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Public Act 100-0502


 

Public Act 0502 100TH GENERAL ASSEMBLY

  
  
  

 


 
Public Act 100-0502
 
HB0311 EnrolledLRB100 05356 RPS 15367 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 1. Short title. This Act may be cited as the
Network Adequacy and Transparency Act.
 
    Section 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.
 
    Section 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.
    "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.
 
    Section 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
    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.
 
    Section 15. Notice of nonrenewal or termination.
    (a) A network plan must give at least 60 days' notice of
nonrenewal or termination of a provider to the provider and to
the beneficiaries served by the provider. The notice shall
include a name and address to which a beneficiary or provider
may direct comments and concerns regarding the nonrenewal or
termination and the telephone number maintained by the
Department for consumer complaints. Immediate written notice
may be provided without 60 days' notice when a provider's
license has been disciplined by a State licensing board or when
the network plan reasonably believes direct imminent physical
harm to patients under the providers care may occur.
    (b) Primary care providers must notify active affected
patients of nonrenewal or termination of the provider from the
network plan, except in the case of incapacitation.
 
    Section 20. Transition of services.
    (a) A network plan shall provide for continuity of care for
its beneficiaries as follows:
        (1) If a beneficiary's physician or hospital provider
    leaves the network plan's network of providers for reasons
    other than termination of a contract in situations
    involving imminent harm to a patient or a final
    disciplinary action by a State licensing board and the
    provider remains within the network plan's service area,
    the network plan shall permit the beneficiary to continue
    an ongoing course of treatment with that provider during a
    transitional period for the following duration:
            (A) 90 days from the date of the notice to the
        beneficiary of the provider's disaffiliation from the
        network plan if the beneficiary has an ongoing course
        of treatment; or
            (B) if the beneficiary has entered the third
        trimester of pregnancy at the time of the provider's
        disaffiliation, a period that includes the provision
        of post-partum care directly related to the delivery.
        (2) Notwithstanding the provisions of paragraph (1) of
    this subsection (a), such care shall be authorized by the
    network plan during the transitional period in accordance
    with the following:
            (A) the provider receives continued reimbursement
        from the network plan at the rates and terms and
        conditions applicable under the terminated contract
        prior to the start of the transitional period;
            (B) the provider adheres to the network plan's
        quality assurance requirements, including provision to
        the network plan of necessary medical information
        related to such care; and
            (C) the provider otherwise adheres to the network
        plan's policies and procedures, including, but not
        limited to, procedures regarding referrals and
        obtaining preauthorizations for treatment.
        (3) The provisions of this Section governing health
    care provided during the transition period do not apply if
    the beneficiary has successfully transitioned to another
    provider participating in the network plan, if the
    beneficiary has already met or exceeded the benefit
    limitations of the plan, or if the care provided is not
    medically necessary.
    (b) A network plan shall provide for continuity of care for
new beneficiaries as follows:
        (1) If a new beneficiary whose provider is not a member
    of the network plan's provider network, but is within the
    network plan's service area, enrolls in the network plan,
    the network plan shall permit the beneficiary to continue
    an ongoing course of treatment with the beneficiary's
    current physician during a transitional period:
            (A) of 90 days from the effective date of
        enrollment if the beneficiary has an ongoing course of
        treatment; or
            (B) if the beneficiary has entered the third
        trimester of pregnancy at the effective date of
        enrollment, that includes the provision of post-partum
        care directly related to the delivery.
        (2) If a beneficiary, or a beneficiary's authorized
    representative, elects in writing to continue to receive
    care from such provider pursuant to paragraph (1) of this
    subsection (b), such care shall be authorized by the
    network plan for the transitional period in accordance with
    the following:
            (A) the provider receives reimbursement from the
        network plan at rates established by the network plan;
            (B) the provider adheres to the network plan's
        quality assurance requirements, including provision to
        the network plan of necessary medical information
        related to such care; and
            (C) the provider otherwise adheres to the network
        plan's policies and procedures, including, but not
        limited to, procedures regarding referrals and
        obtaining preauthorization for treatment.
        (3) The provisions of this Section governing health
    care provided during the transition period do not apply if
    the beneficiary has successfully transitioned to another
    provider participating in the network plan, if the
    beneficiary has already met or exceeded the benefit
    limitations of the plan, or if the care provided is not
    medically necessary.
    (c) In no event shall this Section be construed to require
a network plan to provide coverage for benefits not otherwise
covered or to diminish or impair preexisting condition
limitations contained in the beneficiary's contract.
 
    Section 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.
 
    Section 30. Administration and enforcement.
    (a) Insurers, as defined in this Act, have a continuing
obligation to comply with the requirements of this Act. Other
than the duties specifically created in this Act, nothing in
this Act is intended to preclude, prevent, or require the
adoption, modification, or termination of any utilization
management, quality management, or claims processing
methodologies of an insurer.
    (b) Nothing in this Act precludes, prevents, or requires
the adoption, modification, or termination of any network plan
term, benefit, coverage or eligibility provision, or payment
methodology.
    (c) The Director shall enforce the provisions of this Act
pursuant to the enforcement powers granted to it by law.
    (d) The Department shall adopt rules to enforce compliance
with this Act to the extent necessary.
 
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 09/15/2017