Public Act 100-0601
 
SB3491 EnrolledLRB100 20404 LNS 35726 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 3, 10, and 25 as follows:
 
    (215 ILCS 124/3)
    Sec. 3. Applicability of Act. This Act applies to an
individual or group policy of accident and health insurance
with a network plan amended, delivered, issued, or renewed in
this State on or after January 1, 2019. This Act does not apply
to an individual or group policy for dental or vision insurance
or a limited health service organization with a network plan
amended, delivered, issued, or renewed in this State on or
after January 1, 2019.
(Source: P.A. 100-502, eff. 9-15-17.)
 
    (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
    woman'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, or unreasonable travel distance or delay, 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.
        (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.
        (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.
        (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).
    (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) 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. 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. 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.
        (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.
        (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.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.