Full Text of SB2641 103rd General Assembly
SB2641sam001 103RD GENERAL ASSEMBLY | Sen. Linda Holmes Filed: 4/4/2024 | | 10300SB2641sam001 | | LRB103 35049 RPS 71671 a |
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| 1 | | AMENDMENT TO SENATE BILL 2641
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 2641 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 Section 10 as follows: | 6 | | (215 ILCS 124/10) | 7 | | Sec. 10. Network adequacy. | 8 | | (a) An insurer providing a network plan shall file a | 9 | | description of all of the following with the Director: | 10 | | (1) The written policies and procedures for adding | 11 | | providers to meet patient needs based on increases in the | 12 | | number of beneficiaries, changes in the | 13 | | patient-to-provider ratio, changes in medical and health | 14 | | care capabilities, and increased demand for services. | 15 | | (2) The written policies and procedures for making | 16 | | referrals within and outside the network. |
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| 1 | | (3) The written policies and procedures on how the | 2 | | network plan will provide 24-hour, 7-day per week access | 3 | | to network-affiliated primary care, emergency services, | 4 | | and women's principal health care providers. | 5 | | (4) The process for monitoring health plan | 6 | | beneficiaries' timely in-network access to physician | 7 | | specialist services. | 8 | | An insurer shall not prohibit a preferred provider from | 9 | | discussing any specific or all treatment options with | 10 | | beneficiaries irrespective of the insurer's position on those | 11 | | treatment options or from advocating on behalf of | 12 | | beneficiaries within the utilization review, grievance, or | 13 | | appeals processes established by the insurer in accordance | 14 | | with any rights or remedies available under applicable State | 15 | | or federal law. | 16 | | (a-5) An insurer providing a network plan shall file an | 17 | | insurer's monitoring report for each network hospital and | 18 | | facility, which shall include, but is not limited to, the | 19 | | number and percentage of physician providers under contract in | 20 | | each of the specialties of emergency medicine, anesthesiology, | 21 | | radiology, and pathology practicing in the in-network hospital | 22 | | or facility when such providers are not employees of the | 23 | | hospital or facility. The insurer's monitoring report must be | 24 | | included in an effort to ensure that plan beneficiaries have | 25 | | reasonable and timely in-network access to physician | 26 | | specialist providers at in-network hospitals and facilities. |
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| 1 | | (b) Insurers must file for review a description of the | 2 | | services to be offered through a network plan. The description | 3 | | shall include all of the following: | 4 | | (1) A geographic map of the area proposed to be served | 5 | | by the plan by county service area and zip code, including | 6 | | marked locations for preferred providers. | 7 | | (2) As deemed necessary by the Department, the names, | 8 | | addresses, phone numbers, and specialties of the providers | 9 | | who have entered into preferred provider agreements under | 10 | | the network plan. | 11 | | (3) The number of beneficiaries anticipated to be | 12 | | covered by the network plan. | 13 | | (4) An Internet website and toll-free telephone number | 14 | | for beneficiaries and prospective beneficiaries to access | 15 | | current and accurate lists of preferred providers, | 16 | | additional information about the plan, as well as any | 17 | | other information required by Department rule. | 18 | | (5) A description of how health care services to be | 19 | | rendered under the network plan are reasonably accessible | 20 | | and available to beneficiaries. The description shall | 21 | | address all of the following: | 22 | | (A) the type of health care services to be | 23 | | provided by the network plan; | 24 | | (B) the ratio of physicians and other providers to | 25 | | beneficiaries, by specialty and including primary care | 26 | | physicians and facility-based physicians when |
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| 1 | | applicable under the contract, necessary to meet the | 2 | | health care needs and service demands of the currently | 3 | | enrolled population; | 4 | | (C) the travel and distance standards for plan | 5 | | beneficiaries in county service areas; and | 6 | | (D) a description of how the use of telemedicine, | 7 | | telehealth, or mobile care services may be used to | 8 | | partially meet the network adequacy standards, if | 9 | | applicable. | 10 | | (6) A provision ensuring that whenever a beneficiary | 11 | | has made a good faith effort, as evidenced by accessing | 12 | | the provider directory, calling the network plan, and | 13 | | calling the provider, to utilize preferred providers for a | 14 | | covered service and it is determined the insurer does not | 15 | | have the appropriate preferred providers due to | 16 | | insufficient number, type, unreasonable travel distance or | 17 | | delay, or preferred providers refusing to provide a | 18 | | covered service because it is contrary to the conscience | 19 | | of the preferred providers, as protected by the Health | 20 | | Care Right of Conscience Act, the insurer shall ensure, | 21 | | directly or indirectly, by terms contained in the payer | 22 | | contract, that the beneficiary will be provided the | 23 | | covered service at no greater cost to the beneficiary than | 24 | | if the service had been provided by a preferred provider. | 25 | | This paragraph (6) does not apply to: (A) a beneficiary | 26 | | who willfully chooses to access a non-preferred provider |
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| 1 | | for health care services available through the panel of | 2 | | preferred providers, or (B) a beneficiary enrolled in a | 3 | | health maintenance organization. In these circumstances, | 4 | | the contractual requirements for non-preferred provider | 5 | | reimbursements shall apply unless Section 356z.3a of the | 6 | | Illinois Insurance Code requires otherwise. In no event | 7 | | shall a beneficiary who receives care at a participating | 8 | | health care facility be required to search for | 9 | | participating providers under the circumstances described | 10 | | in subsection (b) or (b-5) of Section 356z.3a of the | 11 | | Illinois Insurance Code except under the circumstances | 12 | | described in paragraph (2) of subsection (b-5). | 13 | | (7) A provision that the beneficiary shall receive | 14 | | emergency care coverage such that payment for this | 15 | | coverage is not dependent upon whether the emergency | 16 | | services are performed by a preferred or non-preferred | 17 | | provider and the coverage shall be at the same benefit | 18 | | level as if the service or treatment had been rendered by a | 19 | | preferred provider. For purposes of this paragraph (7), | 20 | | "the same benefit level" means that the beneficiary is | 21 | | provided the covered service at no greater cost to the | 22 | | beneficiary than if the service had been provided by a | 23 | | preferred provider. This provision shall be consistent | 24 | | with Section 356z.3a of the Illinois Insurance Code. | 25 | | (8) A limitation that, if the plan provides that the | 26 | | beneficiary will incur a penalty for failing to |
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| 1 | | pre-certify inpatient hospital treatment, the penalty may | 2 | | not exceed $1,000 per occurrence in addition to the plan | 3 | | cost sharing provisions. | 4 | | (c) The network plan shall demonstrate to the Director a | 5 | | minimum ratio of providers to plan beneficiaries as required | 6 | | by the Department. | 7 | | (1) The ratio of physicians or other providers to plan | 8 | | beneficiaries shall be established annually by the | 9 | | Department in consultation with the Department of Public | 10 | | Health based upon the guidance from the federal Centers | 11 | | for Medicare and Medicaid Services. The Department shall | 12 | | not establish ratios for vision or dental providers who | 13 | | provide services under dental-specific or vision-specific | 14 | | benefits. The Department shall consider establishing | 15 | | ratios for the following physicians or other providers: | 16 | | (A) Primary Care; | 17 | | (B) Pediatrics; | 18 | | (C) Cardiology; | 19 | | (D) Gastroenterology; | 20 | | (E) General Surgery; | 21 | | (F) Neurology; | 22 | | (G) OB/GYN; | 23 | | (H) Oncology/Radiation; | 24 | | (I) Ophthalmology; | 25 | | (J) Urology; | 26 | | (K) Behavioral Health; |
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| 1 | | (L) Allergy/Immunology; | 2 | | (M) Chiropractic; | 3 | | (N) Dermatology; | 4 | | (O) Endocrinology; | 5 | | (P) Ears, Nose, and Throat (ENT)/Otolaryngology; | 6 | | (Q) Infectious Disease; | 7 | | (R) Nephrology; | 8 | | (S) Neurosurgery; | 9 | | (T) Orthopedic Surgery; | 10 | | (U) Physiatry/Rehabilitative; | 11 | | (V) Plastic Surgery; | 12 | | (W) Pulmonary; | 13 | | (X) Rheumatology; | 14 | | (Y) Anesthesiology; | 15 | | (Z) Pain Medicine; | 16 | | (AA) Pediatric Specialty Services; | 17 | | (BB) Outpatient Dialysis; and | 18 | | (CC) HIV. | 19 | | (2) The Director shall establish a process for the | 20 | | review of the adequacy of these standards, along with an | 21 | | assessment of additional specialties to be included in the | 22 | | list under this subsection (c). | 23 | | (d) The network plan shall demonstrate to the Director | 24 | | maximum travel and distance standards for plan beneficiaries, | 25 | | which shall be established annually by the Department in | 26 | | consultation with the Department of Public Health based upon |
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| 1 | | the guidance from the federal Centers for Medicare and | 2 | | Medicaid Services. These standards shall consist of the | 3 | | maximum minutes or miles to be traveled by a plan beneficiary | 4 | | for each county type, such as large counties, metro counties, | 5 | | or rural counties as defined by Department rule. | 6 | | The maximum travel time and distance standards must | 7 | | include standards for each physician and other provider | 8 | | category listed for which ratios have been established. | 9 | | The Director shall establish a process for the review of | 10 | | the adequacy of these standards along with an assessment of | 11 | | additional specialties to be included in the list under this | 12 | | subsection (d). | 13 | | (d-5)(1) Every insurer shall ensure that beneficiaries | 14 | | have timely and proximate access to treatment for mental, | 15 | | emotional, nervous, or substance use disorders or conditions | 16 | | in accordance with the provisions of paragraph (4) of | 17 | | subsection (a) of Section 370c of the Illinois Insurance Code. | 18 | | Insurers shall use a comparable process, strategy, evidentiary | 19 | | standard, and other factors in the development and application | 20 | | of the network adequacy standards for timely and proximate | 21 | | access to treatment for mental, emotional, nervous, or | 22 | | substance use disorders or conditions and those for the access | 23 | | to treatment for medical and surgical conditions. As such, the | 24 | | network adequacy standards for timely and proximate access | 25 | | shall equally be applied to treatment facilities and providers | 26 | | for mental, emotional, nervous, or substance use disorders or |
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| 1 | | conditions and specialists providing medical or surgical | 2 | | benefits pursuant to the parity requirements of Section 370c.1 | 3 | | of the Illinois Insurance Code and the federal Paul Wellstone | 4 | | and Pete Domenici Mental Health Parity and Addiction Equity | 5 | | Act of 2008. Notwithstanding the foregoing, the network | 6 | | adequacy standards for timely and proximate access to | 7 | | treatment for mental, emotional, nervous, or substance use | 8 | | disorders or conditions shall, at a minimum, satisfy the | 9 | | following requirements: | 10 | | (A) For beneficiaries residing in the metropolitan | 11 | | counties of Cook, DuPage, Kane, Lake, McHenry, and Will, | 12 | | network adequacy standards for timely and proximate access | 13 | | to treatment for mental, emotional, nervous, or substance | 14 | | use disorders or conditions means a beneficiary shall not | 15 | | have to travel longer than 30 minutes or 30 miles from the | 16 | | beneficiary's residence to receive outpatient treatment | 17 | | for mental, emotional, nervous, or substance use disorders | 18 | | or conditions. Beneficiaries shall not be required to wait | 19 | | longer than 10 business days between requesting an initial | 20 | | appointment and being seen by the facility or provider of | 21 | | mental, emotional, nervous, or substance use disorders or | 22 | | conditions for outpatient treatment or to wait longer than | 23 | | 20 business days between requesting a repeat or follow-up | 24 | | appointment and being seen by the facility or provider of | 25 | | mental, emotional, nervous, or substance use disorders or | 26 | | conditions for outpatient treatment; however, subject to |
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| 1 | | the protections of paragraph (3) of this subsection, a | 2 | | network plan shall not be held responsible if the | 3 | | beneficiary or provider voluntarily chooses to schedule an | 4 | | appointment outside of these required time frames. | 5 | | (B) For beneficiaries residing in Illinois counties | 6 | | other than those counties listed in subparagraph (A) of | 7 | | this paragraph, network adequacy standards for timely and | 8 | | proximate access to treatment for mental, emotional, | 9 | | nervous, or substance use disorders or conditions means a | 10 | | beneficiary shall not have to travel longer than 60 | 11 | | minutes or 60 miles from the beneficiary's residence to | 12 | | receive outpatient treatment for mental, emotional, | 13 | | nervous, or substance use disorders or conditions. | 14 | | Beneficiaries shall not be required to wait longer than 10 | 15 | | business days between requesting an initial appointment | 16 | | and being seen by the facility or provider of mental, | 17 | | emotional, nervous, or substance use disorders or | 18 | | conditions for outpatient treatment or to wait longer than | 19 | | 20 business days between requesting a repeat or follow-up | 20 | | appointment and being seen by the facility or provider of | 21 | | mental, emotional, nervous, or substance use disorders or | 22 | | conditions for outpatient treatment; however, subject to | 23 | | the protections of paragraph (3) of this subsection, a | 24 | | network plan shall not be held responsible if the | 25 | | beneficiary or provider voluntarily chooses to schedule an | 26 | | appointment outside of these required time frames. |
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| 1 | | (1.5) Every insurer shall demonstrate to the Director that | 2 | | each in-network hospital and facility has a sufficient number | 3 | | of hospital-based medical specialists to ensure that covered | 4 | | persons have reasonable and timely access to such in-network | 5 | | physicians and the services they direct or supervise. As used | 6 | | in this subsection, "hospital-based medical specialists" means | 7 | | physicians working in specialties that are usually located at | 8 | | in-network hospitals and facilities, including, but not | 9 | | limited to, radiologists, pathologists, anesthesiologists, and | 10 | | emergency room physicians. | 11 | | (2) For beneficiaries residing in all Illinois counties, | 12 | | network adequacy standards for timely and proximate access to | 13 | | treatment for mental, emotional, nervous, or substance use | 14 | | disorders or conditions means a beneficiary shall not have to | 15 | | travel longer than 60 minutes or 60 miles from the | 16 | | beneficiary's residence to receive inpatient or residential | 17 | | treatment for mental, emotional, nervous, or substance use | 18 | | disorders or conditions. | 19 | | (3) If there is no in-network facility or provider | 20 | | available for a beneficiary to receive timely and proximate | 21 | | access to treatment for mental, emotional, nervous, or | 22 | | substance use disorders or conditions in accordance with the | 23 | | network adequacy standards outlined in this subsection, the | 24 | | insurer shall provide necessary exceptions to its network to | 25 | | ensure admission and treatment with a provider or at a | 26 | | treatment facility in accordance with the network adequacy |
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| 1 | | standards in this subsection. | 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 may consider use of other health care | 6 | | service delivery options, such as telemedicine or telehealth, | 7 | | mobile clinics, and centers of excellence, or other ways of | 8 | | delivering care to partially meet the requirements set under | 9 | | this Section. | 10 | | (g) Except for the requirements set forth in subsection | 11 | | (d-5), insurers who are not able to comply with the provider | 12 | | ratios and time and distance standards established by the | 13 | | Department may request an exception to these requirements from | 14 | | the Department. The Department may grant an exception in the | 15 | | following circumstances: | 16 | | (1) if no providers or facilities meet the specific | 17 | | time and distance standard in a specific service area and | 18 | | the insurer (i) discloses information on the distance and | 19 | | travel time points that beneficiaries would have to travel | 20 | | beyond the required criterion to reach the next closest | 21 | | contracted provider outside of the service area and (ii) | 22 | | provides contact information, including names, addresses, | 23 | | and phone numbers for the next closest contracted provider | 24 | | or facility; | 25 | | (2) if patterns of care in the service area do not | 26 | | support the need for the requested number of provider or |
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| 1 | | facility type and the insurer provides data on local | 2 | | patterns of care, such as claims data, referral patterns, | 3 | | or local provider interviews, indicating where the | 4 | | beneficiaries currently seek this type of care or where | 5 | | the physicians currently refer beneficiaries, or both; or | 6 | | (3) other circumstances deemed appropriate by the | 7 | | Department consistent with the requirements of this Act. | 8 | | (h) Insurers are required to report to the Director any | 9 | | material change to an approved network plan within 15 days | 10 | | after the change occurs and any change that would result in | 11 | | failure to meet the requirements of this Act. Upon notice from | 12 | | the insurer, the Director shall reevaluate the network plan's | 13 | | compliance with the network adequacy and transparency | 14 | | standards of this Act. | 15 | | (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; | 16 | | 102-1117, eff. 1-13-23.)". |
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