Full Text of HB0311 100th General Assembly
HB0311eng 100TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 1. Short title. This Act may be cited as the | 5 | | Network Adequacy and Transparency Act. | 6 | | Section 3. Applicability of Act. This Act applies to an | 7 | | individual or group policy of accident and health insurance | 8 | | with a network plan amended, delivered, issued, or renewed in | 9 | | this State on or after January 1, 2019. | 10 | | Section 5. Definitions. In this Act: | 11 | | "Authorized representative" means a person to whom a | 12 | | beneficiary has given express written consent to represent the | 13 | | beneficiary; a person authorized by law to provide substituted | 14 | | consent for a beneficiary; or the beneficiary's treating | 15 | | provider only when the beneficiary or his or her family member | 16 | | is unable to provide consent. | 17 | | "Beneficiary" means an individual, an enrollee, an | 18 | | insured, a participant, or any other person entitled to | 19 | | reimbursement for covered expenses of or the discounting of | 20 | | provider fees for health care services under a program in which | 21 | | the beneficiary has an incentive to utilize the services of a | 22 | | provider that has entered into an agreement or arrangement with |
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| 1 | | an insurer. | 2 | | "Department" means the Department of Insurance. | 3 | | "Director" means the Director of Insurance. | 4 | | "Insurer" means any entity that offers individual or group | 5 | | accident and health insurance, including, but not limited to, | 6 | | health maintenance organizations, preferred provider | 7 | | organizations, exclusive provider organizations, and other | 8 | | plan structures requiring network participation, excluding the | 9 | | medical assistance program under the Illinois Public Aid Code, | 10 | | the State employees group health insurance program, workers | 11 | | compensation insurance, and pharmacy benefit managers. | 12 | | "Material change" means a significant reduction in the | 13 | | number of providers available in a network plan, including, but | 14 | | not limited to, a reduction of 10% or more in a specific type | 15 | | of providers, the removal of a major health system that causes | 16 | | a network to be significantly different from the network when | 17 | | the beneficiary purchased the network plan, or any change that | 18 | | would cause the network to no longer satisfy the requirements | 19 | | of this Act or the Department's rules for network adequacy and | 20 | | transparency. | 21 | | "Network" means the group or groups of preferred providers | 22 | | providing services to a network plan. | 23 | | "Network plan" means an individual or group policy of | 24 | | accident and health insurance that either requires a covered | 25 | | person to use or creates incentives, including financial | 26 | | incentives, for a covered person to use providers managed, |
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| 1 | | owned, under contract with, or employed by the insurer. | 2 | | "Ongoing course of treatment" means (1) treatment for a | 3 | | life-threatening condition, which is a disease or condition for | 4 | | which likelihood of death is probable unless the course of the | 5 | | disease or condition is interrupted; (2) treatment for a | 6 | | serious acute condition, defined as a disease or condition | 7 | | requiring complex ongoing care that the covered person is | 8 | | currently receiving, such as chemotherapy, radiation therapy, | 9 | | or post-operative visits; (3) a course of treatment for a | 10 | | health condition that a treating provider attests that | 11 | | discontinuing care by that provider would worsen the condition | 12 | | or interfere with anticipated outcomes; or (4) the third | 13 | | trimester of pregnancy through the post-partum period. | 14 | | "Preferred provider" means any provider who has entered, | 15 | | either directly or indirectly, into an agreement with an | 16 | | employer or risk-bearing entity relating to health care | 17 | | services that may be rendered to beneficiaries under a network | 18 | | plan. | 19 | | "Providers" means physicians licensed to practice medicine | 20 | | in all its branches, other health care professionals, | 21 | | hospitals, or other health care institutions that provide | 22 | | health care services. | 23 | | "Telehealth" has the meaning given to that term in Section | 24 | | 356z.22 of the Illinois Insurance Code. | 25 | | "Telemedicine" has the meaning given to that term in | 26 | | Section 49.5 of the Medical Practice Act of 1987. |
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| 1 | | "Tiered network" means a network that identifies and groups | 2 | | some or all types of provider and facilities into specific | 3 | | groups to which different provider reimbursement, covered | 4 | | person cost-sharing or provider access requirements, or any | 5 | | combination thereof, apply for the same services. | 6 | | "Woman's principal health care provider" means a physician | 7 | | licensed to practice medicine in all of its branches | 8 | | specializing in obstetrics, gynecology, or family practice. | 9 | | Section 10. Network adequacy. | 10 | | (a) An insurer providing a network plan shall file a | 11 | | description of all of the following with the Director: | 12 | | (1) The written policies and procedures for adding | 13 | | providers to meet patient needs based on increases in the | 14 | | number of beneficiaries, changes in the | 15 | | patient-to-provider ratio, changes in medical and health | 16 | | care capabilities, and increased demand for services. | 17 | | (2) The written policies and procedures for making | 18 | | referrals within and outside the network. | 19 | | (3) The written policies and procedures on how the | 20 | | network plan will provide 24-hour, 7-day per week access to | 21 | | network-affiliated primary care, emergency services, and | 22 | | woman's principal health care providers. | 23 | | An insurer shall not prohibit a preferred provider from | 24 | | discussing any specific or all treatment options with | 25 | | beneficiaries irrespective of the insurer's position on those |
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| 1 | | treatment options or from advocating on behalf of beneficiaries | 2 | | within the utilization review, grievance, or appeals processes | 3 | | established by the insurer in accordance with any rights or | 4 | | remedies available under applicable State or federal law. | 5 | | (b) Insurers must file for review a description of the | 6 | | services to be offered through a network plan. The description | 7 | | shall include all of the following: | 8 | | (1) A geographic map of the area proposed to be served | 9 | | by the plan by county service area and zip code, including | 10 | | marked locations for preferred providers. | 11 | | (2) As deemed necessary by the Department, the names, | 12 | | addresses, phone numbers, and specialties of the providers | 13 | | who have entered into preferred provider agreements under | 14 | | the network plan. | 15 | | (3) The number of beneficiaries anticipated to be | 16 | | covered by the network plan. | 17 | | (4) An Internet website and toll-free telephone number | 18 | | for beneficiaries and prospective beneficiaries to access | 19 | | current and accurate lists of preferred providers, | 20 | | additional information about the plan, as well as any other | 21 | | information required by Department rule. | 22 | | (5) A description of how health care services to be | 23 | | rendered under the network plan are reasonably accessible | 24 | | and available to beneficiaries. The description shall | 25 | | address all of the following: | 26 | | (A) the type of health care services to be provided |
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| 1 | | by the network plan; | 2 | | (B) the ratio of physicians and other providers to | 3 | | beneficiaries, by specialty and including primary care | 4 | | physicians and facility-based physicians when | 5 | | applicable under the contract, necessary to meet the | 6 | | health care needs and service demands of the currently | 7 | | enrolled population; | 8 | | (C) the travel and distance standards for plan | 9 | | beneficiaries in county service areas; and | 10 | | (D) a description of how the use of telemedicine, | 11 | | telehealth, or mobile care services may be used to | 12 | | partially meet the network adequacy standards, if | 13 | | applicable. | 14 | | (6) A provision ensuring that whenever a beneficiary | 15 | | has made a good faith effort, as evidenced by accessing the | 16 | | provider directory, calling the network plan, and calling | 17 | | the provider, to utilize preferred providers for a covered | 18 | | service and it is determined the insurer does not have the | 19 | | appropriate preferred providers due to insufficient | 20 | | number, type, or unreasonable travel distance or delay, the | 21 | | insurer shall ensure, directly or indirectly, by terms | 22 | | contained in the payer contract, that the beneficiary will | 23 | | be provided the covered service at no greater cost to the | 24 | | beneficiary than if the service had been provided by a | 25 | | preferred provider. This paragraph (6) does not apply to: | 26 | | (A) a beneficiary who willfully chooses to access a |
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| 1 | | non-preferred provider for health care services available | 2 | | through the panel of preferred providers, or (B) a | 3 | | beneficiary enrolled in a health maintenance organization. | 4 | | In these circumstances, the contractual requirements for | 5 | | non-preferred provider reimbursements shall apply. | 6 | | (7) A provision that the beneficiary shall receive | 7 | | emergency care coverage such that payment for this coverage | 8 | | is not dependent upon whether the emergency services are | 9 | | performed by a preferred or non-preferred provider and the | 10 | | coverage shall be at the same benefit level as if the | 11 | | service or treatment had been rendered by a preferred | 12 | | provider. For purposes of this paragraph (7), "the same | 13 | | benefit level" means that the beneficiary is provided the | 14 | | covered service at no greater cost to the beneficiary than | 15 | | if the service had been provided by a preferred provider. | 16 | | (8) A limitation that, if the plan provides that the | 17 | | beneficiary will incur a penalty for failing to pre-certify | 18 | | inpatient hospital treatment, the penalty may not exceed | 19 | | $1,000 per occurrence in addition to the plan cost sharing | 20 | | provisions. | 21 | | (c) The network plan shall demonstrate to the Director a | 22 | | minimum ratio of providers to plan beneficiaries as required by | 23 | | the Department. | 24 | | (1) The ratio of physicians or other providers to plan | 25 | | beneficiaries shall be established annually by the | 26 | | Department in consultation with the Department of Public |
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| 1 | | Health based upon the guidance from the federal Centers for | 2 | | Medicare and Medicaid Services. The Department shall | 3 | | consider establishing ratios for the following physicians | 4 | | or other providers: | 5 | | (A) Primary Care; | 6 | | (B) Pediatrics; | 7 | | (C) Cardiology; | 8 | | (D) Gastroenterology; | 9 | | (E) General Surgery; | 10 | | (F) Neurology; | 11 | | (G) OB/GYN; | 12 | | (H) Oncology/Radiation; | 13 | | (I) Ophthalmology; | 14 | | (J) Urology; | 15 | | (K) Behavioral Health; | 16 | | (L) Allergy/Immunology; | 17 | | (M) Chiropractic; | 18 | | (N) Dermatology; | 19 | | (O) Endocrinology; | 20 | | (P) Ears, Nose, and Throat (ENT)/Otolaryngology; | 21 | | (Q) Infectious Disease; | 22 | | (R) Nephrology; | 23 | | (S) Neurosurgery; | 24 | | (T) Orthopedic Surgery; | 25 | | (U) Physiatry/Rehabilitative; | 26 | | (V) Plastic Surgery; |
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| 1 | | (W) Pulmonary; | 2 | | (X) Rheumatology; | 3 | | (Y) Anesthesiology; | 4 | | (Z) Pain Medicine; | 5 | | (AA) Pediatric Specialty Services; | 6 | | (BB) Outpatient Dialysis; and | 7 | | (CC) HIV. | 8 | | (2) The Director shall establish a process for the | 9 | | review of the adequacy of these standards, along with an | 10 | | assessment of additional specialties to be included in the | 11 | | list under this subsection (c). | 12 | | (d) The network plan shall demonstrate to the Director | 13 | | maximum travel and distance standards for plan beneficiaries, | 14 | | which shall be established annually by the Department in | 15 | | consultation with the Department of Public Health based upon | 16 | | the guidance from the federal Centers for Medicare and Medicaid | 17 | | Services. These standards shall consist of the maximum minutes | 18 | | or miles to be traveled by a plan beneficiary for each county | 19 | | type, such as large counties, metro counties, or rural counties | 20 | | as defined by Department rule. | 21 | | The maximum travel time and distance standards must include | 22 | | standards for each physician and other provider category listed | 23 | | for which ratios have been established. | 24 | | The Director shall establish a process for the review of | 25 | | the adequacy of these standards along with an assessment of | 26 | | additional specialties to be included in the list under this |
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| 1 | | subsection (d). | 2 | | (e) Except for network plans solely offered as a group | 3 | | health plan, these ratio and time and distance standards apply | 4 | | to the lowest cost-sharing tier of any tiered network. | 5 | | (f) The network plan shall demonstrate sufficient | 6 | | inpatient services, including, but not limited to, services of | 7 | | preferred providers who specialize in emergency medicine, | 8 | | anesthesiology, pathology, and radiology. | 9 | | (g) The network plan may consider use of other health care | 10 | | service delivery options, such as telemedicine or telehealth, | 11 | | mobile clinics, and centers of excellence, or other ways of | 12 | | delivering care to partially meet the requirements set under | 13 | | this Section. | 14 | | (h) Insurers who are not able to comply with the provider | 15 | | ratios and time and distance standards established by the | 16 | | Department may request an exception to these requirements from | 17 | | the Department. The Department may grant an exception in the | 18 | | following circumstances: | 19 | | (1) if no providers or facilities meet the specific | 20 | | time and distance standard in a specific service area and | 21 | | the insurer (i) discloses information on the distance and | 22 | | travel time points that beneficiaries would have to travel | 23 | | beyond the required criterion to reach the next closest | 24 | | contracted provider outside of the service area and (ii) | 25 | | provides contact information, including names, addresses, | 26 | | and phone numbers for the next closest contracted provider |
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| 1 | | or facility; | 2 | | (2) if patterns of care in the service area do not | 3 | | support the need for the requested number of provider or | 4 | | facility type and the insurer provides data on local | 5 | | patterns of care, such as claims data, referral patterns, | 6 | | or local provider interviews, indicating where the | 7 | | beneficiaries currently seek this type of care or where the | 8 | | physicians currently refer beneficiaries, or both; or | 9 | | (3) other circumstances deemed appropriate by the | 10 | | Department consistent with the requirements of this Act. | 11 | | (i) Insurers are required to report to the Director any | 12 | | material change to an approved network plan within 15 days | 13 | | after the change occurs and any change that would result in | 14 | | failure to meet the requirements of this Act. Upon notice from | 15 | | the insurer, the Director shall reevaluate the network plan's | 16 | | compliance with the network adequacy and transparency | 17 | | standards of this Act. | 18 | | Section 15. Notice of nonrenewal or termination. | 19 | | (a) A network plan must give at least 60 days' notice of | 20 | | nonrenewal or termination of a provider to the provider and to | 21 | | the beneficiaries served by the provider. The notice shall | 22 | | include a name and address to which a beneficiary or provider | 23 | | may direct comments and concerns regarding the nonrenewal or | 24 | | termination and the telephone number maintained by the | 25 | | Department for consumer complaints. Immediate written notice |
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| 1 | | may be provided without 60 days' notice when a provider's | 2 | | license has been disciplined by a State licensing board or when | 3 | | the network plan reasonably believes direct imminent physical | 4 | | harm to patients under the providers care may occur. | 5 | | (b) Primary care providers must notify active affected | 6 | | patients of nonrenewal or termination of the provider from the | 7 | | network plan, except in the case of incapacitation. | 8 | | Section 20. Transition of services. | 9 | | (a) A network plan shall provide for continuity of care for | 10 | | its beneficiaries as follows: | 11 | | (1) If a beneficiary's physician or hospital provider | 12 | | leaves the network plan's network of providers for reasons | 13 | | other than termination of a contract in situations | 14 | | involving imminent harm to a patient or a final | 15 | | disciplinary action by a State licensing board and the | 16 | | provider remains within the network plan's service area, | 17 | | the network plan shall permit the beneficiary to continue | 18 | | an ongoing course of treatment with that provider during a | 19 | | transitional period for the following duration: | 20 | | (A) 90 days from the date of the notice to the | 21 | | beneficiary of the provider's disaffiliation from the | 22 | | network plan if the beneficiary has an ongoing course | 23 | | of treatment; or | 24 | | (B) if the beneficiary has entered the third | 25 | | trimester of pregnancy at the time of the provider's |
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| 1 | | disaffiliation, a period that includes the provision | 2 | | of post-partum care directly related to the delivery. | 3 | | (2) Notwithstanding the provisions of paragraph (1) of | 4 | | this subsection (a), such care shall be authorized by the | 5 | | network plan during the transitional period in accordance | 6 | | with the following: | 7 | | (A) the provider receives continued reimbursement | 8 | | from the network plan at the rates and terms and | 9 | | conditions applicable under the terminated contract | 10 | | prior to the start of the transitional period; | 11 | | (B) the provider adheres to the network plan's | 12 | | quality assurance requirements, including provision to | 13 | | the network plan of necessary medical information | 14 | | related to such care; and | 15 | | (C) the provider otherwise adheres to the network | 16 | | plan's policies and procedures, including, but not | 17 | | limited to, procedures regarding referrals and | 18 | | obtaining preauthorizations for treatment. | 19 | | (3) The provisions of this Section governing health | 20 | | care provided during the transition period do not apply if | 21 | | the beneficiary has successfully transitioned to another | 22 | | provider participating in the network plan, if the | 23 | | beneficiary has already met or exceeded the benefit | 24 | | limitations of the plan, or if the care provided is not | 25 | | medically necessary. | 26 | | (b) A network plan shall provide for continuity of care for |
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| 1 | | new beneficiaries as follows: | 2 | | (1) If a new beneficiary whose provider is not a member | 3 | | of the network plan's provider network, but is within the | 4 | | network plan's service area, enrolls in the network plan, | 5 | | the network plan shall permit the beneficiary to continue | 6 | | an ongoing course of treatment with the beneficiary's | 7 | | current physician during a transitional period: | 8 | | (A) of 90 days from the effective date of | 9 | | enrollment if the beneficiary has an ongoing course of | 10 | | treatment; or | 11 | | (B) if the beneficiary has entered the third | 12 | | trimester of pregnancy at the effective date of | 13 | | enrollment, that includes the provision of post-partum | 14 | | care directly related to the delivery. | 15 | | (2) If a beneficiary, or a beneficiary's authorized | 16 | | representative, elects in writing to continue to receive | 17 | | care from such provider pursuant to paragraph (1) of this | 18 | | subsection (b), such care shall be authorized by the | 19 | | network plan for the transitional period in accordance with | 20 | | the following: | 21 | | (A) the provider receives reimbursement from the | 22 | | network plan at rates established by the network plan; | 23 | | (B) the provider adheres to the network plan's | 24 | | quality assurance requirements, including provision to | 25 | | the network plan of necessary medical information | 26 | | related to such care; and |
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| 1 | | (C) the provider otherwise adheres to the network | 2 | | plan's policies and procedures, including, but not | 3 | | limited to, procedures regarding referrals and | 4 | | obtaining preauthorization for treatment. | 5 | | (3) The provisions of this Section governing health | 6 | | care provided during the transition period do not apply if | 7 | | the beneficiary has successfully transitioned to another | 8 | | provider participating in the network plan, if the | 9 | | beneficiary has already met or exceeded the benefit | 10 | | limitations of the plan, or if the care provided is not | 11 | | medically necessary. | 12 | | (c) In no event shall this Section be construed to require | 13 | | a network plan to provide coverage for benefits not otherwise | 14 | | covered or to diminish or impair preexisting condition | 15 | | limitations contained in the beneficiary's contract. | 16 | | Section 25. Network transparency. | 17 | | (a) A network plan shall post electronically an up-to-date, | 18 | | accurate, and complete provider directory for each of its | 19 | | network plans, with the information and search functions, as | 20 | | described in this Section. | 21 | | (1) In making the directory available electronically, | 22 | | the network plans shall ensure that the general public is | 23 | | able to view all of the current providers for a plan | 24 | | through a clearly identifiable link or tab and without | 25 | | creating or accessing an account or entering a policy or |
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| 1 | | contract number. | 2 | | (2) The network plan shall update the online provider | 3 | | directory at least monthly. Providers shall notify the | 4 | | network plan electronically or in writing of any changes to | 5 | | their information as listed in the provider directory. The | 6 | | network plan shall update its online provider directory in | 7 | | a manner consistent with the information provided by the | 8 | | provider within 10 business days after being notified of | 9 | | the change by the provider. Nothing in this paragraph (2) | 10 | | shall void any contractual relationship between the | 11 | | provider and the plan. | 12 | | (3) The network plan shall audit periodically at least | 13 | | 25% of its provider directories for accuracy, make any | 14 | | corrections necessary, and retain documentation of the | 15 | | audit. The network plan shall submit the audit to the | 16 | | Director upon request. As part of these audits, the network | 17 | | plan shall contact any provider in its network that has not | 18 | | submitted a claim to the plan or otherwise communicated his | 19 | | or her intent to continue participation in the plan's | 20 | | network. | 21 | | (4) A network plan shall provide a print copy of a | 22 | | current provider directory or a print copy of the requested | 23 | | directory information upon request of a beneficiary or a | 24 | | prospective beneficiary. Print copies must be updated | 25 | | quarterly and an errata that reflects changes in the | 26 | | provider network must be updated quarterly. |
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| 1 | | (5) For each network plan, a network plan shall | 2 | | include, in plain language in both the electronic and print | 3 | | directory, the following general information: | 4 | | (A) in plain language, a description of the | 5 | | criteria the plan has used to build its provider | 6 | | network; | 7 | | (B) if applicable, in plain language, a | 8 | | description of the criteria the insurer or network plan | 9 | | has used to create tiered networks; | 10 | | (C) if applicable, in plain language, how the | 11 | | network plan designates the different provider tiers | 12 | | or levels in the network and identifies for each | 13 | | specific provider, hospital, or other type of facility | 14 | | in the network which tier each is placed, for example, | 15 | | by name, symbols, or grouping, in order for a | 16 | | beneficiary-covered person or a prospective | 17 | | beneficiary-covered person to be able to identify the | 18 | | provider tier; and | 19 | | (D) if applicable, a notation that authorization | 20 | | or referral may be required to access some providers. | 21 | | (6) A network plan shall make it clear for both its | 22 | | electronic and print directories what provider directory | 23 | | applies to which network plan, such as including the | 24 | | specific name of the network plan as marketed and issued in | 25 | | this State. The network plan shall include in both its | 26 | | electronic and print directories a customer service email |
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| 1 | | address and telephone number or electronic link that | 2 | | beneficiaries or the general public may use to notify the | 3 | | network plan of inaccurate provider directory information | 4 | | and contact information for the Department's Office of | 5 | | Consumer Health Insurance. | 6 | | (7) A provider directory, whether in electronic or | 7 | | print format, shall accommodate the communication needs of | 8 | | individuals with disabilities, and include a link to or | 9 | | information regarding available assistance for persons | 10 | | with limited English proficiency. | 11 | | (b) For each network plan, a network plan shall make | 12 | | available through an electronic provider directory the | 13 | | following information in a searchable format: | 14 | | (1) for health care professionals: | 15 | | (A) name; | 16 | | (B) gender; | 17 | | (C) participating office locations; | 18 | | (D) specialty, if applicable; | 19 | | (E) medical group affiliations, if applicable; | 20 | | (F) facility affiliations, if applicable; | 21 | | (G) participating facility affiliations, if | 22 | | applicable; | 23 | | (H) languages spoken other than English, if | 24 | | applicable; | 25 | | (I) whether accepting new patients; and | 26 | | (J) board certifications, if applicable. |
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| 1 | | (2) for hospitals: | 2 | | (A) hospital name; | 3 | | (B) hospital type (such as acute, rehabilitation, | 4 | | children's, or cancer); | 5 | | (C) participating hospital location; and | 6 | | (D) hospital accreditation status; and | 7 | | (3) for facilities, other than hospitals, by type: | 8 | | (A) facility name; | 9 | | (B) facility type; | 10 | | (C) types of services performed; and | 11 | | (D) participating facility location or locations. | 12 | | (c) For the electronic provider directories, for each | 13 | | network plan, a network plan shall make available all of the | 14 | | following information in addition to the searchable | 15 | | information required in this Section: | 16 | | (1) for health care professionals: | 17 | | (A) contact information; and | 18 | | (B) languages spoken other than English by | 19 | | clinical staff, if applicable; | 20 | | (2) for hospitals, telephone number; and | 21 | | (3) for facilities other than hospitals, telephone | 22 | | number. | 23 | | (d) The insurer or network plan shall make available in | 24 | | print, upon request, the following provider directory | 25 | | information for the applicable network plan: | 26 | | (1) for health care professionals: |
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| 1 | | (A) name; | 2 | | (B) contact information; | 3 | | (C) participating office location or locations; | 4 | | (D) specialty, if applicable; | 5 | | (E) languages spoken other than English, if | 6 | | applicable; and | 7 | | (F) whether accepting new patients. | 8 | | (2) for hospitals: | 9 | | (A) hospital name; | 10 | | (B) hospital type (such as acute, rehabilitation, | 11 | | children's, or cancer); and | 12 | | (C) participating hospital location and telephone | 13 | | number; and | 14 | | (3) for facilities, other than hospitals, by type: | 15 | | (A) facility name; | 16 | | (B) facility type; | 17 | | (C) types of services performed; and | 18 | | (D) participating facility location or locations | 19 | | and telephone numbers. | 20 | | (e) The network plan shall include a disclosure in the | 21 | | print format provider directory that the information included | 22 | | in the directory is accurate as of the date of printing and | 23 | | that beneficiaries or prospective beneficiaries should consult | 24 | | the insurer's electronic provider directory on its website and | 25 | | contact the provider. The network plan shall also include a | 26 | | telephone number in the print format provider directory for a |
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| 1 | | customer service representative where the beneficiary can | 2 | | obtain current provider directory information. | 3 | | (f) The Director may conduct periodic audits of the | 4 | | accuracy of provider directories. | 5 | | Section 30. Facility nonparticipating provider | 6 | | transparency. Prior to providing a non-emergency outpatient | 7 | | procedure to a beneficiary in an in-network facility or during | 8 | | the admission or as soon as practicable thereafter, the | 9 | | hospital must provide an insured patient with written notice | 10 | | that: | 11 | | (1) the patient may receive separate bills for services | 12 | | provided by health care professionals affiliated with the | 13 | | hospital; | 14 | | (2) if applicable, some hospital staff members may not | 15 | | be participating providers in the same insurance plans and | 16 | | networks as the hospital; | 17 | | (3) if applicable, the patient may have a greater | 18 | | financial responsibility for services provided by health | 19 | | care professionals at the hospital who are not under | 20 | | contract with the patient's health care plan; and | 21 | | (4) questions about coverage or benefit levels should | 22 | | be directed to the patient's health care plan and the | 23 | | patient's certificate of coverage. | 24 | | Section 35. Administration and enforcement.
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| 1 | | (a) Insurers, as defined in this Act, have a continuing | 2 | | obligation to comply with the requirements of this Act. Other | 3 | | than the duties specifically created in this Act, nothing in | 4 | | this Act is intended to preclude, prevent, or require the | 5 | | adoption, modification, or termination of any utilization | 6 | | management, quality management, or claims processing | 7 | | methodologies of an insurer. | 8 | | (b) Nothing in this Act precludes, prevents, or requires | 9 | | the adoption, modification, or termination of any network plan | 10 | | term, benefit, coverage or eligibility provision, or payment | 11 | | methodology. | 12 | | (c) The Director shall enforce the provisions of this Act | 13 | | pursuant to the enforcement powers granted to it by law. | 14 | | (d) The Department shall adopt rules to enforce compliance | 15 | | with this Act to the extent necessary.
| 16 | | Section 99. Effective date. This Act takes effect upon | 17 | | becoming law.
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