 | Sec. 15. Notice of nonrenewal or termination. | ||||||
15 | (a) A network plan must give at least 60 days' notice of | ||||||
16 | nonrenewal or termination of a provider to the provider and to | ||||||
17 | the beneficiaries served by the provider. The notice shall | ||||||
18 | include a name and address to which a beneficiary or provider | ||||||
19 | may direct comments and concerns regarding the nonrenewal or | ||||||
20 | termination and the telephone number maintained by the | ||||||
21 | Department for consumer complaints. Immediate written notice | ||||||
22 | may be provided without 60 days' notice when a provider's | ||||||
23 | license has been disciplined by a State licensing board or | ||||||
24 | when the network plan reasonably believes direct imminent | ||||||
25 | physical harm to patients under the provider's providers care |
| |||||||
| |||||||
1 | may occur. The notice to the beneficiary shall provide the | ||||||
2 | individual with an opportunity to notify the issuer of the | ||||||
3 | individual's need for transitional care. | ||||||
4 | (b) Primary care providers must notify active affected | ||||||
5 | patients of nonrenewal or termination of the provider from the | ||||||
6 | network plan, except in the case of incapacitation.
| ||||||
7 | (Source: P.A. 100-502, eff. 9-15-17.) | ||||||
8 | (215 ILCS 124/20)
| ||||||
9 | Sec. 20. Transition of services. | ||||||
10 | (a) A network plan shall provide for continuity of care | ||||||
11 | for its beneficiaries as follows: | ||||||
12 | (1) If a beneficiary's physician or hospital provider | ||||||
13 | leaves the network plan's network of providers for reasons | ||||||
14 | other than termination of a contract in situations | ||||||
15 | involving imminent harm to a patient or a final | ||||||
16 | disciplinary action by a State licensing board and the | ||||||
17 | provider remains within the network plan's service area, | ||||||
18 | if benefits provided under such network plan with respect | ||||||
19 | to such provider or facility are terminated because of a | ||||||
20 | change in the terms of the participation of such provider | ||||||
21 | or facility in such plan, or if a contract between a group | ||||||
22 | health plan and a health insurance issuer offering a | ||||||
23 | network plan in connection with the group health plan is | ||||||
24 | terminated and results in a loss of benefits provided | ||||||
25 | under such plan with respect to such provider, then the |
| |||||||
| |||||||
1 | network plan shall permit the beneficiary to continue an | ||||||
2 | ongoing course of treatment with that provider during a | ||||||
3 | transitional period for the following duration: | ||||||
4 | (A) 90 days from the date of the notice to the | ||||||
5 | beneficiary of the provider's disaffiliation from the | ||||||
6 | network plan if the beneficiary has an ongoing course | ||||||
7 | of treatment; or | ||||||
8 | (B) if the beneficiary has entered the third | ||||||
9 | trimester of pregnancy at the time of the provider's | ||||||
10 | disaffiliation, a period that includes the provision | ||||||
11 | of post-partum care directly related to the delivery. | ||||||
12 | (2) Notwithstanding the provisions of paragraph (1) of | ||||||
13 | this subsection (a), such care shall be authorized by the | ||||||
14 | network plan during the transitional period in accordance | ||||||
15 | with the following: | ||||||
16 | (A) the provider receives continued reimbursement | ||||||
17 | from the network plan at the rates and terms and | ||||||
18 | conditions applicable under the terminated contract | ||||||
19 | prior to the start of the transitional period; | ||||||
20 | (B) the provider adheres to the network plan's | ||||||
21 | quality assurance requirements, including provision to | ||||||
22 | the network plan of necessary medical information | ||||||
23 | related to such care; and | ||||||
24 | (C) the provider otherwise adheres to the network | ||||||
25 | plan's policies and procedures, including, but not | ||||||
26 | limited to, procedures regarding referrals and |
| |||||||
| |||||||
1 | obtaining preauthorizations for treatment. | ||||||
2 | (3) The provisions of this Section governing health | ||||||
3 | care provided during the transition period do not apply if | ||||||
4 | the beneficiary has successfully transitioned to another | ||||||
5 | provider participating in the network plan, if the | ||||||
6 | beneficiary has already met or exceeded the benefit | ||||||
7 | limitations of the plan, or if the care provided is not | ||||||
8 | medically necessary. | ||||||
9 | (b) A network plan shall provide for continuity of care | ||||||
10 | for new beneficiaries as follows: | ||||||
11 | (1) If a new beneficiary whose provider is not a | ||||||
12 | member of the network plan's provider network, but is | ||||||
13 | within the network plan's service area, enrolls in the | ||||||
14 | network plan, the network plan shall permit the | ||||||
15 | beneficiary to continue an ongoing course of treatment | ||||||
16 | with the beneficiary's current physician during a | ||||||
17 | transitional period: | ||||||
18 | (A) of 90 days from the effective date of | ||||||
19 | enrollment if the beneficiary has an ongoing course of | ||||||
20 | treatment; or | ||||||
21 | (B) if the beneficiary has entered the third | ||||||
22 | trimester of pregnancy at the effective date of | ||||||
23 | enrollment, that includes the provision of post-partum | ||||||
24 | care directly related to the delivery. | ||||||
25 | (2) If a beneficiary, or a beneficiary's authorized | ||||||
26 | representative, elects in writing to continue to receive |
| |||||||
| |||||||
1 | care from such provider pursuant to paragraph (1) of this | ||||||
2 | subsection (b), such care shall be authorized by the | ||||||
3 | network plan for the transitional period in accordance | ||||||
4 | with the following: | ||||||
5 | (A) the provider receives reimbursement from the | ||||||
6 | network plan at rates established by the network plan; | ||||||
7 | (B) the provider adheres to the network plan's | ||||||
8 | quality assurance requirements, including provision to | ||||||
9 | the network plan of necessary medical information | ||||||
10 | related to such care; and | ||||||
11 | (C) the provider otherwise adheres to the network | ||||||
12 | plan's policies and procedures, including, but not | ||||||
13 | limited to, procedures regarding referrals and | ||||||
14 | obtaining preauthorization for treatment. | ||||||
15 | (3) The provisions of this Section governing health | ||||||
16 | care provided during the transition period do not apply if | ||||||
17 | the beneficiary has successfully transitioned to another | ||||||
18 | provider participating in the network plan, if the | ||||||
19 | beneficiary has already met or exceeded the benefit | ||||||
20 | limitations of the plan, or if the care provided is not | ||||||
21 | medically necessary. | ||||||
22 | (c) In no event shall this Section be construed to require | ||||||
23 | a network plan to provide coverage for benefits not otherwise | ||||||
24 | covered or to diminish or impair preexisting condition | ||||||
25 | limitations contained in the beneficiary's contract.
| ||||||
26 | (d) A provider shall comply with the requirements of 42 |
| |||||||
| |||||||
1 | U.S.C. 300gg-138. | ||||||
2 | (Source: P.A. 100-502, eff. 9-15-17.) | ||||||
3 | (215 ILCS 124/25)
| ||||||
4 | Sec. 25. Network transparency. | ||||||
5 | (a) A network plan shall post electronically an | ||||||
6 | up-to-date, accurate, and complete provider directory for each | ||||||
7 | of its network plans, with the information and search | ||||||
8 | functions, as described in this Section. | ||||||
9 | (1) In making the directory available electronically, | ||||||
10 | the network plans shall ensure that the general public is | ||||||
11 | able to view all of the current providers for a plan | ||||||
12 | through a clearly identifiable link or tab and without | ||||||
13 | creating or accessing an account or entering a policy or | ||||||
14 | contract number. | ||||||
15 | (2) The network plan shall update the online provider | ||||||
16 | directory at least monthly. An issuer's failure to update | ||||||
17 | a network plan's directory shall subject the issuer to a | ||||||
18 | civil penalty of $5,000 per month. Providers shall notify | ||||||
19 | the network plan electronically or in writing of any | ||||||
20 | changes to their information as listed in the provider | ||||||
21 | directory, including the information required in | ||||||
22 | subparagraph (K) of paragraph (1) of subsection (b). If a | ||||||
23 | provider is no longer accepting new patients, the provider | ||||||
24 | must give notice to the issuer within 5 business days | ||||||
25 | after deciding to cease accepting new patients, or within |
| |||||||
| |||||||
1 | 5 business days after the effective date of this | ||||||
2 | amendatory Act of the 102nd General Assembly, whichever is | ||||||
3 | later. The network plan shall update its online provider | ||||||
4 | directory in a manner consistent with the information | ||||||
5 | provided by the provider within 2 10 business days after | ||||||
6 | being notified of the change by the provider. Nothing in | ||||||
7 | this paragraph (2) shall void any contractual relationship | ||||||
8 | between the provider and the plan. | ||||||
9 | (3) At least once every 90 days, the The network plan | ||||||
10 | shall audit each periodically at least 25% of its print | ||||||
11 | and online provider directories for accuracy, make any | ||||||
12 | corrections necessary, and retain documentation of the | ||||||
13 | audit. The network plan shall submit the audit to the | ||||||
14 | Director upon request. As part of these audits, the | ||||||
15 | network plan shall contact any provider in its network | ||||||
16 | that has not submitted a claim to the plan or otherwise | ||||||
17 | communicated his or her intent to continue participation | ||||||
18 | in the plan's network. The audits shall comply with 42 | ||||||
19 | U.S.C. 300gg-115(a)(2), except that "provider directory | ||||||
20 | information" shall include all information required to be | ||||||
21 | included in a provider directory pursuant to this Act. | ||||||
22 | (4) A network plan shall provide a print copy of a | ||||||
23 | current provider directory or a print copy of the | ||||||
24 | requested directory information upon request of a | ||||||
25 | beneficiary or a prospective beneficiary. Print copies | ||||||
26 | must be updated quarterly and an errata that reflects |
| |||||||
| |||||||
1 | changes in the provider network must be updated quarterly. | ||||||
2 | (5) For each network plan, a network plan shall | ||||||
3 | include, in plain language in both the electronic and | ||||||
4 | print directory, the following general information: | ||||||
5 | (A) in plain language, a description of the | ||||||
6 | criteria the plan has used to build its provider | ||||||
7 | network; | ||||||
8 | (B) if applicable, in plain language, a | ||||||
9 | description of the criteria the issuer insurer or | ||||||
10 | network plan has used to create tiered networks; | ||||||
11 | (C) if applicable, in plain language, how the | ||||||
12 | network plan designates the different provider tiers | ||||||
13 | or levels in the network and identifies for each | ||||||
14 | specific provider, hospital, or other type of facility | ||||||
15 | in the network which tier each is placed, for example, | ||||||
16 | by name, symbols, or grouping, in order for a | ||||||
17 | beneficiary-covered person or a prospective | ||||||
18 | beneficiary-covered person to be able to identify the | ||||||
19 | provider tier; and | ||||||
20 | (D) if applicable, a notation that authorization | ||||||
21 | or referral may be required to access some providers. | ||||||
22 | (6) A network plan shall make it clear for both its | ||||||
23 | electronic and print directories what provider directory | ||||||
24 | applies to which network plan, such as including the | ||||||
25 | specific name of the network plan as marketed and issued | ||||||
26 | in this State. The network plan shall include in both its |
| |||||||
| |||||||
1 | electronic and print directories a customer service email | ||||||
2 | address and telephone number or electronic link that | ||||||
3 | beneficiaries or the general public may use to notify the | ||||||
4 | network plan of inaccurate provider directory information | ||||||
5 | and contact information for the Department's Office of | ||||||
6 | Consumer Health Insurance. | ||||||
7 | (7) A provider directory, whether in electronic or | ||||||
8 | print format, shall accommodate the communication needs of | ||||||
9 | individuals with disabilities, and include a link to or | ||||||
10 | information regarding available assistance for persons | ||||||
11 | with limited English proficiency. | ||||||
12 | (b) For each network plan, a network plan shall make | ||||||
13 | available through an electronic provider directory the | ||||||
14 | following information in a searchable format: | ||||||
15 | (1) for health care professionals: | ||||||
16 | (A) name; | ||||||
17 | (B) gender; | ||||||
18 | (C) participating office locations; | ||||||
19 | (D) specialty, if applicable; | ||||||
20 | (E) medical group affiliations, if applicable; | ||||||
21 | (F) facility affiliations, if applicable; | ||||||
22 | (G) participating facility affiliations, if | ||||||
23 | applicable; | ||||||
24 | (H) languages spoken other than English, if | ||||||
25 | applicable; | ||||||
26 | (I) whether accepting new patients; |
| |||||||
| |||||||
1 | (J) board certifications, if applicable; and | ||||||
2 | (K) use of telehealth or telemedicine, including, | ||||||
3 | but not limited to: | ||||||
4 | (i) whether the provider offers the use of | ||||||
5 | telehealth or telemedicine to deliver services to | ||||||
6 | patients for whom it would be clinically | ||||||
7 | appropriate; | ||||||
8 | (ii) what modalities are used and what types | ||||||
9 | of services may be provided via telehealth or | ||||||
10 | telemedicine; and | ||||||
11 | (iii) whether the provider has the ability and | ||||||
12 | willingness to include in a telehealth or | ||||||
13 | telemedicine encounter a family caregiver who is | ||||||
14 | in a separate location than the patient if the | ||||||
15 | patient wishes and provides his or her consent; | ||||||
16 | (2) for hospitals: | ||||||
17 | (A) hospital name; | ||||||
18 | (B) hospital type (such as acute, rehabilitation, | ||||||
19 | children's, or cancer); | ||||||
20 | (C) participating hospital location; and | ||||||
21 | (D) hospital accreditation status; and | ||||||
22 | (3) for facilities, other than hospitals, by type: | ||||||
23 | (A) facility name; | ||||||
24 | (B) facility type; | ||||||
25 | (C) types of services performed; and | ||||||
26 | (D) participating facility location or locations , |
| |||||||
| |||||||
1 | including for each location where the health care | ||||||
2 | professional is at the location at least 3 days per | ||||||
3 | week . | ||||||
4 | (c) For the electronic provider directories, for each | ||||||
5 | network plan, a network plan shall make available all of the | ||||||
6 | following information in addition to the searchable | ||||||
7 | information required in this Section: | ||||||
8 | (1) for health care professionals: | ||||||
9 | (A) contact information , including both a | ||||||
10 | telephone number and digital contact information if | ||||||
11 | the provider has supplied digital contact information ; | ||||||
12 | and | ||||||
13 | (B) languages spoken other than English by | ||||||
14 | clinical staff, if applicable; | ||||||
15 | (2) for hospitals, telephone number and digital | ||||||
16 | contact information ; and | ||||||
17 | (3) for facilities other than hospitals, telephone | ||||||
18 | number. | ||||||
19 | (d) The issuer insurer or network plan shall make | ||||||
20 | available in print, upon request, the following provider | ||||||
21 | directory information for the applicable network plan: | ||||||
22 | (1) for health care professionals: | ||||||
23 | (A) name; | ||||||
24 | (B) contact information , including telephone | ||||||
25 | number and digital contact information if the provider | ||||||
26 | has supplied digital contact information ; |
| |||||||
| |||||||
1 | (C) participating office location or locations , | ||||||
2 | including for each location where the health care | ||||||
3 | professional is at the location at least 3 days per | ||||||
4 | week ; | ||||||
5 | (D) specialty, if applicable; | ||||||
6 | (E) languages spoken other than English, if | ||||||
7 | applicable; | ||||||
8 | (F) whether accepting new patients; and | ||||||
9 | (G) use of telehealth or telemedicine, including, | ||||||
10 | but not limited to: | ||||||
11 | (i) whether the provider offers the use of | ||||||
12 | telehealth or telemedicine to deliver services to | ||||||
13 | patients for whom it would be clinically | ||||||
14 | appropriate; | ||||||
15 | (ii) what modalities are used and what types | ||||||
16 | of services may be provided via telehealth or | ||||||
17 | telemedicine; and | ||||||
18 | (iii) whether the provider has the ability and | ||||||
19 | willingness to include in a telehealth or | ||||||
20 | telemedicine encounter a family caregiver who is | ||||||
21 | in a separate location than the patient if the | ||||||
22 | patient wishes and provides his or her consent; | ||||||
23 | (2) for hospitals: | ||||||
24 | (A) hospital name; | ||||||
25 | (B) hospital type (such as acute, rehabilitation, | ||||||
26 | children's, or cancer); and |
| |||||||
| |||||||
1 | (C) participating hospital location , and telephone | ||||||
2 | number , and digital contact information ; and | ||||||
3 | (3) for facilities, other than hospitals, by type: | ||||||
4 | (A) facility name; | ||||||
5 | (B) facility type; | ||||||
6 | (C) types of services performed; and | ||||||
7 | (D) participating facility location or locations , | ||||||
8 | and telephone numbers , and digital contact information | ||||||
9 | for each location . | ||||||
10 | (e) The network plan shall include a disclosure in the | ||||||
11 | print format provider directory that the information included | ||||||
12 | in the directory is accurate as of the date of printing and | ||||||
13 | that beneficiaries or prospective beneficiaries should consult | ||||||
14 | the issuer's insurer's electronic provider directory on its | ||||||
15 | website and contact the provider. The network plan shall also | ||||||
16 | include a telephone number in the print format provider | ||||||
17 | directory for a customer service representative where the | ||||||
18 | beneficiary can obtain current provider directory information. | ||||||
19 | (f) The Director may conduct periodic audits of the | ||||||
20 | accuracy of provider directories. A network plan shall not be | ||||||
21 | subject to any fines or penalties for information required in | ||||||
22 | this Section that a provider submits that is inaccurate or | ||||||
23 | incomplete.
| ||||||
24 | (g) To the extent not otherwise provided in this Act, an | ||||||
25 | issuer shall comply with the requirements of 42 U.S.C. | ||||||
26 | 300gg-115, except that "provider directory information" shall |
| |||||||
| |||||||
1 | include all information required to be included in a provider | ||||||
2 | directory pursuant to this Section. | ||||||
3 | (Source: P.A. 102-92, eff. 7-9-21.) | ||||||
4 | (215 ILCS 124/30)
| ||||||
5 | Sec. 30. Administration and enforcement.
| ||||||
6 | (a) Issuers Insurers , as defined in this Act, have a | ||||||
7 | continuing obligation to comply with the requirements of this | ||||||
8 | Act. Other than the duties specifically created in this Act, | ||||||
9 | nothing in this Act is intended to preclude, prevent, or | ||||||
10 | require the adoption, modification, or termination of any | ||||||
11 | utilization management, quality management, or claims | ||||||
12 | processing methodologies of an issuer insurer . | ||||||
13 | (b) Nothing in this Act precludes, prevents, or requires | ||||||
14 | the adoption, modification, or termination of any network plan | ||||||
15 | term, benefit, coverage or eligibility provision, or payment | ||||||
16 | methodology. | ||||||
17 | (c) The Director shall enforce the provisions of this Act | ||||||
18 | pursuant to the enforcement powers granted to it by law. | ||||||
19 | (d) The Department shall adopt rules to enforce compliance | ||||||
20 | with this Act to the extent necessary.
| ||||||
21 | (e) In accordance with Section 5-45.21 of the Illinois | ||||||
22 | Administrative Procedure Act, the Department may adopt | ||||||
23 | emergency rules to implement federal standards for provider | ||||||
24 | ratios, travel time and distance, and appointment wait times | ||||||
25 | if such standards apply to health insurance coverage regulated |
| |||||||
| |||||||
1 | by the Department and are more stringent than the State | ||||||
2 | standards extant at the time the final federal standards are | ||||||
3 | published. | ||||||
4 | (Source: P.A. 100-502, eff. 9-15-17.) | ||||||
5 | (215 ILCS 124/35 new) | ||||||
6 | Sec. 35. Provider requirements. Providers shall comply | ||||||
7 | with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations | ||||||
8 | promulgated thereunder, as well as Section 20 and paragraph | ||||||
9 | (2) of subsection (a) of Section 25 of this Act, except that | ||||||
10 | "provider directory information" includes all information | ||||||
11 | required to be included in a provider directory pursuant to | ||||||
12 | Section 25 of this Act. To the extent a provider is licensed by | ||||||
13 | the Department of Financial and Professional Regulation or by | ||||||
14 | the Department of Public Health, that agency shall have the | ||||||
15 | authority to investigate, examine, process complaints, issue | ||||||
16 | subpoenas, examine witnesses under oath, issue a fine, or take | ||||||
17 | disciplinary action against the provider's license for | ||||||
18 | violations of these requirements in accordance with the | ||||||
19 | provider's applicable licensing statute. | ||||||
20 | (215 ILCS 124/40 new) | ||||||
21 | Sec. 40. Confidentiality. | ||||||
22 | (a) All records in the custody or possession of the | ||||||
23 | Department are presumed to be open to public inspection or | ||||||
24 | copying unless exempt from disclosure by Section 7 or 7.5 of |
| |||||||
| |||||||
1 | the Freedom of Information Act. Except as otherwise provided | ||||||
2 | in this Section or other applicable law, the filings required | ||||||
3 | under this Act shall be open to public inspection or copying. | ||||||
4 | (b) The following information shall not be deemed | ||||||
5 | confidential: | ||||||
6 | (1) actual or projected ratios of providers to | ||||||
7 | beneficiaries; | ||||||
8 | (2) actual or projected time and distance between | ||||||
9 | network providers and beneficiaries or actual or projected | ||||||
10 | waiting times for a beneficiary to see a network provider; | ||||||
11 | (3) geographic maps of network providers; | ||||||
12 | (4) requests for exceptions under subsection (g) of | ||||||
13 | Section 10, except with respect to any discussion of | ||||||
14 | ongoing or planned contractual negotiations with providers | ||||||
15 | that the issuer requests to be treated as confidential; | ||||||
16 | and | ||||||
17 | (5) provider directories. | ||||||
18 | (c) An issuer's work papers and reports on the results of a | ||||||
19 | self-audit of its provider directories shall remain | ||||||
20 | confidential unless expressly waived by the insurer or unless | ||||||
21 | deemed public information under federal law. | ||||||
22 | (d) The filings required under Section 10 of this Act | ||||||
23 | shall be confidential while they remain under the Department's | ||||||
24 | review but shall become open to public inspection and copying | ||||||
25 | upon completion of the review, except as provided in this | ||||||
26 | Section or under other applicable law. |
| |||||||
| |||||||
1 | (e) Nothing in this Section shall supersede the statutory | ||||||
2 | requirement that work papers obtained during a market conduct | ||||||
3 | examination be deemed confidential. | ||||||
4 | Section 20. The Managed Care Reform and Patient Rights Act | ||||||
5 | is amended by changing Sections 20 and 25 as follows:
| ||||||
6 | (215 ILCS 134/20)
| ||||||
7 | Sec. 20. Notice of nonrenewal or termination. A health | ||||||
8 | care plan must
give at least 60
days notice of nonrenewal or | ||||||
9 | termination of a health
care provider to the health care
| ||||||
10 | provider and to the enrollees served by the health care | ||||||
11 | provider.
The notice shall include a name and address to which | ||||||
12 | an enrollee or health care
provider may direct
comments and | ||||||
13 | concerns regarding the nonrenewal or termination.
Immediate | ||||||
14 | written notice may be provided without 60 days notice when a | ||||||
15 | health
care provider's license has been disciplined by a State | ||||||
16 | licensing board. The notice to the enrollee shall provide the | ||||||
17 | individual with an opportunity to notify the health care plan | ||||||
18 | of the individual's need for transitional care.
| ||||||
19 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
20 | (215 ILCS 134/25)
| ||||||
21 | Sec. 25. Transition of services.
| ||||||
22 | (a) A health care plan shall provide for continuity of | ||||||
23 | care for its
enrollees as follows:
|
| |||||||
| |||||||
1 | (1) If an enrollee's health care provider physician | ||||||
2 | leaves the health care plan's network
of
health care | ||||||
3 | providers for reasons other than termination of a contract | ||||||
4 | in
situations
involving imminent harm to a patient
or a | ||||||
5 | final disciplinary action by a State
licensing board
and | ||||||
6 | the provider physician
remains within the health care | ||||||
7 | plan's service area, or if benefits provided under such | ||||||
8 | health care plan with respect to such provider are | ||||||
9 | terminated because of a change in the terms of the | ||||||
10 | participation of such provider in such plan, or if a | ||||||
11 | contract between a group health plan, as defined in | ||||||
12 | Section 5 of the Illinois Health Insurance Portability and | ||||||
13 | Accountability Act, and a health care plan offered | ||||||
14 | connection with the group health plan is terminated and | ||||||
15 | results in a loss of benefits provided under such plan | ||||||
16 | with respect to such provider, the health care plan
shall
| ||||||
17 | permit the enrollee to continue an ongoing course of | ||||||
18 | treatment with that provider
physician during a | ||||||
19 | transitional period:
| ||||||
20 | (A) of 90 days from the date of the notice of | ||||||
21 | provider's physician's
termination
from the health | ||||||
22 | care plan to the enrollee of the provider's | ||||||
23 | physician's
disaffiliation from the health care plan | ||||||
24 | if the enrollee has an ongoing course
of treatment; or
| ||||||
25 | (B) if the enrollee has entered the third | ||||||
26 | trimester of pregnancy at the
time
of the provider's |
| |||||||
| |||||||
1 | physician's disaffiliation, that includes the
| ||||||
2 | provision of post-partum care directly related to the | ||||||
3 | delivery.
| ||||||
4 | (2) Notwithstanding the provisions in item (1) of this | ||||||
5 | subsection, such
care shall be
authorized by the health | ||||||
6 | care plan during the transitional period only if
the | ||||||
7 | provider
physician agrees:
| ||||||
8 | (A) to continue to accept reimbursement from the | ||||||
9 | health care plan
at the
rates applicable prior to the | ||||||
10 | start of the transitional period;
| ||||||
11 | (B) to adhere to the health care plan's quality | ||||||
12 | assurance
requirements
and
to provide to the health | ||||||
13 | care plan necessary medical information related
to
| ||||||
14 | such care; and
| ||||||
15 | (C) to otherwise adhere to the health care plan's | ||||||
16 | policies and
procedures,
including but not limited to | ||||||
17 | procedures regarding referrals and obtaining
| ||||||
18 | preauthorizations for treatment.
| ||||||
19 | (3) During an enrollee's plan year, a health care plan | ||||||
20 | shall not remove a drug from its formulary or negatively | ||||||
21 | change its preferred or cost-tier sharing unless, at least | ||||||
22 | 60 days before making the formulary change, the health | ||||||
23 | care plan: | ||||||
24 | (A) provides general notification of the change in | ||||||
25 | its formulary to current and prospective enrollees; | ||||||
26 | (B) directly notifies enrollees currently |
| |||||||
| |||||||
1 | receiving coverage for the drug, including information | ||||||
2 | on the specific drugs involved and the steps they may | ||||||
3 | take to request coverage determinations and | ||||||
4 | exceptions, including a statement that a certification | ||||||
5 | of medical necessity by the enrollee's prescribing | ||||||
6 | provider will result in continuation of coverage at | ||||||
7 | the existing level; and | ||||||
8 | (C) directly notifies by first class mail and | ||||||
9 | through an electronic transmission, if available, the | ||||||
10 | prescribing provider of all health care plan enrollees | ||||||
11 | currently prescribed the drug affected by the proposed | ||||||
12 | change; the notice shall include a one-page form by | ||||||
13 | which the prescribing provider can notify the health | ||||||
14 | care plan by first class mail that coverage of the drug | ||||||
15 | for the enrollee is medically necessary. | ||||||
16 | The notification in paragraph (C) may direct the | ||||||
17 | prescribing provider to an electronic portal through which | ||||||
18 | the prescribing provider may electronically file a | ||||||
19 | certification to the health care plan that coverage of the | ||||||
20 | drug for the enrollee is medically necessary. The | ||||||
21 | prescribing provider may make a secure electronic | ||||||
22 | signature beside the words "certification of medical | ||||||
23 | necessity", and this certification shall authorize | ||||||
24 | continuation of coverage for the drug. | ||||||
25 | If the prescribing provider certifies to the health | ||||||
26 | care plan either in writing or electronically that the |
| |||||||
| |||||||
1 | drug is medically necessary for the enrollee as provided | ||||||
2 | in paragraph (C), a health care plan shall authorize | ||||||
3 | coverage for the drug prescribed based solely on the | ||||||
4 | prescribing provider's assertion that coverage is | ||||||
5 | medically necessary, and the health care plan is | ||||||
6 | prohibited from making modifications to the coverage | ||||||
7 | related to the covered drug, including, but not limited | ||||||
8 | to: | ||||||
9 | (i) increasing the out-of-pocket costs for the | ||||||
10 | covered drug; | ||||||
11 | (ii) moving the covered drug to a more restrictive | ||||||
12 | tier; or | ||||||
13 | (iii) denying an enrollee coverage of the drug for | ||||||
14 | which the enrollee has been previously approved for | ||||||
15 | coverage by the health care plan. | ||||||
16 | Nothing in this item (3) prevents a health care plan | ||||||
17 | from removing a drug from its formulary or denying an | ||||||
18 | enrollee coverage if the United States Food and Drug | ||||||
19 | Administration has issued a statement about the drug that | ||||||
20 | calls into question the clinical safety of the drug, the | ||||||
21 | drug manufacturer has notified the United States Food and | ||||||
22 | Drug Administration of a manufacturing discontinuance or | ||||||
23 | potential discontinuance of the drug as required by | ||||||
24 | Section 506C of the Federal Food, Drug, and Cosmetic Act, | ||||||
25 | as codified in 21 U.S.C. 356c, or the drug manufacturer | ||||||
26 | has removed the drug from the market. |
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1 | Nothing in this item (3) prohibits a health care plan, | ||||||
2 | by contract, written policy or procedure, or any other | ||||||
3 | agreement or course of conduct, from requiring a | ||||||
4 | pharmacist to effect substitutions of prescription drugs | ||||||
5 | consistent with Section 19.5 of the Pharmacy Practice Act, | ||||||
6 | under which a pharmacist may substitute an interchangeable | ||||||
7 | biologic for a prescribed biologic product, and Section 25 | ||||||
8 | of the Pharmacy Practice Act, under which a pharmacist may | ||||||
9 | select a generic drug determined to be therapeutically | ||||||
10 | equivalent by the United States Food and Drug | ||||||
11 | Administration and in accordance with the Illinois Food, | ||||||
12 | Drug and Cosmetic Act. | ||||||
13 | This item (3) applies to a policy or contract that is | ||||||
14 | amended, delivered, issued, or renewed on or after January | ||||||
15 | 1, 2019. This item (3) does not apply to a health plan as | ||||||
16 | defined in the State Employees Group Insurance Act of 1971 | ||||||
17 | or medical assistance under Article V of the Illinois | ||||||
18 | Public Aid Code. | ||||||
19 | (b) A health care plan shall provide for continuity of | ||||||
20 | care for new
enrollees as follows:
| ||||||
21 | (1) If a new enrollee whose physician is not a member | ||||||
22 | of the health care
plan's provider network, but is within | ||||||
23 | the health care plan's service
area,
enrolls in the health | ||||||
24 | care plan, the health care plan shall permit
the enrollee
| ||||||
25 | to continue an ongoing course of treatment with the | ||||||
26 | enrollee's current
physician during a transitional period:
|
| |||||||
| |||||||
1 | (A) of 90 days from the
effective
date of | ||||||
2 | enrollment if
the enrollee has an ongoing course of | ||||||
3 | treatment;
or
| ||||||
4 | (B) if the enrollee has entered the third | ||||||
5 | trimester of pregnancy at the
effective date of | ||||||
6 | enrollment, that
includes the provision of post-partum | ||||||
7 | care directly related to the delivery.
| ||||||
8 | (2) If an enrollee elects to continue to receive care | ||||||
9 | from such physician
pursuant to item (1) of this | ||||||
10 | subsection, such care shall be authorized by the
health | ||||||
11 | care plan for the transitional period only if the | ||||||
12 | physician agrees:
| ||||||
13 | (A) to accept reimbursement from the health care | ||||||
14 | plan at rates
established
by the health care plan; | ||||||
15 | such rates shall be
the level of reimbursement | ||||||
16 | applicable to similar physicians within the health
| ||||||
17 | care plan for such services;
| ||||||
18 | (B) to adhere to the health care plan's quality | ||||||
19 | assurance
requirements
and to provide to the health | ||||||
20 | care plan necessary medical information
related to | ||||||
21 | such care; and
| ||||||
22 | (C) to otherwise adhere to the health care plan's | ||||||
23 | policies and
procedures
including, but not limited to | ||||||
24 | procedures regarding referrals and obtaining
| ||||||
25 | preauthorization for treatment.
| ||||||
26 | (c) In no event shall this Section be construed to require |
| |||||||
| |||||||
1 | a health care
plan
to
provide coverage for benefits not | ||||||
2 | otherwise covered or to diminish or
impair preexisting | ||||||
3 | condition limitations contained in the enrollee's
contract. In | ||||||
4 | no event shall this Section be construed to prohibit the | ||||||
5 | addition of prescription drugs to a health care plan's list of | ||||||
6 | covered drugs during the coverage year.
| ||||||
7 | (d) In this Section, "ongoing course of treatment" has the | ||||||
8 | meaning ascribed to that term in Section 5 of the Network | ||||||
9 | Adequacy and Transparency Act. | ||||||
10 | (Source: P.A. 100-1052, eff. 8-24-18.)
| ||||||
11 | Section 99. Effective date. This Act takes effect upon | ||||||
12 | becoming law.".
|