Public Act 103-0906
 
SB2641 EnrolledLRB103 35049 JAG 64994 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 Section 10 as follows:
 
    (215 ILCS 124/10)
    Sec. 10. Network adequacy.
    (a) An insurer providing a network plan shall file a
description of all of the following with the Director:
        (1) The written policies and procedures for adding
    providers to meet patient needs based on increases in the
    number of beneficiaries, changes in the
    patient-to-provider ratio, changes in medical and health
    care capabilities, and increased demand for services.
        (2) The written policies and procedures for making
    referrals within and outside the network.
        (3) The written policies and procedures on how the
    network plan will provide 24-hour, 7-day per week access
    to network-affiliated primary care, emergency services,
    and women's principal health care providers.
    An insurer shall not prohibit a preferred provider from
discussing any specific or all treatment options with
beneficiaries irrespective of the insurer's position on those
treatment options or from advocating on behalf of
beneficiaries within the utilization review, grievance, or
appeals processes established by the insurer in accordance
with any rights or remedies available under applicable State
or federal law.
    (b) Insurers must file for review a description of the
services to be offered through a network plan. The description
shall include all of the following:
        (1) A geographic map of the area proposed to be served
    by the plan by county service area and zip code, including
    marked locations for preferred providers.
        (2) As deemed necessary by the Department, the names,
    addresses, phone numbers, and specialties of the providers
    who have entered into preferred provider agreements under
    the network plan.
        (3) The number of beneficiaries anticipated to be
    covered by the network plan.
        (4) An Internet website and toll-free telephone number
    for beneficiaries and prospective beneficiaries to access
    current and accurate lists of preferred providers,
    additional information about the plan, as well as any
    other information required by Department rule.
        (5) A description of how health care services to be
    rendered under the network plan are reasonably accessible
    and available to beneficiaries. The description shall
    address all of the following:
            (A) the type of health care services to be
        provided by the network plan;
            (B) the ratio of physicians and other providers to
        beneficiaries, by specialty and including primary care
        physicians and facility-based physicians when
        applicable under the contract, necessary to meet the
        health care needs and service demands of the currently
        enrolled population;
            (C) the travel and distance standards for plan
        beneficiaries in county service areas; and
            (D) a description of how the use of telemedicine,
        telehealth, or mobile care services may be used to
        partially meet the network adequacy standards, if
        applicable.
        (6) A provision ensuring that whenever a beneficiary
    has made a good faith effort, as evidenced by accessing
    the provider directory, calling the network plan, and
    calling the provider, to utilize preferred providers for a
    covered service and it is determined the insurer does not
    have the appropriate preferred providers due to
    insufficient number, type, unreasonable travel distance or
    delay, or preferred providers refusing to provide a
    covered service because it is contrary to the conscience
    of the preferred providers, as protected by the Health
    Care Right of Conscience Act, the insurer shall ensure,
    directly or indirectly, by terms contained in the payer
    contract, that the beneficiary will be provided the
    covered service at no greater cost to the beneficiary than
    if the service had been provided by a preferred provider.
    This paragraph (6) does not apply to: (A) a beneficiary
    who willfully chooses to access a non-preferred provider
    for health care services available through the panel of
    preferred providers, or (B) a beneficiary enrolled in a
    health maintenance organization. In these circumstances,
    the contractual requirements for non-preferred provider
    reimbursements shall apply unless Section 356z.3a of the
    Illinois Insurance Code requires otherwise. In no event
    shall a beneficiary who receives care at a participating
    health care facility be required to search for
    participating providers under the circumstances described
    in subsection (b) or (b-5) of Section 356z.3a of the
    Illinois Insurance Code except under the circumstances
    described in paragraph (2) of subsection (b-5).
        (7) A provision that the beneficiary shall receive
    emergency care coverage such that payment for this
    coverage is not dependent upon whether the emergency
    services are performed by a preferred or non-preferred
    provider and the coverage shall be at the same benefit
    level as if the service or treatment had been rendered by a
    preferred provider. For purposes of this paragraph (7),
    "the same benefit level" means that the beneficiary is
    provided the covered service at no greater cost to the
    beneficiary than if the service had been provided by a
    preferred provider. This provision shall be consistent
    with Section 356z.3a of the Illinois Insurance Code.
        (8) A limitation that, if the plan provides that the
    beneficiary will incur a penalty for failing to
    pre-certify inpatient hospital treatment, the penalty may
    not exceed $1,000 per occurrence in addition to the plan
    cost sharing provisions.
    (c) The network plan shall demonstrate to the Director a
minimum ratio of providers to plan beneficiaries as required
by the Department.
        (1) The ratio of physicians or other providers to plan
    beneficiaries shall be established annually by the
    Department in consultation with the Department of Public
    Health based upon the guidance from the federal Centers
    for Medicare and Medicaid Services. The Department shall
    not establish ratios for vision or dental providers who
    provide services under dental-specific or vision-specific
    benefits. The Department shall consider establishing
    ratios for the following physicians or other providers:
            (A) Primary Care;
            (B) Pediatrics;
            (C) Cardiology;
            (D) Gastroenterology;
            (E) General Surgery;
            (F) Neurology;
            (G) OB/GYN;
            (H) Oncology/Radiation;
            (I) Ophthalmology;
            (J) Urology;
            (K) Behavioral Health;
            (L) Allergy/Immunology;
            (M) Chiropractic;
            (N) Dermatology;
            (O) Endocrinology;
            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
            (Q) Infectious Disease;
            (R) Nephrology;
            (S) Neurosurgery;
            (T) Orthopedic Surgery;
            (U) Physiatry/Rehabilitative;
            (V) Plastic Surgery;
            (W) Pulmonary;
            (X) Rheumatology;
            (Y) Anesthesiology;
            (Z) Pain Medicine;
            (AA) Pediatric Specialty Services;
            (BB) Outpatient Dialysis; and
            (CC) HIV.
        (1.5) Beginning January 1, 2026, every insurer shall
    demonstrate to the Director that each in-network hospital
    has at least one radiologist, pathologist,
    anesthesiologist, and emergency room physician as a
    preferred provider in a network plan. The Department may,
    by rule, require additional types of hospital-based
    medical specialists to be included as preferred providers
    in each in-network hospital in a network plan.
        (2) The Director shall establish a process for the
    review of the adequacy of these standards, along with an
    assessment of additional specialties to be included in the
    list under this subsection (c).
    (d) The network plan shall demonstrate to the Director
maximum travel and distance standards for plan beneficiaries,
which shall be established annually by the Department in
consultation with the Department of Public Health based upon
the guidance from the federal Centers for Medicare and
Medicaid Services. These standards shall consist of the
maximum minutes or miles to be traveled by a plan beneficiary
for each county type, such as large counties, metro counties,
or rural counties as defined by Department rule.
    The maximum travel time and distance standards must
include standards for each physician and other provider
category listed for which ratios have been established.
    The Director shall establish a process for the review of
the adequacy of these standards along with an assessment of
additional specialties to be included in the list under this
subsection (d).
    (d-5)(1) Every insurer shall ensure that beneficiaries
have timely and proximate access to treatment for mental,
emotional, nervous, or substance use disorders or conditions
in accordance with the provisions of paragraph (4) of
subsection (a) of Section 370c of the Illinois Insurance Code.
Insurers shall use a comparable process, strategy, evidentiary
standard, and other factors in the development and application
of the network adequacy standards for timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions and those for the access
to treatment for medical and surgical conditions. As such, the
network adequacy standards for timely and proximate access
shall equally be applied to treatment facilities and providers
for mental, emotional, nervous, or substance use disorders or
conditions and specialists providing medical or surgical
benefits pursuant to the parity requirements of Section 370c.1
of the Illinois Insurance Code and the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008. Notwithstanding the foregoing, the network
adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions shall, at a minimum, satisfy the
following requirements:
        (A) For beneficiaries residing in the metropolitan
    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
    network adequacy standards for timely and proximate access
    to treatment for mental, emotional, nervous, or substance
    use disorders or conditions means a beneficiary shall not
    have to travel longer than 30 minutes or 30 miles from the
    beneficiary's residence to receive outpatient treatment
    for mental, emotional, nervous, or substance use disorders
    or conditions. Beneficiaries shall not be required to wait
    longer than 10 business days between requesting an initial
    appointment and being seen by the facility or provider of
    mental, emotional, nervous, or substance use disorders or
    conditions for outpatient treatment or to wait longer than
    20 business days between requesting a repeat or follow-up
    appointment and being seen by the facility or provider of
    mental, emotional, nervous, or substance use disorders or
    conditions for outpatient treatment; however, subject to
    the protections of paragraph (3) of this subsection, a
    network plan shall not be held responsible if the
    beneficiary or provider voluntarily chooses to schedule an
    appointment outside of these required time frames.
        (B) For beneficiaries residing in Illinois counties
    other than those counties listed in subparagraph (A) of
    this paragraph, network adequacy standards for timely and
    proximate access to treatment for mental, emotional,
    nervous, or substance use disorders or conditions means a
    beneficiary shall not have to travel longer than 60
    minutes or 60 miles from the beneficiary's residence to
    receive outpatient treatment for mental, emotional,
    nervous, or substance use disorders or conditions.
    Beneficiaries shall not be required to wait longer than 10
    business days between requesting an initial appointment
    and being seen by the facility or provider of mental,
    emotional, nervous, or substance use disorders or
    conditions for outpatient treatment or to wait longer than
    20 business days between requesting a repeat or follow-up
    appointment and being seen by the facility or provider of
    mental, emotional, nervous, or substance use disorders or
    conditions for outpatient treatment; however, subject to
    the protections of paragraph (3) of this subsection, a
    network plan shall not be held responsible if the
    beneficiary or provider voluntarily chooses to schedule an
    appointment outside of these required time frames.
    (2) For beneficiaries residing in all Illinois counties,
network adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions means a beneficiary shall not have to
travel longer than 60 minutes or 60 miles from the
beneficiary's residence to receive inpatient or residential
treatment for mental, emotional, nervous, or substance use
disorders or conditions.
    (3) If there is no in-network facility or provider
available for a beneficiary to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with the
network adequacy standards outlined in this subsection, the
insurer shall provide necessary exceptions to its network to
ensure admission and treatment with a provider or at a
treatment facility in accordance with the network adequacy
standards in this subsection.
    (e) Except for network plans solely offered as a group
health plan, these ratio and time and distance standards apply
to the lowest cost-sharing tier of any tiered network.
    (f) The network plan may consider use of other health care
service delivery options, such as telemedicine or telehealth,
mobile clinics, and centers of excellence, or other ways of
delivering care to partially meet the requirements set under
this Section.
    (g) Except for the requirements set forth in subsection
(d-5), insurers who are not able to comply with the provider
ratios and time and distance standards established by the
Department may request an exception to these requirements from
the Department. The Department may grant an exception in the
following circumstances:
        (1) if no providers or facilities meet the specific
    time and distance standard in a specific service area and
    the insurer (i) discloses information on the distance and
    travel time points that beneficiaries would have to travel
    beyond the required criterion to reach the next closest
    contracted provider outside of the service area and (ii)
    provides contact information, including names, addresses,
    and phone numbers for the next closest contracted provider
    or facility;
        (2) if patterns of care in the service area do not
    support the need for the requested number of provider or
    facility type and the insurer provides data on local
    patterns of care, such as claims data, referral patterns,
    or local provider interviews, indicating where the
    beneficiaries currently seek this type of care or where
    the physicians currently refer beneficiaries, or both; or
        (3) other circumstances deemed appropriate by the
    Department consistent with the requirements of this Act.
    (h) Insurers are required to report to the Director any
material change to an approved network plan within 15 days
after the change occurs and any change that would result in
failure to meet the requirements of this Act. Upon notice from
the insurer, the Director shall reevaluate the network plan's
compliance with the network adequacy and transparency
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
102-1117, eff. 1-13-23.)

Effective Date: 1/1/2025