Full Text of SB3130 103rd General Assembly
SB3130sam002 103RD GENERAL ASSEMBLY | Sen. Ann Gillespie Filed: 3/12/2024 | | 10300SB3130sam002 | | LRB103 38249 RPS 70647 a |
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| 1 | | AMENDMENT TO SENATE BILL 3130
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 3130 by replacing | 3 | | everything after the enacting clause with the following: | 4 | | "Section 5. The Department of Insurance Law of the Civil | 5 | | Administrative Code of Illinois is amended by changing Section | 6 | | 1405-50 as follows: | 7 | | (20 ILCS 1405/1405-50) | 8 | | Sec. 1405-50. Marketplace Director of the Illinois Health | 9 | | Benefits Exchange. The Governor shall appoint, with the advice | 10 | | and consent of the Senate, a person within the Department of | 11 | | Insurance to serve as the Marketplace Director of the Illinois | 12 | | Health Benefits Exchange. The Marketplace Director shall serve | 13 | | for a term of 2 years, and until a successor is appointed and | 14 | | qualified; except that the term of the first Marketplace | 15 | | Director appointed under this Law shall expire on the third | 16 | | Monday in January 2027. The Marketplace Director may serve for |
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| 1 | | more than one term. The Governor may make a temporary | 2 | | appointment until the next meeting of the Senate. This person | 3 | | may be an existing employee with other duties. The Marketplace | 4 | | Director shall receive an annual salary as set by the Governor | 5 | | and shall be paid out of the appropriations to the Department. | 6 | | The Marketplace Director shall not be subject to the Personnel | 7 | | Code. The Marketplace Director, under the direction of the | 8 | | Director, shall manage the operations and staff of the | 9 | | Illinois Health Benefits Exchange to ensure optimal exchange | 10 | | performance. | 11 | | (Source: P.A. 103-103, eff. 6-27-23.) | 12 | | Section 10. The Illinois Insurance Code is amended by | 13 | | adding Section 356z.40a as follows: | 14 | | (215 ILCS 5/356z.40a new) | 15 | | Sec. 356z.40a. Pregnancy as a qualifying life event for | 16 | | qualified health plans. Beginning with the operation of a | 17 | | State-based exchange in plan year 2026, a pregnant individual | 18 | | has the right to enroll in a qualified health plan through a | 19 | | special enrollment period within 60 days after any qualified | 20 | | health care professional, including a licensed certified | 21 | | professional midwife, licensed or certified under the laws of | 22 | | this State or any other state to provide pregnancy-related | 23 | | health care services certifies that the individual is | 24 | | pregnant. Upon enrollment, coverage shall be effective on and |
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| 1 | | after the first day of the month in which the qualified health | 2 | | care professional certifies that the individual is pregnant, | 3 | | unless the individual elects to have coverage effective on the | 4 | | first day of the month following the date that the individual | 5 | | received certification of the pregnancy. | 6 | | Section 15. The Illinois Health Insurance Portability and | 7 | | Accountability Act is amended by changing Sections 30, 50, and | 8 | | 60 as follows: | 9 | | (215 ILCS 97/30) | 10 | | Sec. 30. Guaranteed renewability of coverage for employers | 11 | | in the group market. | 12 | | (A) In general. Except as provided in this Section, if a | 13 | | health insurance issuer offers health insurance coverage in | 14 | | the small or large group market in connection with a group | 15 | | health plan, the issuer must renew or continue in force such | 16 | | coverage at the option of the plan sponsor of the plan. | 17 | | (B) General exceptions. A health insurance issuer may | 18 | | nonrenew or discontinue health insurance coverage offered in | 19 | | connection with a group health plan in the small or large group | 20 | | market based only on one or more of the following: | 21 | | (1) Nonpayment of premiums. The plan sponsor has | 22 | | failed to pay premiums or contributions in accordance with | 23 | | the terms of the health insurance coverage or the issuer | 24 | | has not received timely premium payments. |
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| 1 | | (2) Fraud. The plan sponsor has performed an act or | 2 | | practice that constitutes fraud or made an intentional | 3 | | misrepresentation of material fact under the terms of the | 4 | | coverage. | 5 | | (3) Violation of participation or contribution rules. | 6 | | The plan sponsor has failed to comply with a material plan | 7 | | provision relating to employer contribution or group | 8 | | participation rules, as permitted under Section 40(D) in | 9 | | the case of the small group market or pursuant to | 10 | | applicable State law in the case of the large group | 11 | | market. | 12 | | (4) Termination of coverage. The issuer is ceasing to | 13 | | offer coverage in such market in accordance with | 14 | | subsection (C) and applicable State law. | 15 | | (5) Movement outside service area. In the case of a | 16 | | health insurance issuer that offers health insurance | 17 | | coverage in the market through a network plan, there is no | 18 | | longer any enrollee in connection with such plan who | 19 | | lives, resides, or works in the service area of the issuer | 20 | | (or in the area for which the issuer is authorized to do | 21 | | business) and, in the case of the small group market, the | 22 | | issuer would deny enrollment with respect to such plan | 23 | | under Section 40(C)(1)(a). | 24 | | (6) Association membership ceases. In the case of | 25 | | health insurance coverage that is made available in the | 26 | | small or large group market (as the case may be) only |
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| 1 | | through one or more bona fide association, the membership | 2 | | of an employer in the association (on the basis of which | 3 | | the coverage is provided) ceases but only if such coverage | 4 | | is terminated under this paragraph uniformly without | 5 | | regard to any health status-related factor relating to any | 6 | | covered individual. | 7 | | (C) Requirements for uniform termination of coverage. | 8 | | (1) Particular type of coverage not offered. In any | 9 | | case in which an issuer decides to discontinue offering a | 10 | | particular type of group health insurance coverage offered | 11 | | in the small or large group market, coverage of such type | 12 | | may be discontinued by the issuer in accordance with | 13 | | applicable State law in such market only if: | 14 | | (a) the issuer provides notice to each plan | 15 | | sponsor provided coverage of this type in such market | 16 | | (and participants and beneficiaries covered under such | 17 | | coverage) of such discontinuation at least 90 days | 18 | | prior to the date of the discontinuation of such | 19 | | coverage; | 20 | | (b) the issuer offers to each plan sponsor | 21 | | provided coverage of this type in such market, the | 22 | | option to purchase all (or, in the case of the large | 23 | | group market, any) other health insurance coverage | 24 | | currently being offered by the issuer to a group | 25 | | health plan in such market; and | 26 | | (c) in exercising the option to discontinue |
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| 1 | | coverage of this type and in offering the option of | 2 | | coverage under subparagraph (b), the issuer acts | 3 | | uniformly without regard to the claims experience of | 4 | | those sponsors or any health status-related factor | 5 | | relating to any participants or beneficiaries who may | 6 | | become eligible for such coverage. | 7 | | (2) Discontinuance of all coverage. | 8 | | (a) In general. In any case in which a health | 9 | | insurance issuer elects to discontinue offering all | 10 | | health insurance coverage in the small group market or | 11 | | the large group market, or both markets, in Illinois, | 12 | | health insurance coverage may be discontinued by the | 13 | | issuer only in accordance with Illinois law and if: | 14 | | (i) the issuer provides notice to the | 15 | | Department and to each plan sponsor (and | 16 | | participants and beneficiaries covered under such | 17 | | coverage) of such discontinuation at least 180 | 18 | | days prior to the date of the discontinuation of | 19 | | such coverage and to the Department as provided in | 20 | | Section 60 of this Act ; and | 21 | | (ii) all health insurance issued or delivered | 22 | | for issuance in Illinois in such market (or | 23 | | markets) are discontinued and coverage under such | 24 | | health insurance coverage in such market (or | 25 | | markets) is not renewed. | 26 | | (b) Prohibition on market reentry. In the case of |
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| 1 | | a discontinuation under subparagraph (a) in a market, | 2 | | the issuer may not provide for the issuance of any | 3 | | health insurance coverage in the Illinois market | 4 | | involved during the 5-year period beginning on the | 5 | | date of the discontinuation of the last health | 6 | | insurance coverage not so renewed. | 7 | | (D) Exception for uniform modification of coverage. At the | 8 | | time of coverage renewal, a health insurance issuer may modify | 9 | | the health insurance coverage for a product offered to a group | 10 | | health plan: | 11 | | (1) in the large group market; or | 12 | | (2) in the small group market if, for coverage that is | 13 | | available in such market other than only through one or | 14 | | more bona fide associations, such modification is | 15 | | consistent with State law and effective on a uniform basis | 16 | | among group health plans with that product. | 17 | | (E) Application to coverage offered only through | 18 | | associations. In applying this Section in the case of health | 19 | | insurance coverage that is made available by a health | 20 | | insurance issuer in the small or large group market to | 21 | | employers only through one or more associations, a reference | 22 | | to "plan sponsor" is deemed, with respect to coverage provided | 23 | | to an employer member of the association, to include a | 24 | | reference to such employer. | 25 | | (Source: P.A. 90-30, eff. 7-1-97.) |
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| 1 | | (215 ILCS 97/50) | 2 | | Sec. 50. Guaranteed renewability of individual health | 3 | | insurance coverage. | 4 | | (A) In general. Except as provided in this Section, a | 5 | | health insurance issuer that provides individual health | 6 | | insurance coverage to an individual shall renew or continue in | 7 | | force such coverage at the option of the individual. | 8 | | (B) General exceptions. A health insurance issuer may | 9 | | nonrenew or discontinue health insurance coverage of an | 10 | | individual in the individual market based only on one or more | 11 | | of the following: | 12 | | (1) Nonpayment of premiums. The individual has failed | 13 | | to pay premiums or contributions in accordance with the | 14 | | terms of the health insurance coverage or the issuer has | 15 | | not received timely premium payments. | 16 | | (2) Fraud. The individual has performed an act or | 17 | | practice that constitutes fraud or made an intentional | 18 | | misrepresentation of material fact under the terms of the | 19 | | coverage. | 20 | | (3) Termination of plan. The issuer is ceasing to | 21 | | offer coverage in the individual market in accordance with | 22 | | subsection (C) of this Section and applicable Illinois | 23 | | law. | 24 | | (4) Movement outside the service area. In the case of | 25 | | a health insurance issuer that offers health insurance | 26 | | coverage in the market through a network plan, the |
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| 1 | | individual no longer resides, lives, or works in the | 2 | | service area (or in an area for which the issuer is | 3 | | authorized to do business), but only if such coverage is | 4 | | terminated under this paragraph uniformly without regard | 5 | | to any health status-related factor of covered | 6 | | individuals. | 7 | | (5) Association membership ceases. In the case of | 8 | | health insurance coverage that is made available in the | 9 | | individual market only through one or more bona fide | 10 | | associations, the membership of the individual in the | 11 | | association (on the basis of which the coverage is | 12 | | provided) ceases, but only if such coverage is terminated | 13 | | under this paragraph uniformly without regard to any | 14 | | health status-related factor of covered individuals. | 15 | | (C) Requirements for uniform termination of coverage. | 16 | | (1) Particular type of coverage not offered. In any | 17 | | case in which an issuer decides to discontinue offering a | 18 | | particular type of health insurance coverage offered in | 19 | | the individual market, coverage of such type may be | 20 | | discontinued by the issuer only if: | 21 | | (a) the issuer provides notice to each covered | 22 | | individual provided coverage of this type in such | 23 | | market of such discontinuation at least 90 days prior | 24 | | to the date of the discontinuation of such coverage; | 25 | | (b) the issuer offers, to each individual in the | 26 | | individual market provided coverage of this type, the |
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| 1 | | option to purchase any other individual health | 2 | | insurance coverage currently being offered by the | 3 | | issuer for individuals in such market; and | 4 | | (c) in exercising the option to discontinue | 5 | | coverage of that type and in offering the option of | 6 | | coverage under subparagraph (b), the issuer acts | 7 | | uniformly without regard to any health status-related | 8 | | factor of enrolled individuals or individuals who may | 9 | | become eligible for such coverage. | 10 | | (2) Discontinuance of all coverage. | 11 | | (a) In general. Subject to subparagraph (c), in | 12 | | any case in which a health insurance issuer elects to | 13 | | discontinue offering all health insurance coverage in | 14 | | the individual market in Illinois, health insurance | 15 | | coverage may be discontinued by the issuer only if: | 16 | | (i) the issuer provides notice to the Director | 17 | | and to each individual of the discontinuation at | 18 | | least 180 days prior to the date of the expiration | 19 | | of such coverage and to the Director as provided | 20 | | in Section 60 of this Act ; | 21 | | (ii) all health insurance issued or delivered | 22 | | for issuance in Illinois in such market is | 23 | | discontinued and coverage under such health | 24 | | insurance coverage in such market is not renewed; | 25 | | and | 26 | | (iii) in the case where the issuer has |
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| 1 | | affiliates in the individual market, the issuer | 2 | | gives notice to each affected individual at least | 3 | | 180 days prior to the date of the expiration of the | 4 | | coverage of the individual's option to purchase | 5 | | all other individual health benefit plans | 6 | | currently offered by any affiliate of the carrier. | 7 | | (b) Prohibition on market reentry. In the case of | 8 | | a discontinuation under subparagraph (a) in the | 9 | | individual market, the issuer may not provide for the | 10 | | issuance of any health insurance coverage in Illinois | 11 | | involved during the 5-year period beginning on the | 12 | | date of the discontinuation of the last health | 13 | | insurance coverage not so renewed. | 14 | | (c) If an issuer elects to discontinue offering | 15 | | all health insurance coverage in the individual market | 16 | | under subparagraph (a), its affiliates that offer | 17 | | health insurance coverage in the individual market in | 18 | | Illinois shall offer individual health insurance | 19 | | coverage to all individuals who were covered by the | 20 | | discontinued health insurance coverage on the date of | 21 | | the notice provided to affected individuals under | 22 | | subdivision (iii) of subparagraph (a) of this item (2) | 23 | | if the individual applies for coverage no later than | 24 | | 63 days after the discontinuation of coverage. | 25 | | (d) Subject to subparagraph (e) of this item (2), | 26 | | an affiliate that issues coverage under subparagraph |
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| 1 | | (c) shall waive the preexisting condition exclusion | 2 | | period to the extent that the individual has satisfied | 3 | | the preexisting condition exclusion period under the | 4 | | individual's prior contract or policy. | 5 | | (e) An affiliate that issues coverage under | 6 | | subparagraph (c) may require the individual to satisfy | 7 | | the remaining part of the preexisting condition | 8 | | exclusion period, if any, under the individual's prior | 9 | | contract or policy that has not been satisfied, unless | 10 | | the coverage has a shorter preexisting condition | 11 | | exclusion period, and may include in any coverage | 12 | | issued under subparagraph (c) any waivers or | 13 | | limitations of coverage that were included in the | 14 | | individual's prior contract or policy. | 15 | | (D) Exception for uniform modification of coverage. At the | 16 | | time of coverage renewal, a health insurance issuer may modify | 17 | | the health insurance coverage for a policy form offered to | 18 | | individuals in the individual market so long as the | 19 | | modification is consistent with Illinois law and effective on | 20 | | a uniform basis among all individuals with that policy form. | 21 | | (E) Application to coverage offered only through | 22 | | associations. In applying this Section in the case of health | 23 | | insurance coverage that is made available by a health | 24 | | insurance issuer in the individual market to individuals only | 25 | | through one or more associations, a reference to an | 26 | | "individual" is deemed to include a reference to such an |
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| 1 | | association (of which the individual is a member). | 2 | | The changes to this Section made by this amendatory Act of | 3 | | the 94th General Assembly apply only to discontinuances of | 4 | | coverage occurring on or after the effective date of this | 5 | | amendatory Act of the 94th General Assembly. | 6 | | (Source: P.A. 94-502, eff. 8-8-05.) | 7 | | (215 ILCS 97/60) | 8 | | Sec. 60. Notice requirement. In any case where a health | 9 | | insurance issuer elects to uniformly modify coverage, | 10 | | uniformly terminate coverage, or discontinue coverage in a | 11 | | marketplace in accordance with Sections 30 and 50 of this Act, | 12 | | the issuer shall provide notice to the Department prior to | 13 | | notifying the plan sponsors, participants, beneficiaries, and | 14 | | covered individuals. The notice shall be sent by certified | 15 | | mail to the Department 45 90 days in advance of any | 16 | | notification of the company's actions sent to plan sponsors, | 17 | | participants, beneficiaries, and covered individuals. The | 18 | | notice shall include: (i) a complete description of the action | 19 | | to be taken, (ii) a specific description of the type of | 20 | | coverage affected, (iii) the total number of covered lives | 21 | | affected, (iv) a sample draft of all letters being sent to the | 22 | | plan sponsors, participants, beneficiaries, or covered | 23 | | individuals, (v) time frames for the actions being taken, (vi) | 24 | | options the plans sponsors, participants, beneficiaries, or | 25 | | covered individuals may have available to them under this Act, |
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| 1 | | and (vii) any other information as required by the Department. | 2 | | The Department may designate an email address or online | 3 | | platform to receive electronic notification in lieu of | 4 | | certified mail. | 5 | | This Section applies only to discontinuances of coverage | 6 | | occurring on or after the effective date of this amendatory | 7 | | Act of the 94th General Assembly. | 8 | | (Source: P.A. 94-502, eff. 8-8-05.) | 9 | | Section 20. The Network Adequacy and Transparency Act is | 10 | | amended by changing Sections 3, 5, 10, and 25 as follows: | 11 | | (215 ILCS 124/3) | 12 | | Sec. 3. Applicability of Act. This Act applies to an | 13 | | individual or group policy of accident and health insurance | 14 | | with a network plan amended, delivered, issued, or renewed in | 15 | | this State on or after January 1, 2019. This Act does not apply | 16 | | to an individual or group policy for excepted benefits or | 17 | | short-term, limited-duration health insurance coverage dental | 18 | | or vision insurance or a limited health service organization | 19 | | with a network plan amended, delivered, issued, or renewed in | 20 | | this State on or after January 1, 2019 , except to the extent | 21 | | that federal law establishes network adequacy and transparency | 22 | | standards for stand-alone dental plans, which the Department | 23 | | shall enforce . | 24 | | (Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.) |
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| 1 | | (215 ILCS 124/5) | 2 | | Sec. 5. Definitions. In this Act: | 3 | | "Authorized representative" means a person to whom a | 4 | | beneficiary has given express written consent to represent the | 5 | | beneficiary; a person authorized by law to provide substituted | 6 | | consent for a beneficiary; or the beneficiary's treating | 7 | | provider only when the beneficiary or his or her family member | 8 | | is unable to provide consent. | 9 | | "Beneficiary" means an individual, an enrollee, an | 10 | | insured, a participant, or any other person entitled to | 11 | | reimbursement for covered expenses of or the discounting of | 12 | | provider fees for health care services under a program in | 13 | | which the beneficiary has an incentive to utilize the services | 14 | | of a provider that has entered into an agreement or | 15 | | arrangement with an insurer. | 16 | | "Department" means the Department of Insurance. | 17 | | "Director" means the Director of Insurance. | 18 | | "Excepted benefits" has the meaning given to that term in | 19 | | 42 U.S.C. 300gg-91(c). | 20 | | "Family caregiver" means a relative, partner, friend, or | 21 | | neighbor who has a significant relationship with the patient | 22 | | and administers or assists the patient with activities of | 23 | | daily living, instrumental activities of daily living, or | 24 | | other medical or nursing tasks for the quality and welfare of | 25 | | that patient. |
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| 1 | | "Insurer" means any entity that offers individual or group | 2 | | accident and health insurance, including, but not limited to, | 3 | | health maintenance organizations, preferred provider | 4 | | organizations, exclusive provider organizations, and other | 5 | | plan structures requiring network participation, excluding the | 6 | | medical assistance program under the Illinois Public Aid Code, | 7 | | the State employees group health insurance program, workers | 8 | | compensation insurance, and pharmacy benefit managers. | 9 | | "Material change" means a significant reduction in the | 10 | | number of providers available in a network plan, including, | 11 | | but not limited to, a reduction of 10% or more in a specific | 12 | | type of providers, the removal of a major health system that | 13 | | causes a network to be significantly different from the | 14 | | network when the beneficiary purchased the network plan, or | 15 | | any change that would cause the network to no longer satisfy | 16 | | the requirements of this Act or the Department's rules for | 17 | | network adequacy and transparency. | 18 | | "Network" means the group or groups of preferred providers | 19 | | providing services to a network plan. | 20 | | "Network plan" means an individual or group policy of | 21 | | accident and health insurance that either requires a covered | 22 | | person to use or creates incentives, including financial | 23 | | incentives, for a covered person to use providers managed, | 24 | | owned, under contract with, or employed by the insurer. | 25 | | "Ongoing course of treatment" means (1) treatment for a | 26 | | life-threatening condition, which is a disease or condition |
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| 1 | | for which likelihood of death is probable unless the course of | 2 | | the disease or condition is interrupted; (2) treatment for a | 3 | | serious acute condition, defined as a disease or condition | 4 | | requiring complex ongoing care that the covered person is | 5 | | currently receiving, such as chemotherapy, radiation therapy, | 6 | | or post-operative visits; (3) a course of treatment for a | 7 | | health condition that a treating provider attests that | 8 | | discontinuing care by that provider would worsen the condition | 9 | | or interfere with anticipated outcomes; or (4) the third | 10 | | trimester of pregnancy through the post-partum period. | 11 | | "Preferred provider" means any provider who has entered, | 12 | | either directly or indirectly, into an agreement with an | 13 | | employer or risk-bearing entity relating to health care | 14 | | services that may be rendered to beneficiaries under a network | 15 | | plan. | 16 | | "Providers" means physicians licensed to practice medicine | 17 | | in all its branches, other health care professionals, | 18 | | hospitals, or other health care institutions that provide | 19 | | health care services. | 20 | | "Short-term, limited-duration health insurance coverage | 21 | | has the meaning given to that term in Section 5 of the | 22 | | Short-Term, Limited-Duration Health Insurance Coverage Act. | 23 | | "Stand-alone dental plan" has the meaning given to that | 24 | | term in 45 CFR 156.400. | 25 | | "Telehealth" has the meaning given to that term in Section | 26 | | 356z.22 of the Illinois Insurance Code. |
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| 1 | | "Telemedicine" has the meaning given to that term in | 2 | | Section 49.5 of the Medical Practice Act of 1987. | 3 | | "Tiered network" means a network that identifies and | 4 | | groups some or all types of provider and facilities into | 5 | | specific groups to which different provider reimbursement, | 6 | | covered person cost-sharing or provider access requirements, | 7 | | or any combination thereof, apply for the same services. | 8 | | "Woman's principal health care provider" means a physician | 9 | | licensed to practice medicine in all of its branches | 10 | | specializing in obstetrics, gynecology, or family practice. | 11 | | (Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.) | 12 | | (215 ILCS 124/10) | 13 | | Sec. 10. Network adequacy. | 14 | | (a) An insurer providing a network plan shall file a | 15 | | description of all of the following with the Director: | 16 | | (1) The written policies and procedures for adding | 17 | | providers to meet patient needs based on increases in the | 18 | | number of beneficiaries, changes in the | 19 | | patient-to-provider ratio, changes in medical and health | 20 | | care capabilities, and increased demand for services. | 21 | | (2) The written policies and procedures for making | 22 | | referrals within and outside the network. | 23 | | (3) The written policies and procedures on how the | 24 | | network plan will provide 24-hour, 7-day per week access | 25 | | to network-affiliated primary care, emergency services, |
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| 1 | | and women's principal health care providers. | 2 | | An insurer shall not prohibit a preferred provider from | 3 | | discussing any specific or all treatment options with | 4 | | beneficiaries irrespective of the insurer's position on those | 5 | | treatment options or from advocating on behalf of | 6 | | beneficiaries within the utilization review, grievance, or | 7 | | appeals processes established by the insurer in accordance | 8 | | with any rights or remedies available under applicable State | 9 | | or federal law. | 10 | | (b) Insurers must file for review a description of the | 11 | | services to be offered through a network plan. The description | 12 | | shall include all of the following: | 13 | | (1) A geographic map of the area proposed to be served | 14 | | by the plan by county service area and zip code, including | 15 | | marked locations for preferred providers. | 16 | | (2) As deemed necessary by the Department, the names, | 17 | | addresses, phone numbers, and specialties of the providers | 18 | | who have entered into preferred provider agreements under | 19 | | the network plan. | 20 | | (3) The number of beneficiaries anticipated to be | 21 | | covered by the network plan. | 22 | | (4) An Internet website and toll-free telephone number | 23 | | for beneficiaries and prospective beneficiaries to access | 24 | | current and accurate lists of preferred providers, | 25 | | additional information about the plan, as well as any | 26 | | other information required by Department rule. |
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| 1 | | (5) A description of how health care services to be | 2 | | rendered under the network plan are reasonably accessible | 3 | | and available to beneficiaries. The description shall | 4 | | address all of the following: | 5 | | (A) the type of health care services to be | 6 | | provided by the network plan; | 7 | | (B) the ratio of physicians and other providers to | 8 | | beneficiaries, by specialty and including primary care | 9 | | physicians and facility-based physicians when | 10 | | applicable under the contract, necessary to meet the | 11 | | health care needs and service demands of the currently | 12 | | enrolled population; | 13 | | (C) the travel and distance standards for plan | 14 | | beneficiaries in county service areas; and | 15 | | (D) a description of how the use of telemedicine, | 16 | | telehealth, or mobile care services may be used to | 17 | | partially meet the network adequacy standards, if | 18 | | applicable. | 19 | | (6) A provision ensuring that whenever a beneficiary | 20 | | has made a good faith effort, as evidenced by accessing | 21 | | the provider directory, calling the network plan, and | 22 | | calling the provider, to utilize preferred providers for a | 23 | | covered service and it is determined the insurer does not | 24 | | have the appropriate preferred providers due to | 25 | | insufficient number, type, unreasonable travel distance or | 26 | | delay, or preferred providers refusing to provide a |
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| 1 | | covered service because it is contrary to the conscience | 2 | | of the preferred providers, as protected by the Health | 3 | | Care Right of Conscience Act, the insurer shall ensure, | 4 | | directly or indirectly, by terms contained in the payer | 5 | | contract, that the beneficiary will be provided the | 6 | | covered service at no greater cost to the beneficiary than | 7 | | if the service had been provided by a preferred provider. | 8 | | This paragraph (6) does not apply to: (A) a beneficiary | 9 | | who willfully chooses to access a non-preferred provider | 10 | | for health care services available through the panel of | 11 | | preferred providers, or (B) a beneficiary enrolled in a | 12 | | health maintenance organization. In these circumstances, | 13 | | the contractual requirements for non-preferred provider | 14 | | reimbursements shall apply unless Section 356z.3a of the | 15 | | Illinois Insurance Code requires otherwise. In no event | 16 | | shall a beneficiary who receives care at a participating | 17 | | health care facility be required to search for | 18 | | participating providers under the circumstances described | 19 | | in subsection (b) or (b-5) of Section 356z.3a of the | 20 | | Illinois Insurance Code except under the circumstances | 21 | | described in paragraph (2) of subsection (b-5). | 22 | | (7) A provision that the beneficiary shall receive | 23 | | emergency care coverage such that payment for this | 24 | | coverage is not dependent upon whether the emergency | 25 | | services are performed by a preferred or non-preferred | 26 | | provider and the coverage shall be at the same benefit |
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| 1 | | level as if the service or treatment had been rendered by a | 2 | | preferred provider. For purposes of this paragraph (7), | 3 | | "the same benefit level" means that the beneficiary is | 4 | | provided the covered service at no greater cost to the | 5 | | beneficiary than if the service had been provided by a | 6 | | preferred provider. This provision shall be consistent | 7 | | with Section 356z.3a of the Illinois Insurance Code. | 8 | | (8) A limitation that, if the plan provides that the | 9 | | beneficiary will incur a penalty for failing to | 10 | | pre-certify inpatient hospital treatment, the penalty may | 11 | | not exceed $1,000 per occurrence in addition to the plan | 12 | | cost sharing provisions. | 13 | | (c) The network plan shall demonstrate to the Director a | 14 | | minimum ratio of providers to plan beneficiaries as required | 15 | | by the Department. | 16 | | (1) The ratio of physicians or other providers to plan | 17 | | beneficiaries shall be established annually by the | 18 | | Department in consultation with the Department of Public | 19 | | Health based upon the guidance from the federal Centers | 20 | | for Medicare and Medicaid Services. The Department shall | 21 | | not establish ratios for vision or dental providers who | 22 | | provide services under dental-specific or vision-specific | 23 | | benefits , except to the extent provided under federal law | 24 | | for stand-alone dental plans . The Department shall | 25 | | consider establishing ratios for the following physicians | 26 | | or other providers: |
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| 1 | | (A) Primary Care; | 2 | | (B) Pediatrics; | 3 | | (C) Cardiology; | 4 | | (D) Gastroenterology; | 5 | | (E) General Surgery; | 6 | | (F) Neurology; | 7 | | (G) OB/GYN; | 8 | | (H) Oncology/Radiation; | 9 | | (I) Ophthalmology; | 10 | | (J) Urology; | 11 | | (K) Behavioral Health; | 12 | | (L) Allergy/Immunology; | 13 | | (M) Chiropractic; | 14 | | (N) Dermatology; | 15 | | (O) Endocrinology; | 16 | | (P) Ears, Nose, and Throat (ENT)/Otolaryngology; | 17 | | (Q) Infectious Disease; | 18 | | (R) Nephrology; | 19 | | (S) Neurosurgery; | 20 | | (T) Orthopedic Surgery; | 21 | | (U) Physiatry/Rehabilitative; | 22 | | (V) Plastic Surgery; | 23 | | (W) Pulmonary; | 24 | | (X) Rheumatology; | 25 | | (Y) Anesthesiology; | 26 | | (Z) Pain Medicine; |
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| 1 | | (AA) Pediatric Specialty Services; | 2 | | (BB) Outpatient Dialysis; and | 3 | | (CC) HIV. | 4 | | (2) The Director shall establish a process for the | 5 | | review of the adequacy of these standards, along with an | 6 | | assessment of additional specialties to be included in the | 7 | | list under this subsection (c). | 8 | | (3) If the federal Centers for Medicare and Medicaid | 9 | | Services establishes minimum provider ratios for | 10 | | stand-alone dental plans in the type of exchange in use in | 11 | | this State for a given plan year, the Department shall | 12 | | enforce those standards for stand-alone dental plans for | 13 | | that plan year. | 14 | | (d) The network plan shall demonstrate to the Director | 15 | | maximum travel and distance standards for plan beneficiaries, | 16 | | which shall be established annually by the Department in | 17 | | consultation with the Department of Public Health based upon | 18 | | the guidance from the federal Centers for Medicare and | 19 | | Medicaid Services. These standards shall consist of the | 20 | | maximum minutes or miles to be traveled by a plan beneficiary | 21 | | for each county type, such as large counties, metro counties, | 22 | | or rural counties as defined by Department rule. | 23 | | The maximum travel time and distance standards must | 24 | | include standards for each physician and other provider | 25 | | category listed for which ratios have been established. | 26 | | The Director shall establish a process for the review of |
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| 1 | | the adequacy of these standards along with an assessment of | 2 | | additional specialties to be included in the list under this | 3 | | subsection (d). | 4 | | If the federal Centers for Medicare and Medicaid Services | 5 | | establishes appointment wait-time standards for qualified | 6 | | health plans, including stand-alone dental plans, in the type | 7 | | of exchange in use in this State for a given plan year, the | 8 | | Department shall enforce those standards for the same types of | 9 | | qualified health plans for that plan year. If the federal | 10 | | Centers for Medicare and Medicaid Services establishes time | 11 | | and distance standards for stand-alone dental plans in the | 12 | | type of exchange in use in this State for a given plan year, | 13 | | the Department shall enforce those standards for stand-alone | 14 | | dental plans for that plan year. | 15 | | (d-5)(1) Every insurer shall ensure that beneficiaries | 16 | | have timely and proximate access to treatment for mental, | 17 | | emotional, nervous, or substance use disorders or conditions | 18 | | in accordance with the provisions of paragraph (4) of | 19 | | subsection (a) of Section 370c of the Illinois Insurance Code. | 20 | | Insurers shall use a comparable process, strategy, evidentiary | 21 | | standard, and other factors in the development and application | 22 | | of the network adequacy standards for timely and proximate | 23 | | access to treatment for mental, emotional, nervous, or | 24 | | substance use disorders or conditions and those for the access | 25 | | to treatment for medical and surgical conditions. As such, the | 26 | | network adequacy standards for timely and proximate access |
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| 1 | | shall equally be applied to treatment facilities and providers | 2 | | for mental, emotional, nervous, or substance use disorders or | 3 | | conditions and specialists providing medical or surgical | 4 | | benefits pursuant to the parity requirements of Section 370c.1 | 5 | | of the Illinois Insurance Code and the federal Paul Wellstone | 6 | | and Pete Domenici Mental Health Parity and Addiction Equity | 7 | | Act of 2008. Notwithstanding the foregoing, the network | 8 | | adequacy standards for timely and proximate access to | 9 | | treatment for mental, emotional, nervous, or substance use | 10 | | disorders or conditions shall, at a minimum, satisfy the | 11 | | following requirements: | 12 | | (A) For beneficiaries residing in the metropolitan | 13 | | counties of Cook, DuPage, Kane, Lake, McHenry, and Will, | 14 | | network adequacy standards for timely and proximate access | 15 | | to treatment for mental, emotional, nervous, or substance | 16 | | use disorders or conditions means a beneficiary shall not | 17 | | have to travel longer than 30 minutes or 30 miles from the | 18 | | beneficiary's residence to receive outpatient treatment | 19 | | for mental, emotional, nervous, or substance use disorders | 20 | | or conditions. Beneficiaries shall not be required to wait | 21 | | longer than 10 business days between requesting an initial | 22 | | appointment and being seen by the facility or provider of | 23 | | mental, emotional, nervous, or substance use disorders or | 24 | | conditions for outpatient treatment or to wait longer than | 25 | | 20 business days between requesting a repeat or follow-up | 26 | | appointment and being seen by the facility or provider of |
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| 1 | | mental, emotional, nervous, or substance use disorders or | 2 | | conditions for outpatient treatment; however, subject to | 3 | | the protections of paragraph (3) of this subsection, a | 4 | | network plan shall not be held responsible if the | 5 | | beneficiary or provider voluntarily chooses to schedule an | 6 | | appointment outside of these required time frames. | 7 | | (B) For beneficiaries residing in Illinois counties | 8 | | other than those counties listed in subparagraph (A) of | 9 | | this paragraph, network adequacy standards for timely and | 10 | | proximate access to treatment for mental, emotional, | 11 | | nervous, or substance use disorders or conditions means a | 12 | | beneficiary shall not have to travel longer than 60 | 13 | | minutes or 60 miles from the beneficiary's residence to | 14 | | receive outpatient treatment for mental, emotional, | 15 | | nervous, or substance use disorders or conditions. | 16 | | Beneficiaries shall not be required to wait longer than 10 | 17 | | business days between requesting an initial appointment | 18 | | and being seen by the facility or provider of mental, | 19 | | emotional, nervous, or substance use disorders or | 20 | | conditions for outpatient treatment or to wait longer than | 21 | | 20 business days between requesting a repeat or follow-up | 22 | | appointment and being seen by the facility or provider of | 23 | | mental, emotional, nervous, or substance use disorders or | 24 | | conditions for outpatient treatment; however, subject to | 25 | | the protections of paragraph (3) of this subsection, a | 26 | | network plan shall not be held responsible if the |
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| 1 | | beneficiary or provider voluntarily chooses to schedule an | 2 | | appointment outside of these required time frames. | 3 | | (2) For beneficiaries residing in all Illinois counties, | 4 | | network adequacy standards for timely and proximate access to | 5 | | treatment for mental, emotional, nervous, or substance use | 6 | | disorders or conditions means a beneficiary shall not have to | 7 | | travel longer than 60 minutes or 60 miles from the | 8 | | beneficiary's residence to receive inpatient or residential | 9 | | treatment for mental, emotional, nervous, or substance use | 10 | | disorders or conditions. | 11 | | (3) If there is no in-network facility or provider | 12 | | available for a beneficiary to receive timely and proximate | 13 | | access to treatment for mental, emotional, nervous, or | 14 | | substance use disorders or conditions in accordance with the | 15 | | network adequacy standards outlined in this subsection, the | 16 | | insurer shall provide necessary exceptions to its network to | 17 | | ensure admission and treatment with a provider or at a | 18 | | treatment facility in accordance with the network adequacy | 19 | | standards in this subsection. | 20 | | (4) If the federal Centers for Medicare and Medicaid | 21 | | Services establishes a more stringent standard in any county | 22 | | than specified in paragraph (1) or (2) of this subsection | 23 | | (d-5) for qualified health plans in the type of exchange in use | 24 | | in this State for a given plan year, the federal standard shall | 25 | | apply in lieu of the standard in paragraph (1) or (2) of this | 26 | | subsection (d-5) for qualified health plans for that plan |
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| 1 | | year. | 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 , and appointment | 13 | | wait-time standards established under this Act or federal law | 14 | | established by the Department may request an exception to | 15 | | these requirements from the Department. The Department may | 16 | | grant an exception in the following circumstances: | 17 | | (1) if no providers or facilities meet the specific | 18 | | time and distance standard in a specific service area and | 19 | | the insurer (i) discloses information on the distance and | 20 | | travel time points that beneficiaries would have to travel | 21 | | beyond the required criterion to reach the next closest | 22 | | contracted provider outside of the service area and (ii) | 23 | | provides contact information, including names, addresses, | 24 | | and phone numbers for the next closest contracted provider | 25 | | or facility; | 26 | | (2) if patterns of care in the service area do not |
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| 1 | | support the need for the requested number of provider or | 2 | | facility type and the insurer provides data on local | 3 | | patterns of care, such as claims data, referral patterns, | 4 | | or local provider interviews, indicating where the | 5 | | beneficiaries currently seek this type of care or where | 6 | | the physicians currently refer beneficiaries, or both; or | 7 | | (3) other circumstances deemed appropriate by the | 8 | | Department consistent with the requirements of this Act. | 9 | | (h) Insurers are required to report to the Director any | 10 | | material change to an approved network plan within 15 days | 11 | | after the change occurs and any change that would result in | 12 | | failure to meet the requirements of this Act. Upon notice from | 13 | | the insurer, the Director shall reevaluate the network plan's | 14 | | compliance with the network adequacy and transparency | 15 | | standards of this Act. | 16 | | (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; | 17 | | 102-1117, eff. 1-13-23.) | 18 | | (215 ILCS 124/25) | 19 | | Sec. 25. Network transparency. | 20 | | (a) A network plan shall post electronically an | 21 | | up-to-date, accurate, and complete provider directory for each | 22 | | of its network plans, with the information and search | 23 | | functions, as described in this Section. | 24 | | (1) In making the directory available electronically, | 25 | | the network plans shall ensure that the general public is |
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| 1 | | able to view all of the current providers for a plan | 2 | | through a clearly identifiable link or tab and without | 3 | | creating or accessing an account or entering a policy or | 4 | | contract number. | 5 | | (2) The network plan shall update the online provider | 6 | | directory at least monthly. Providers shall notify the | 7 | | network plan electronically or in writing of any changes | 8 | | to their information as listed in the provider directory, | 9 | | including the information required in subparagraph (K) of | 10 | | paragraph (1) of subsection (b). The network plan shall | 11 | | update its online provider directory in a manner | 12 | | consistent with the information provided by the provider | 13 | | within 10 business days after being notified of the change | 14 | | by the provider. Nothing in this paragraph (2) shall void | 15 | | any contractual relationship between the provider and the | 16 | | plan. | 17 | | (3) The network plan shall audit periodically at least | 18 | | 25% of its provider directories for accuracy, make any | 19 | | corrections necessary, and retain documentation of the | 20 | | audit. The network plan shall submit the audit to the | 21 | | Director upon request. As part of these audits, the | 22 | | network plan shall contact any provider in its network | 23 | | that has not submitted a claim to the plan or otherwise | 24 | | communicated his or her intent to continue participation | 25 | | in the plan's network. | 26 | | (4) A network plan shall provide a printed print copy |
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| 1 | | of a current provider directory or a printed print copy of | 2 | | the requested directory information upon request of a | 3 | | beneficiary or a prospective beneficiary. Printed Print | 4 | | copies must be updated quarterly and an errata that | 5 | | reflects changes in the provider network must be updated | 6 | | 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; | 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; |
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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 | | (g) This Section applies to network plans that are not | 17 | | otherwise exempt under Section 3, including stand-alone dental | 18 | | plans that are subject to provider directory requirements | 19 | | under federal law. | 20 | | (Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.) | 21 | | Section 25. The Health Maintenance Organization Act is | 22 | | amended by changing Section 5-3 as follows: | 23 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | 24 | | Sec. 5-3. Insurance Code provisions. |
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| 1 | | (a) Health Maintenance Organizations shall be subject to | 2 | | the provisions of Sections 133, 134, 136, 137, 139, 140, | 3 | | 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | 4 | | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | 5 | | 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v, | 6 | | 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, | 7 | | 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, | 8 | | 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, | 9 | | 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, | 10 | | 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35, | 11 | | 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.40a, | 12 | | 356z.41, 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, | 13 | | 356z.50, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, | 14 | | 356z.58, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, | 15 | | 356z.67, 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, | 16 | | 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, | 17 | | 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) | 18 | | of subsection (2) of Section 367, and Articles IIA, VIII 1/2, | 19 | | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | 20 | | Illinois Insurance Code. | 21 | | (b) For purposes of the Illinois Insurance Code, except | 22 | | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | 23 | | Health Maintenance Organizations in the following categories | 24 | | are deemed to be "domestic companies": | 25 | | (1) a corporation authorized under the Dental Service | 26 | | Plan Act or the Voluntary Health Services Plans Act; |
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| 1 | | (2) a corporation organized under the laws of this | 2 | | State; or | 3 | | (3) a corporation organized under the laws of another | 4 | | state, 30% or more of the enrollees of which are residents | 5 | | of this State, except a corporation subject to | 6 | | substantially the same requirements in its state of | 7 | | organization as is a "domestic company" under Article VIII | 8 | | 1/2 of the Illinois Insurance Code. | 9 | | (c) In considering the merger, consolidation, or other | 10 | | acquisition of control of a Health Maintenance Organization | 11 | | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | 12 | | (1) the Director shall give primary consideration to | 13 | | the continuation of benefits to enrollees and the | 14 | | financial conditions of the acquired Health Maintenance | 15 | | Organization after the merger, consolidation, or other | 16 | | acquisition of control takes effect; | 17 | | (2)(i) the criteria specified in subsection (1)(b) of | 18 | | Section 131.8 of the Illinois Insurance Code shall not | 19 | | apply and (ii) the Director, in making his determination | 20 | | with respect to the merger, consolidation, or other | 21 | | acquisition of control, need not take into account the | 22 | | effect on competition of the merger, consolidation, or | 23 | | other acquisition of control; | 24 | | (3) the Director shall have the power to require the | 25 | | following information: | 26 | | (A) certification by an independent actuary of the |
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| 1 | | adequacy of the reserves of the Health Maintenance | 2 | | Organization sought to be acquired; | 3 | | (B) pro forma financial statements reflecting the | 4 | | combined balance sheets of the acquiring company and | 5 | | the Health Maintenance Organization sought to be | 6 | | acquired as of the end of the preceding year and as of | 7 | | a date 90 days prior to the acquisition, as well as pro | 8 | | forma financial statements reflecting projected | 9 | | combined operation for a period of 2 years; | 10 | | (C) a pro forma business plan detailing an | 11 | | acquiring party's plans with respect to the operation | 12 | | of the Health Maintenance Organization sought to be | 13 | | acquired for a period of not less than 3 years; and | 14 | | (D) such other information as the Director shall | 15 | | require. | 16 | | (d) The provisions of Article VIII 1/2 of the Illinois | 17 | | Insurance Code and this Section 5-3 shall apply to the sale by | 18 | | any health maintenance organization of greater than 10% of its | 19 | | enrollee population (including , without limitation , the health | 20 | | maintenance organization's right, title, and interest in and | 21 | | to its health care certificates). | 22 | | (e) In considering any management contract or service | 23 | | agreement subject to Section 141.1 of the Illinois Insurance | 24 | | Code, the Director (i) shall, in addition to the criteria | 25 | | specified in Section 141.2 of the Illinois Insurance Code, | 26 | | take into account the effect of the management contract or |
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| 1 | | service agreement on the continuation of benefits to enrollees | 2 | | and the financial condition of the health maintenance | 3 | | organization to be managed or serviced, and (ii) need not take | 4 | | into account the effect of the management contract or service | 5 | | agreement on competition. | 6 | | (f) Except for small employer groups as defined in the | 7 | | Small Employer Rating, Renewability and Portability Health | 8 | | Insurance Act and except for medicare supplement policies as | 9 | | defined in Section 363 of the Illinois Insurance Code, a | 10 | | Health Maintenance Organization may by contract agree with a | 11 | | group or other enrollment unit to effect refunds or charge | 12 | | additional premiums under the following terms and conditions: | 13 | | (i) the amount of, and other terms and conditions with | 14 | | respect to, the refund or additional premium are set forth | 15 | | in the group or enrollment unit contract agreed in advance | 16 | | of the period for which a refund is to be paid or | 17 | | additional premium is to be charged (which period shall | 18 | | not be less than one year); and | 19 | | (ii) the amount of the refund or additional premium | 20 | | shall not exceed 20% of the Health Maintenance | 21 | | Organization's profitable or unprofitable experience with | 22 | | respect to the group or other enrollment unit for the | 23 | | period (and, for purposes of a refund or additional | 24 | | premium, the profitable or unprofitable experience shall | 25 | | be calculated taking into account a pro rata share of the | 26 | | Health Maintenance Organization's administrative and |
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| 1 | | marketing expenses, but shall not include any refund to be | 2 | | made or additional premium to be paid pursuant to this | 3 | | subsection (f)). The Health Maintenance Organization and | 4 | | the group or enrollment unit may agree that the profitable | 5 | | or unprofitable experience may be calculated taking into | 6 | | account the refund period and the immediately preceding 2 | 7 | | plan years. | 8 | | The Health Maintenance Organization shall include a | 9 | | statement in the evidence of coverage issued to each enrollee | 10 | | describing the possibility of a refund or additional premium, | 11 | | and upon request of any group or enrollment unit, provide to | 12 | | the group or enrollment unit a description of the method used | 13 | | to calculate (1) the Health Maintenance Organization's | 14 | | profitable experience with respect to the group or enrollment | 15 | | unit and the resulting refund to the group or enrollment unit | 16 | | or (2) the Health Maintenance Organization's unprofitable | 17 | | experience with respect to the group or enrollment unit and | 18 | | the resulting additional premium to be paid by the group or | 19 | | enrollment unit. | 20 | | In no event shall the Illinois Health Maintenance | 21 | | Organization Guaranty Association be liable to pay any | 22 | | contractual obligation of an insolvent organization to pay any | 23 | | refund authorized under this Section. | 24 | | (g) Rulemaking authority to implement Public Act 95-1045, | 25 | | if any, is conditioned on the rules being adopted in | 26 | | accordance with all provisions of the Illinois Administrative |
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| 1 | | Procedure Act and all rules and procedures of the Joint | 2 | | Committee on Administrative Rules; any purported rule not so | 3 | | adopted, for whatever reason, is unauthorized. | 4 | | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | 5 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | 6 | | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | 7 | | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | 8 | | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | 9 | | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | 10 | | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | 11 | | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | 12 | | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | 13 | | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | 14 | | Section 30. The Managed Care Reform and Patient Rights Act | 15 | | is amended by changing Section 45.3 as follows: | 16 | | (215 ILCS 134/45.3) | 17 | | Sec. 45.3. Prescription drug benefits; plan choice. | 18 | | (a) Notwithstanding any other provision of law, beginning | 19 | | January 1, 2023, every health insurance carrier that offers an | 20 | | individual health plan that provides coverage for prescription | 21 | | drugs shall ensure that at least 10% of individual health care | 22 | | plans offered in each applicable service area and at each | 23 | | level of coverage as defined in 42 U.S.C. 18022 (d) apply a | 24 | | flat-dollar copayment structure to the entire drug benefit. |
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| 1 | | Beginning January 1, 2024, every health insurance carrier that | 2 | | offers an individual health plan that provides coverage for | 3 | | prescription drugs shall ensure that at least 25% of | 4 | | individual health care plans offered in each applicable | 5 | | service area and at each level of coverage as defined in 42 | 6 | | U.S.C. 18022 (d) apply a flat-dollar copayment structure to the | 7 | | entire drug benefit. If a health insurance carrier offers | 8 | | fewer than 4 plans in a service area, then the health insurance | 9 | | carrier shall ensure that one plan applies a flat-dollar | 10 | | copayment structure to the entire drug benefit. | 11 | | (b) Beginning January 1, 2023, every health insurance | 12 | | carrier that offers a group health plan that provides coverage | 13 | | for prescription drugs shall offer at least one group health | 14 | | plan in each applicable service area and at each level of | 15 | | coverage as defined in 42 U.S.C. 18022 that applies a | 16 | | flat-dollar copayment structure to the entire drug benefit. | 17 | | Every Beginning January 1, 2024, every health insurance | 18 | | carrier that offers a small group health plan that provides | 19 | | coverage for prescription drugs shall offer at least 2 small | 20 | | group health plans in each applicable service area and at each | 21 | | level of coverage as defined in 42 U.S.C. 18022 (d) that apply a | 22 | | flat-dollar copayment structure to the entire drug benefit. | 23 | | (c) The flat-dollar copayment structure for prescription | 24 | | drugs under subsections (a) and (b) must be applied | 25 | | pre-deductible and be reasonably graduated and proportionately | 26 | | related in all tier levels such that the copayment structure |
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| 1 | | as a whole does not discriminate against or discourage the | 2 | | enrollment of individuals with significant health care needs. | 3 | | Notwithstanding the other provisions of this subsection, | 4 | | beginning January 1, 2025, each level of coverage that a | 5 | | health insurance carrier offers of a standardized option in | 6 | | each applicable service area shall be deemed to satisfy the | 7 | | requirements for a flat-dollar copay structure in subsection | 8 | | (a). | 9 | | For purposes of this subsection, "standardized option" has | 10 | | the meaning given to that term in 45 CFR 155.20 or, when | 11 | | Illinois has a State-based exchange, a substantially similar | 12 | | definition to "standardized option" in 45 CFR 155.20 that | 13 | | substitutes the Illinois Health Benefits Exchange for the | 14 | | United States Department of Health and Human Services. | 15 | | (d) A health insurance carrier that offers individual or | 16 | | small group health care plans shall clearly and appropriately | 17 | | name the plans described in subsections (a) and (b) to aid in | 18 | | the individual or small group plan selection process. | 19 | | (e) A health insurance carrier shall market plans | 20 | | described in subsections (a) and (b) in the same manner as | 21 | | plans not described in subsections (a) and (b). | 22 | | (f) The Department shall adopt rules necessary to | 23 | | implement and enforce the provisions of this Section. | 24 | | (Source: P.A. 102-391, eff. 1-1-23 .) | 25 | | Section 99. Effective date. This Act takes effect upon |
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| 1 | | becoming law, except that the changes to Sections 3, 5, 10, and | 2 | | 25 of the Network Adequacy and Transparency Act take effect | 3 | | January 1, 2025.". |
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