Full Text of SB0332 102nd General Assembly
SB0332sam001 102ND GENERAL ASSEMBLY | Sen. Jacqueline Y. Collins Filed: 4/9/2021
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| 1 | | AMENDMENT TO SENATE BILL 332
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 332 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Network Adequacy and Transparency Act is | 5 | | amended by changing Sections 5 and 25 as follows: | 6 | | (215 ILCS 124/5)
| 7 | | Sec. 5. Definitions. In this Act: | 8 | | "Authorized representative" means a person to whom a | 9 | | beneficiary has given express written consent to represent the | 10 | | beneficiary; a person authorized by law to provide substituted | 11 | | consent for a beneficiary; or the beneficiary's treating | 12 | | provider only when the beneficiary or his or her family member | 13 | | is unable to provide consent. | 14 | | "Beneficiary" means an individual, an enrollee, an | 15 | | insured, a participant, or any other person entitled to | 16 | | reimbursement for covered expenses of or the discounting of |
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| 1 | | provider fees for health care services under a program in | 2 | | which the beneficiary has an incentive to utilize the services | 3 | | of a provider that has entered into an agreement or | 4 | | arrangement with an insurer. | 5 | | "Department" means the Department of Insurance. | 6 | | "Director" means the Director of Insurance. | 7 | | "Family caregiver" means a relative, partner, friend, or | 8 | | neighbor who has a significant relationship with the patient | 9 | | and administers or assists them with activities of daily | 10 | | living, instrumental activities of daily living, or other | 11 | | medical or nursing tasks for the quality and welfare of that | 12 | | patient. | 13 | | "Insurer" means any entity that offers individual or group | 14 | | accident and health insurance, including, but not limited to, | 15 | | health maintenance organizations, preferred provider | 16 | | organizations, exclusive provider organizations, and other | 17 | | plan structures requiring network participation, excluding the | 18 | | medical assistance program under the Illinois Public Aid Code, | 19 | | the State employees group health insurance program, workers | 20 | | compensation insurance, and pharmacy benefit managers. | 21 | | "Material change" means a significant reduction in the | 22 | | number of providers available in a network plan, including, | 23 | | but not limited to, a reduction of 10% or more in a specific | 24 | | type of providers, the removal of a major health system that | 25 | | causes a network to be significantly different from the | 26 | | network when the beneficiary purchased the network plan, or |
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| 1 | | any change that would cause the network to no longer satisfy | 2 | | the requirements of this Act or the Department's rules for | 3 | | network adequacy and transparency. | 4 | | "Network" means the group or groups of preferred providers | 5 | | providing services to a network plan. | 6 | | "Network plan" means an individual or group policy of | 7 | | accident and health insurance that either requires a covered | 8 | | person to use or creates incentives, including financial | 9 | | incentives, for a covered person to use providers managed, | 10 | | owned, under contract with, or employed by the insurer. | 11 | | "Ongoing course of treatment" means (1) treatment for a | 12 | | life-threatening condition, which is a disease or condition | 13 | | for which likelihood of death is probable unless the course of | 14 | | the disease or condition is interrupted; (2) treatment for a | 15 | | serious acute condition, defined as a disease or condition | 16 | | requiring complex ongoing care that the covered person is | 17 | | currently receiving, such as chemotherapy, radiation therapy, | 18 | | or post-operative visits; (3) a course of treatment for a | 19 | | health condition that a treating provider attests that | 20 | | discontinuing care by that provider would worsen the condition | 21 | | or interfere with anticipated outcomes; or (4) the third | 22 | | trimester of pregnancy through the post-partum period. | 23 | | "Preferred provider" means any provider who has entered, | 24 | | either directly or indirectly, into an agreement with an | 25 | | employer or risk-bearing entity relating to health care | 26 | | services that may be rendered to beneficiaries under a network |
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| 1 | | plan. | 2 | | "Providers" means physicians licensed to practice medicine | 3 | | in all its branches, other health care professionals, | 4 | | hospitals, or other health care institutions that provide | 5 | | health care services. | 6 | | "Telehealth" has the meaning given to that term in Section | 7 | | 356z.22 of the Illinois Insurance Code. | 8 | | "Telemedicine" has the meaning given to that term in | 9 | | Section 49.5 of the Medical Practice Act of 1987. | 10 | | "Tiered network" means a network that identifies and | 11 | | groups some or all types of provider and facilities into | 12 | | specific groups to which different provider reimbursement, | 13 | | covered person cost-sharing or provider access requirements, | 14 | | or any combination thereof, apply for the same services. | 15 | | "Woman's principal health care provider" means a physician | 16 | | licensed to practice medicine in all of its branches | 17 | | specializing in obstetrics, gynecology, or family practice.
| 18 | | (Source: P.A. 100-502, eff. 9-15-17.) | 19 | | (215 ILCS 124/25)
| 20 | | Sec. 25. Network transparency. | 21 | | (a) A network plan shall post electronically an | 22 | | up-to-date, accurate, and complete provider directory for each | 23 | | of its network plans, with the information and search | 24 | | functions, as described in this Section. | 25 | | (1) In making the directory available electronically, |
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| 1 | | the network plans shall ensure that the general public is | 2 | | able to view all of the current providers for a plan | 3 | | through a clearly identifiable link or tab and without | 4 | | creating or accessing an account or entering a policy or | 5 | | contract number. | 6 | | (2) The network plan shall update the online provider | 7 | | directory at least monthly. Providers shall notify the | 8 | | network plan electronically or in writing of any changes | 9 | | to their information as listed in the provider directory , | 10 | | including the information required in subparagraph (K) of | 11 | | paragraph (1) of subsection (b) . The network plan shall | 12 | | update its online provider directory in a manner | 13 | | consistent with the information provided by the provider | 14 | | within 10 business days after being notified of the change | 15 | | by the provider. Nothing in this paragraph (2) shall void | 16 | | any contractual relationship between the provider and the | 17 | | plan. | 18 | | (3) The network plan shall audit periodically at least | 19 | | 25% of its provider directories for accuracy, make any | 20 | | corrections necessary, and retain documentation of the | 21 | | audit. The network plan shall submit the audit to the | 22 | | Director upon request. As part of these audits, the | 23 | | network plan shall contact any provider in its network | 24 | | that has not submitted a claim to the plan or otherwise | 25 | | communicated his or her intent to continue participation | 26 | | in the plan's network. |
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| 1 | | (4) A network plan shall provide a print copy of a | 2 | | current provider directory or a print copy of the | 3 | | requested directory information upon request of a | 4 | | beneficiary or a prospective beneficiary. Print copies | 5 | | must be updated quarterly and an errata that reflects | 6 | | changes in the provider network must be updated quarterly. | 7 | | (5) For each network plan, a network plan shall | 8 | | include, in plain language in both the electronic and | 9 | | print directory, the following general information: | 10 | | (A) in plain language, a description of the | 11 | | criteria the plan has used to build its provider | 12 | | network; | 13 | | (B) if applicable, in plain language, a | 14 | | description of the criteria the insurer or network | 15 | | plan has used to create tiered networks; | 16 | | (C) if applicable, in plain language, how the | 17 | | network plan designates the different provider tiers | 18 | | or levels in the network and identifies for each | 19 | | specific provider, hospital, or other type of facility | 20 | | in the network which tier each is placed, for example, | 21 | | by name, symbols, or grouping, in order for a | 22 | | beneficiary-covered person or a prospective | 23 | | beneficiary-covered person to be able to identify the | 24 | | provider tier; and | 25 | | (D) if applicable, a notation that authorization | 26 | | or referral may be required to access some providers. |
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| 1 | | (6) A network plan shall make it clear for both its | 2 | | electronic and print directories what provider directory | 3 | | applies to which network plan, such as including the | 4 | | specific name of the network plan as marketed and issued | 5 | | in this State. The network plan shall include in both its | 6 | | electronic and print directories a customer service email | 7 | | address and telephone number or electronic link that | 8 | | beneficiaries or the general public may use to notify the | 9 | | network plan of inaccurate provider directory information | 10 | | and contact information for the Department's Office of | 11 | | Consumer Health Insurance. | 12 | | (7) A provider directory, whether in electronic or | 13 | | print format, shall accommodate the communication needs of | 14 | | individuals with disabilities, and include a link to or | 15 | | information regarding available assistance for persons | 16 | | with limited English proficiency. | 17 | | (b) For each network plan, a network plan shall make | 18 | | available through an electronic provider directory the | 19 | | following information in a searchable format: | 20 | | (1) for health care professionals: | 21 | | (A) name; | 22 | | (B) gender; | 23 | | (C) participating office locations; | 24 | | (D) specialty, if applicable; | 25 | | (E) medical group affiliations, if applicable; | 26 | | (F) facility affiliations, if applicable; |
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| 1 | | (G) participating facility affiliations, if | 2 | | applicable; | 3 | | (H) languages spoken other than English, if | 4 | | applicable; | 5 | | (I) whether accepting new patients; and | 6 | | (J) board certifications, if applicable ; and . | 7 | | (K) use of telehealth or telemedicine, including, | 8 | | but not limited to: | 9 | | (i) whether the provider offers the use of | 10 | | telehealth or telemedicine to deliver services to | 11 | | patients for whom it would be clinically | 12 | | appropriate; | 13 | | (ii) what modalities are used and what types | 14 | | of services may be provided via telehealth or | 15 | | telemedicine; and | 16 | | (iii) whether the provider has the ability and | 17 | | willingness to include in a telehealth or | 18 | | telemedicine encounter a family caregiver who is | 19 | | in a separate location than the patient if the | 20 | | patient wishes and provides his or her consent; | 21 | | (2) for hospitals: | 22 | | (A) hospital name; | 23 | | (B) hospital type (such as acute, rehabilitation, | 24 | | children's, or cancer); | 25 | | (C) participating hospital location; and | 26 | | (D) hospital accreditation status; and |
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| 1 | | (3) for facilities, other than hospitals, by type: | 2 | | (A) facility name; | 3 | | (B) facility type; | 4 | | (C) types of services performed; and | 5 | | (D) participating facility location or locations. | 6 | | (c) For the electronic provider directories, for each | 7 | | network plan, a network plan shall make available all of the | 8 | | following information in addition to the searchable | 9 | | information required in this Section: | 10 | | (1) for health care professionals: | 11 | | (A) contact information; and | 12 | | (B) languages spoken other than English by | 13 | | clinical staff, if applicable; | 14 | | (2) for hospitals, telephone number; and | 15 | | (3) for facilities other than hospitals, telephone | 16 | | number. | 17 | | (d) The insurer or network plan shall make available in | 18 | | print, upon request, the following provider directory | 19 | | information for the applicable network plan: | 20 | | (1) for health care professionals: | 21 | | (A) name; | 22 | | (B) contact information; | 23 | | (C) participating office location or locations; | 24 | | (D) specialty, if applicable; | 25 | | (E) languages spoken other than English, if | 26 | | applicable; and |
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| 1 | | (F) whether accepting new patients ; and . | 2 | | (G) 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); and | 20 | | (C) participating hospital location and telephone | 21 | | number; 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 |
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| 1 | | and telephone numbers. | 2 | | (e) The network plan shall include a disclosure in the | 3 | | print format provider directory that the information included | 4 | | in the directory is accurate as of the date of printing and | 5 | | that beneficiaries or prospective beneficiaries should consult | 6 | | the insurer's electronic provider directory on its website and | 7 | | contact the provider. The network plan shall also include a | 8 | | telephone number in the print format provider directory for a | 9 | | customer service representative where the beneficiary can | 10 | | obtain current provider directory information. | 11 | | (f) The Director may conduct periodic audits of the | 12 | | accuracy of provider directories. A network plan shall not be | 13 | | subject to any fines or penalties for information required in | 14 | | this Section that a provider submits that is inaccurate or | 15 | | incomplete.
| 16 | | (Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
| 17 | | Section 99. Effective date. This Act takes effect upon | 18 | | becoming law.".
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