103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB0241

 

Introduced 1/31/2023, by Sen. Laura Ellman

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.3
215 ILCS 5/356z.3a
215 ILCS 124/10

    Amends the Illinois Insurance Code. Makes a change in provisions concerning disclosure of nonparticipating provider limited benefits. Adds reproductive health care to the definition of "ancillary services". Amends the Network Adequacy and Transparency Act. Provides that an insurer providing a network plan shall file a description with the Director of Insurance of written policies and procedures on how the network plan will provide 24-hour, 7-day per week access to reproductive health care. Provides that the Department of Insurance shall consider establishing ratios for reproductive health care physicians or other providers. Effective July 1, 2024, except that certain changes take effect January 1, 2025.


LRB103 27273 BMS 53644 b

 

 

A BILL FOR

 

SB0241LRB103 27273 BMS 53644 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Sections 356z.3 and 356z.3a as follows:
 
6    (215 ILCS 5/356z.3)
7    Sec. 356z.3. Disclosure of limited benefit. An insurer
8that issues, delivers, amends, or renews an individual or
9group policy of accident and health insurance in this State
10after the effective date of this amendatory Act of the 92nd
11General Assembly and arranges, contracts with, or administers
12contracts with a provider whereby beneficiaries are provided
13an incentive to use the services of such provider must include
14the following disclosure on its contracts and evidences of
15coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
16NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that
17when you elect to utilize the services of a non-participating
18provider for a covered service in non-emergency situations,
19benefit payments to such non-participating provider are not
20based upon the amount billed. The basis of your benefit
21payment will be determined according to your policy's fee
22schedule, usual and customary charge (which is determined by
23comparing charges for similar services adjusted to the

 

 

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1geographical area where the services are performed), or other
2method as defined by the policy. YOU CAN EXPECT TO PAY MORE
3THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE
4PLAN HAS PAID ITS REQUIRED PORTION. Non-participating
5providers may bill members for any amount up to the billed
6charge after the plan has paid its portion of the bill, except
7as provided in Section 356z.3a of the Illinois Insurance Code
8for covered services received at a participating health care
9facility from a nonparticipating provider that are: (a)
10ancillary services, (b) items or services furnished as a
11result of unforeseen, urgent medical needs that arise at the
12time the item or service is furnished, or (c) items or services
13received when the facility or the non-participating provider
14fails to satisfy the notice and consent criteria specified
15under Section 356z.3a, or (d) reproductive health care, as
16defined in Section 1-10 of the Reproductive Health Act.
17Participating providers have agreed to accept discounted
18payments for services with no additional billing to the member
19other than co-insurance and deductible amounts. You may obtain
20further information about the participating status of
21professional providers and information on out-of-pocket
22expenses by calling the toll free telephone number on your
23identification card.".
24(Source: P.A. 102-901, eff. 1-1-23.)
 
25    (215 ILCS 5/356z.3a)

 

 

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1    Sec. 356z.3a. Billing; emergency services;
2nonparticipating providers.
3    (a) As used in this Section:
4    "Ancillary services" means:
5        (1) items and services related to emergency medicine,
6    anesthesiology, pathology, radiology, and neonatology that
7    are provided by any health care provider;
8        (2) items and services provided by assistant surgeons,
9    hospitalists, and intensivists;
10        (3) diagnostic services, including radiology and
11    laboratory services, except for advanced diagnostic
12    laboratory tests identified on the most current list
13    published by the United States Secretary of Health and
14    Human Services under 42 U.S.C. 300gg-132(b)(3);
15        (4) items and services provided by other specialty
16    practitioners as the United States Secretary of Health and
17    Human Services specifies through rulemaking under 42
18    U.S.C. 300gg-132(b)(3);
19        (5) items and services provided by a nonparticipating
20    provider if there is no participating provider who can
21    furnish the item or service at the facility; and
22        (6) items and services provided by a nonparticipating
23    provider if there is no participating provider who will
24    furnish the item or service because a participating
25    provider has asserted the participating provider's rights
26    under the Health Care Right of Conscience Act; and .

 

 

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1        (7) reproductive health care, as defined in Section
2    1-10 of the Reproductive Health Act.
3    "Cost sharing" means the amount an insured, beneficiary,
4or enrollee is responsible for paying for a covered item or
5service under the terms of the policy or certificate. "Cost
6sharing" includes copayments, coinsurance, and amounts paid
7toward deductibles, but does not include amounts paid towards
8premiums, balance billing by out-of-network providers, or the
9cost of items or services that are not covered under the policy
10or certificate.
11    "Emergency department of a hospital" means any hospital
12department that provides emergency services, including a
13hospital outpatient department.
14    "Emergency medical condition" has the meaning ascribed to
15that term in Section 10 of the Managed Care Reform and Patient
16Rights Act.
17    "Emergency medical screening examination" has the meaning
18ascribed to that term in Section 10 of the Managed Care Reform
19and Patient Rights Act.
20    "Emergency services" means, with respect to an emergency
21medical condition:
22        (1) in general, an emergency medical screening
23    examination, including ancillary services routinely
24    available to the emergency department to evaluate such
25    emergency medical condition, and such further medical
26    examination and treatment as would be required to

 

 

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1    stabilize the patient regardless of the department of the
2    hospital or other facility in which such further
3    examination or treatment is furnished; or
4        (2) additional items and services for which benefits
5    are provided or covered under the coverage and that are
6    furnished by a nonparticipating provider or
7    nonparticipating emergency facility regardless of the
8    department of the hospital or other facility in which such
9    items are furnished after the insured, beneficiary, or
10    enrollee is stabilized and as part of outpatient
11    observation or an inpatient or outpatient stay with
12    respect to the visit in which the services described in
13    paragraph (1) are furnished. Services after stabilization
14    cease to be emergency services only when all the
15    conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
16    regulations thereunder are met.
17    "Freestanding Emergency Center" means a facility licensed
18under Section 32.5 of the Emergency Medical Services (EMS)
19Systems Act.
20    "Health care facility" means, in the context of
21non-emergency services, any of the following:
22        (1) a hospital as defined in 42 U.S.C. 1395x(e);
23        (2) a hospital outpatient department;
24        (3) a critical access hospital certified under 42
25    U.S.C. 1395i-4(e);
26        (4) an ambulatory surgical treatment center as defined

 

 

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1    in the Ambulatory Surgical Treatment Center Act; or
2        (5) any recipient of a license under the Hospital
3    Licensing Act that is not otherwise described in this
4    definition.
5    "Health care provider" means a provider as defined in
6subsection (d) of Section 370g. "Health care provider" does
7not include a provider of air ambulance or ground ambulance
8services.
9    "Health care services" has the meaning ascribed to that
10term in subsection (a) of Section 370g.
11    "Health insurance issuer" has the meaning ascribed to that
12term in Section 5 of the Illinois Health Insurance Portability
13and Accountability Act.
14    "Nonparticipating emergency facility" means, with respect
15to the furnishing of an item or service under a policy of group
16or individual health insurance coverage, any of the following
17facilities that does not have a contractual relationship
18directly or indirectly with a health insurance issuer in
19relation to the coverage:
20        (1) an emergency department of a hospital;
21        (2) a Freestanding Emergency Center;
22        (3) an ambulatory surgical treatment center as defined
23    in the Ambulatory Surgical Treatment Center Act; or
24        (4) with respect to emergency services described in
25    paragraph (2) of the definition of "emergency services", a
26    hospital.

 

 

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1    "Nonparticipating provider" means, with respect to the
2furnishing of an item or service under a policy of group or
3individual health insurance coverage, any health care provider
4who does not have a contractual relationship directly or
5indirectly with a health insurance issuer in relation to the
6coverage.
7    "Participating emergency facility" means any of the
8following facilities that has a contractual relationship
9directly or indirectly with a health insurance issuer offering
10group or individual health insurance coverage setting forth
11the terms and conditions on which a relevant health care
12service is provided to an insured, beneficiary, or enrollee
13under the coverage:
14        (1) an emergency department of a hospital;
15        (2) a Freestanding Emergency Center;
16        (3) an ambulatory surgical treatment center as defined
17    in the Ambulatory Surgical Treatment Center Act; or
18        (4) with respect to emergency services described in
19    paragraph (2) of the definition of "emergency services", a
20    hospital.
21    For purposes of this definition, a single case agreement
22between an emergency facility and an issuer that is used to
23address unique situations in which an insured, beneficiary, or
24enrollee requires services that typically occur out-of-network
25constitutes a contractual relationship and is limited to the
26parties to the agreement.

 

 

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1    "Participating health care facility" means any health care
2facility that has a contractual relationship directly or
3indirectly with a health insurance issuer offering group or
4individual health insurance coverage setting forth the terms
5and conditions on which a relevant health care service is
6provided to an insured, beneficiary, or enrollee under the
7coverage. A single case agreement between an emergency
8facility and an issuer that is used to address unique
9situations in which an insured, beneficiary, or enrollee
10requires services that typically occur out-of-network
11constitutes a contractual relationship for purposes of this
12definition and is limited to the parties to the agreement.
13    "Participating provider" means any health care provider
14that has a contractual relationship directly or indirectly
15with a health insurance issuer offering group or individual
16health insurance coverage setting forth the terms and
17conditions on which a relevant health care service is provided
18to an insured, beneficiary, or enrollee under the coverage.
19    "Qualifying payment amount" has the meaning given to that
20term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
21promulgated thereunder.
22    "Recognized amount" means the lesser of the amount
23initially billed by the provider or the qualifying payment
24amount.
25    "Stabilize" means "stabilization" as defined in Section 10
26of the Managed Care Reform and Patient Rights Act.

 

 

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1    "Treating provider" means a health care provider who has
2evaluated the individual.
3    "Visit" means, with respect to health care services
4furnished to an individual at a health care facility, health
5care services furnished by a provider at the facility, as well
6as equipment, devices, telehealth services, imaging services,
7laboratory services, and preoperative and postoperative
8services regardless of whether the provider furnishing such
9services is at the facility.
10    (b) Emergency services. When a beneficiary, insured, or
11enrollee receives emergency services from a nonparticipating
12provider or a nonparticipating emergency facility, the health
13insurance issuer shall ensure that the beneficiary, insured,
14or enrollee shall incur no greater out-of-pocket costs than
15the beneficiary, insured, or enrollee would have incurred with
16a participating provider or a participating emergency
17facility. Any cost-sharing requirements shall be applied as
18though the emergency services had been received from a
19participating provider or a participating facility. Cost
20sharing shall be calculated based on the recognized amount for
21the emergency services. If the cost sharing for the same item
22or service furnished by a participating provider would have
23been a flat-dollar copayment, that amount shall be the
24cost-sharing amount unless the provider has billed a lesser
25total amount. In no event shall the beneficiary, insured,
26enrollee, or any group policyholder or plan sponsor be liable

 

 

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1to or billed by the health insurance issuer, the
2nonparticipating provider, or the nonparticipating emergency
3facility for any amount beyond the cost sharing calculated in
4accordance with this subsection with respect to the emergency
5services delivered. Administrative requirements or limitations
6shall be no greater than those applicable to emergency
7services received from a participating provider or a
8participating emergency facility.
9    (b-5) Non-emergency services at participating health care
10facilities.
11        (1) When a beneficiary, insured, or enrollee utilizes
12    a participating health care facility and, due to any
13    reason, covered ancillary services are provided by a
14    nonparticipating provider during or resulting from the
15    visit, the health insurance issuer shall ensure that the
16    beneficiary, insured, or enrollee shall incur no greater
17    out-of-pocket costs than the beneficiary, insured, or
18    enrollee would have incurred with a participating provider
19    for the ancillary services. Any cost-sharing requirements
20    shall be applied as though the ancillary services had been
21    received from a participating provider. Cost sharing shall
22    be calculated based on the recognized amount for the
23    ancillary services. If the cost sharing for the same item
24    or service furnished by a participating provider would
25    have been a flat-dollar copayment, that amount shall be
26    the cost-sharing amount unless the provider has billed a

 

 

SB0241- 11 -LRB103 27273 BMS 53644 b

1    lesser total amount. In no event shall the beneficiary,
2    insured, enrollee, or any group policyholder or plan
3    sponsor be liable to or billed by the health insurance
4    issuer, the nonparticipating provider, or the
5    participating health care facility for any amount beyond
6    the cost sharing calculated in accordance with this
7    subsection with respect to the ancillary services
8    delivered. In addition to ancillary services, the
9    requirements of this paragraph shall also apply with
10    respect to covered items or services furnished as a result
11    of unforeseen, urgent medical needs that arise at the time
12    an item or service is furnished, regardless of whether the
13    nonparticipating provider satisfied the notice and consent
14    criteria under paragraph (2) of this subsection.
15        (2) When a beneficiary, insured, or enrollee utilizes
16    a participating health care facility and receives
17    non-emergency covered health care services other than
18    those described in paragraph (1) of this subsection from a
19    nonparticipating provider during or resulting from the
20    visit, the health insurance issuer shall ensure that the
21    beneficiary, insured, or enrollee incurs no greater
22    out-of-pocket costs than the beneficiary, insured, or
23    enrollee would have incurred with a participating provider
24    unless the nonparticipating provider or the participating
25    health care facility on behalf of the nonparticipating
26    provider satisfies the notice and consent criteria

 

 

SB0241- 12 -LRB103 27273 BMS 53644 b

1    provided in 42 U.S.C. 300gg-132 and regulations
2    promulgated thereunder. If the notice and consent criteria
3    are not satisfied, then:
4            (A) any cost-sharing requirements shall be applied
5        as though the health care services had been received
6        from a participating provider;
7            (B) cost sharing shall be calculated based on the
8        recognized amount for the health care services; and
9            (C) in no event shall the beneficiary, insured,
10        enrollee, or any group policyholder or plan sponsor be
11        liable to or billed by the health insurance issuer,
12        the nonparticipating provider, or the participating
13        health care facility for any amount beyond the cost
14        sharing calculated in accordance with this subsection
15        with respect to the health care services delivered.
16    (c) Notwithstanding any other provision of this Code,
17except when the notice and consent criteria are satisfied for
18the situation in paragraph (2) of subsection (b-5), any
19benefits a beneficiary, insured, or enrollee receives for
20services under the situations in subsection (b) or (b-5) are
21assigned to the nonparticipating providers or the facility
22acting on their behalf. Upon receipt of the provider's bill or
23facility's bill, the health insurance issuer shall provide the
24nonparticipating provider or the facility with a written
25explanation of benefits that specifies the proposed
26reimbursement and the applicable deductible, copayment, or

 

 

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1coinsurance amounts owed by the insured, beneficiary, or
2enrollee. The health insurance issuer shall pay any
3reimbursement subject to this Section directly to the
4nonparticipating provider or the facility.
5    (d) For bills assigned under subsection (c), the
6nonparticipating provider or the facility may bill the health
7insurance issuer for the services rendered, and the health
8insurance issuer may pay the billed amount or attempt to
9negotiate reimbursement with the nonparticipating provider or
10the facility. Within 30 calendar days after the provider or
11facility transmits the bill to the health insurance issuer,
12the issuer shall send an initial payment or notice of denial of
13payment with the written explanation of benefits to the
14provider or facility. If attempts to negotiate reimbursement
15for services provided by a nonparticipating provider do not
16result in a resolution of the payment dispute within 30 days
17after receipt of written explanation of benefits by the health
18insurance issuer, then the health insurance issuer or
19nonparticipating provider or the facility may initiate binding
20arbitration to determine payment for services provided on a
21per-bill basis. The party requesting arbitration shall notify
22the other party arbitration has been initiated and state its
23final offer before arbitration. In response to this notice,
24the nonrequesting party shall inform the requesting party of
25its final offer before the arbitration occurs. Arbitration
26shall be initiated by filing a request with the Department of

 

 

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1Insurance.
2    (e) The Department of Insurance shall publish a list of
3approved arbitrators or entities that shall provide binding
4arbitration. These arbitrators shall be American Arbitration
5Association or American Health Lawyers Association trained
6arbitrators. Both parties must agree on an arbitrator from the
7Department of Insurance's or its approved entity's list of
8arbitrators. If no agreement can be reached, then a list of 5
9arbitrators shall be provided by the Department of Insurance
10or the approved entity. From the list of 5 arbitrators, the
11health insurance issuer can veto 2 arbitrators and the
12provider or facility can veto 2 arbitrators. The remaining
13arbitrator shall be the chosen arbitrator. This arbitration
14shall consist of a review of the written submissions by both
15parties. The arbitrator shall not establish a rebuttable
16presumption that the qualifying payment amount should be the
17total amount owed to the provider or facility by the
18combination of the issuer and the insured, beneficiary, or
19enrollee. Binding arbitration shall provide for a written
20decision within 45 days after the request is filed with the
21Department of Insurance. Both parties shall be bound by the
22arbitrator's decision. The arbitrator's expenses and fees,
23together with other expenses, not including attorney's fees,
24incurred in the conduct of the arbitration, shall be paid as
25provided in the decision.
26    (f) (Blank).

 

 

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1    (g) Section 368a of this Act shall not apply during the
2pendency of a decision under subsection (d). Upon the issuance
3of the arbitrator's decision, Section 368a applies with
4respect to the amount, if any, by which the arbitrator's
5determination exceeds the issuer's initial payment under
6subsection (c), or the entire amount of the arbitrator's
7determination if initial payment was denied. Any interest
8required to be paid to a provider under Section 368a shall not
9accrue until after 30 days of an arbitrator's decision as
10provided in subsection (d), but in no circumstances longer
11than 150 days from the date the nonparticipating
12facility-based provider billed for services rendered.
13    (h) Nothing in this Section shall be interpreted to change
14the prudent layperson provisions with respect to emergency
15services under the Managed Care Reform and Patient Rights Act.
16    (i) Nothing in this Section shall preclude a health care
17provider from billing a beneficiary, insured, or enrollee for
18reasonable administrative fees, such as service fees for
19checks returned for nonsufficient funds and missed
20appointments.
21    (j) Nothing in this Section shall preclude a beneficiary,
22insured, or enrollee from assigning benefits to a
23nonparticipating provider when the notice and consent criteria
24are satisfied under paragraph (2) of subsection (b-5) or in
25any other situation not described in subsection (b) or (b-5).
26    (k) Except when the notice and consent criteria are

 

 

SB0241- 16 -LRB103 27273 BMS 53644 b

1satisfied under paragraph (2) of subsection (b-5), if an
2individual receives health care services under the situations
3described in subsection (b) or (b-5), no referral requirement
4or any other provision contained in the policy or certificate
5of coverage shall deny coverage, reduce benefits, or otherwise
6defeat the requirements of this Section for services that
7would have been covered with a participating provider.
8However, this subsection shall not be construed to preclude a
9provider contract with a health insurance issuer, or with an
10administrator or similar entity acting on the issuer's behalf,
11from imposing requirements on the participating provider,
12participating emergency facility, or participating health care
13facility relating to the referral of covered individuals to
14nonparticipating providers.
15    (l) Except if the notice and consent criteria are
16satisfied under paragraph (2) of subsection (b-5),
17cost-sharing amounts calculated in conformity with this
18Section shall count toward any deductible or out-of-pocket
19maximum applicable to in-network coverage.
20    (m) The Department has the authority to enforce the
21requirements of this Section in the situations described in
22subsections (b) and (b-5), and in any other situation for
23which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
24regulations promulgated thereunder would prohibit an
25individual from being billed or liable for emergency services
26furnished by a nonparticipating provider or nonparticipating

 

 

SB0241- 17 -LRB103 27273 BMS 53644 b

1emergency facility or for non-emergency health care services
2furnished by a nonparticipating provider at a participating
3health care facility.
4    (n) This Section does not apply with respect to air
5ambulance or ground ambulance services. This Section does not
6apply to any policy of excepted benefits or to short-term,
7limited-duration health insurance coverage.
8(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
 
9    Section 10. The Network Adequacy and Transparency Act is
10amended by changing Section 10 as follows:
 
11    (215 ILCS 124/10)
12    Sec. 10. Network adequacy.
13    (a) An insurer providing a network plan shall file a
14description of all of the following with the Director:
15        (1) The written policies and procedures for adding
16    providers to meet patient needs based on increases in the
17    number of beneficiaries, changes in the
18    patient-to-provider ratio, changes in medical and health
19    care capabilities, and increased demand for services.
20        (2) The written policies and procedures for making
21    referrals within and outside the network.
22        (3) The written policies and procedures on how the
23    network plan will provide 24-hour, 7-day per week access
24    to network-affiliated primary care, emergency services,

 

 

SB0241- 18 -LRB103 27273 BMS 53644 b

1    reproductive health care, and women's principal health
2    care providers.
3    An insurer shall not prohibit a preferred provider from
4discussing any specific or all treatment options with
5beneficiaries irrespective of the insurer's position on those
6treatment options or from advocating on behalf of
7beneficiaries within the utilization review, grievance, or
8appeals processes established by the insurer in accordance
9with any rights or remedies available under applicable State
10or federal law.
11    (b) Insurers must file for review a description of the
12services to be offered through a network plan. The description
13shall include all of the following:
14        (1) A geographic map of the area proposed to be served
15    by the plan by county service area and zip code, including
16    marked locations for preferred providers.
17        (2) As deemed necessary by the Department, the names,
18    addresses, phone numbers, and specialties of the providers
19    who have entered into preferred provider agreements under
20    the network plan.
21        (3) The number of beneficiaries anticipated to be
22    covered by the network plan.
23        (4) An Internet website and toll-free telephone number
24    for beneficiaries and prospective beneficiaries to access
25    current and accurate lists of preferred providers,
26    additional information about the plan, as well as any

 

 

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1    other information required by Department rule.
2        (5) A description of how health care services to be
3    rendered under the network plan are reasonably accessible
4    and available to beneficiaries. The description shall
5    address all of the following:
6            (A) the type of health care services to be
7        provided by the network plan;
8            (B) the ratio of physicians and other providers to
9        beneficiaries, by specialty and including primary care
10        physicians and facility-based physicians when
11        applicable under the contract, necessary to meet the
12        health care needs and service demands of the currently
13        enrolled population;
14            (C) the travel and distance standards for plan
15        beneficiaries in county service areas; and
16            (D) a description of how the use of telemedicine,
17        telehealth, or mobile care services may be used to
18        partially meet the network adequacy standards, if
19        applicable.
20        (6) A provision ensuring that whenever a beneficiary
21    has made a good faith effort, as evidenced by accessing
22    the provider directory, calling the network plan, and
23    calling the provider, to utilize preferred providers for a
24    covered service and it is determined the insurer does not
25    have the appropriate preferred providers due to
26    insufficient number, type, unreasonable travel distance or

 

 

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1    delay, or preferred providers refusing to provide a
2    covered service because it is contrary to the conscience
3    of the preferred providers, as protected by the Health
4    Care Right of Conscience Act, the insurer shall ensure,
5    directly or indirectly, by terms contained in the payer
6    contract, that the beneficiary will be provided the
7    covered service at no greater cost to the beneficiary than
8    if the service had been provided by a preferred provider.
9    This paragraph (6) does not apply to: (A) a beneficiary
10    who willfully chooses to access a non-preferred provider
11    for health care services available through the panel of
12    preferred providers, or (B) a beneficiary enrolled in a
13    health maintenance organization. In these circumstances,
14    the contractual requirements for non-preferred provider
15    reimbursements shall apply unless Section 356z.3a of the
16    Illinois Insurance Code requires otherwise. In no event
17    shall a beneficiary who receives care at a participating
18    health care facility be required to search for
19    participating providers under the circumstances described
20    in subsection (b) or (b-5) of Section 356z.3a of the
21    Illinois Insurance Code except under the circumstances
22    described in paragraph (2) of subsection (b-5).
23        (7) A provision that the beneficiary shall receive
24    emergency care coverage such that payment for this
25    coverage is not dependent upon whether the emergency
26    services are performed by a preferred or non-preferred

 

 

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1    provider and the coverage shall be at the same benefit
2    level as if the service or treatment had been rendered by a
3    preferred provider. For purposes of this paragraph (7),
4    "the same benefit level" means that the beneficiary is
5    provided the covered service at no greater cost to the
6    beneficiary than if the service had been provided by a
7    preferred provider. This provision shall be consistent
8    with Section 356z.3a of the Illinois Insurance Code.
9        (8) A limitation that, if the plan provides that the
10    beneficiary will incur a penalty for failing to
11    pre-certify inpatient hospital treatment, the penalty may
12    not exceed $1,000 per occurrence in addition to the plan
13    cost sharing provisions.
14    (c) The network plan shall demonstrate to the Director a
15minimum ratio of providers to plan beneficiaries as required
16by the Department.
17        (1) The ratio of physicians or other providers to plan
18    beneficiaries shall be established annually by the
19    Department in consultation with the Department of Public
20    Health based upon the guidance from the federal Centers
21    for Medicare and Medicaid Services. The Department shall
22    not establish ratios for vision or dental providers who
23    provide services under dental-specific or vision-specific
24    benefits. The Department shall consider establishing
25    ratios for the following physicians or other providers:
26            (A) Primary Care;

 

 

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1            (B) Pediatrics;
2            (C) Cardiology;
3            (D) Gastroenterology;
4            (E) General Surgery;
5            (F) Neurology;
6            (G) OB/GYN;
7            (H) Oncology/Radiation;
8            (I) Ophthalmology;
9            (J) Urology;
10            (K) Behavioral Health;
11            (L) Allergy/Immunology;
12            (M) Chiropractic;
13            (N) Dermatology;
14            (O) Endocrinology;
15            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
16            (Q) Infectious Disease;
17            (R) Nephrology;
18            (S) Neurosurgery;
19            (T) Orthopedic Surgery;
20            (U) Physiatry/Rehabilitative;
21            (V) Plastic Surgery;
22            (W) Pulmonary;
23            (X) Rheumatology;
24            (Y) Anesthesiology;
25            (Z) Pain Medicine;
26            (AA) Pediatric Specialty Services;

 

 

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1            (BB) Outpatient Dialysis; and
2            (CC) HIV; and .
3            (DD) Reproductive Health Care.
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    (d) The network plan shall demonstrate to the Director
9maximum travel and distance standards for plan beneficiaries,
10which shall be established annually by the Department in
11consultation with the Department of Public Health based upon
12the guidance from the federal Centers for Medicare and
13Medicaid Services. These standards shall consist of the
14maximum minutes or miles to be traveled by a plan beneficiary
15for each county type, such as large counties, metro counties,
16or rural counties as defined by Department rule.
17    The maximum travel time and distance standards must
18include standards for each physician and other provider
19category listed for which ratios have been established.
20    The Director shall establish a process for the review of
21the adequacy of these standards along with an assessment of
22additional specialties to be included in the list under this
23subsection (d).
24    (d-5)(1) Every insurer shall ensure that beneficiaries
25have timely and proximate access to treatment for mental,
26emotional, nervous, or substance use disorders or conditions

 

 

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1in accordance with the provisions of paragraph (4) of
2subsection (a) of Section 370c of the Illinois Insurance Code.
3Insurers shall use a comparable process, strategy, evidentiary
4standard, and other factors in the development and application
5of the network adequacy standards for timely and proximate
6access to treatment for mental, emotional, nervous, or
7substance use disorders or conditions and those for the access
8to treatment for medical and surgical conditions. As such, the
9network adequacy standards for timely and proximate access
10shall equally be applied to treatment facilities and providers
11for mental, emotional, nervous, or substance use disorders or
12conditions and specialists providing medical or surgical
13benefits pursuant to the parity requirements of Section 370c.1
14of the Illinois Insurance Code and the federal Paul Wellstone
15and Pete Domenici Mental Health Parity and Addiction Equity
16Act of 2008. Notwithstanding the foregoing, the network
17adequacy standards for timely and proximate access to
18treatment for mental, emotional, nervous, or substance use
19disorders or conditions shall, at a minimum, satisfy the
20following requirements:
21        (A) For beneficiaries residing in the metropolitan
22    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
23    network adequacy standards for timely and proximate access
24    to treatment for mental, emotional, nervous, or substance
25    use disorders or conditions means a beneficiary shall not
26    have to travel longer than 30 minutes or 30 miles from the

 

 

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1    beneficiary's residence to receive outpatient treatment
2    for mental, emotional, nervous, or substance use disorders
3    or conditions. Beneficiaries shall not be required to wait
4    longer than 10 business days between requesting an initial
5    appointment and being seen by the facility or provider of
6    mental, emotional, nervous, or substance use disorders or
7    conditions for outpatient treatment or to wait longer than
8    20 business days between requesting a repeat or follow-up
9    appointment and being seen by the facility or provider of
10    mental, emotional, nervous, or substance use disorders or
11    conditions for outpatient treatment; however, subject to
12    the protections of paragraph (3) of this subsection, a
13    network plan shall not be held responsible if the
14    beneficiary or provider voluntarily chooses to schedule an
15    appointment outside of these required time frames.
16        (B) For beneficiaries residing in Illinois counties
17    other than those counties listed in subparagraph (A) of
18    this paragraph, network adequacy standards for timely and
19    proximate access to treatment for mental, emotional,
20    nervous, or substance use disorders or conditions means a
21    beneficiary shall not have to travel longer than 60
22    minutes or 60 miles from the beneficiary's residence to
23    receive outpatient treatment for mental, emotional,
24    nervous, or substance use disorders or conditions.
25    Beneficiaries shall not be required to wait longer than 10
26    business days between requesting an initial appointment

 

 

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1    and being seen by the facility or provider of mental,
2    emotional, nervous, or substance use disorders or
3    conditions for outpatient treatment or to wait longer than
4    20 business days between requesting a repeat or follow-up
5    appointment and being seen by the facility or provider of
6    mental, emotional, nervous, or substance use disorders or
7    conditions for outpatient treatment; however, subject to
8    the protections of paragraph (3) of this subsection, a
9    network plan shall not be held responsible if the
10    beneficiary or provider voluntarily chooses to schedule an
11    appointment outside of these required time frames.
12    (2) For beneficiaries residing in all Illinois counties,
13network adequacy standards for timely and proximate access to
14treatment for mental, emotional, nervous, or substance use
15disorders or conditions means a beneficiary shall not have to
16travel longer than 60 minutes or 60 miles from the
17beneficiary's residence to receive inpatient or residential
18treatment for mental, emotional, nervous, or substance use
19disorders or conditions.
20    (3) If there is no in-network facility or provider
21available for a beneficiary to receive timely and proximate
22access to treatment for mental, emotional, nervous, or
23substance use disorders or conditions in accordance with the
24network adequacy standards outlined in this subsection, the
25insurer shall provide necessary exceptions to its network to
26ensure admission and treatment with a provider or at a

 

 

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1treatment facility in accordance with the network adequacy
2standards in this subsection.
3    (e) Except for network plans solely offered as a group
4health plan, these ratio and time and distance standards apply
5to the lowest cost-sharing tier of any tiered network.
6    (f) The network plan may consider use of other health care
7service delivery options, such as telemedicine or telehealth,
8mobile clinics, and centers of excellence, or other ways of
9delivering care to partially meet the requirements set under
10this Section.
11    (g) Except for the requirements set forth in subsection
12(d-5), insurers who are not able to comply with the provider
13ratios and time and distance standards established by the
14Department may request an exception to these requirements from
15the Department. The Department may grant an exception in the
16following 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
10material change to an approved network plan within 15 days
11after the change occurs and any change that would result in
12failure to meet the requirements of this Act. Upon notice from
13the insurer, the Director shall reevaluate the network plan's
14compliance with the network adequacy and transparency
15standards of this Act.
16(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
17102-1117, eff. 1-13-23.)
 
18    Section 99. Effective date. This Act takes effect July 1,
192024, except that the changes to Section 356z.3 of the
20Illinois Insurance Code take effect January 1, 2025.