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Public Act 102-0092


 

Public Act 0092 102ND GENERAL ASSEMBLY

  
  
  

 


 
Public Act 102-0092
 
SB0332 EnrolledLRB102 13548 BMS 18895 b

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

Effective Date: 7/9/2021