99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
HB6562

 

Introduced , by Rep. Gregory Harris - Chad Hays - Ann M. Williams - Jeanne M Ives - Tom Demmer, et al.

 

SYNOPSIS AS INTRODUCED:
 
New Act

    Creates the Network Adequacy and Transparency Act. Provides that administrators and insurers, prior to going to market, must file with the Department of Insurance for review and approval a description of the services to be offered through a health care network plan with certain criteria included in the description. Provides that the health care network plan shall demonstrate to the Department, prior to approval, a minimum ratio of full-time equivalent providers to plan beneficiaries and maximum travel and distance burdens for plan beneficiaries based in the maximum minutes or miles to be traveled by a plan beneficiary for each county type as defined under the Act. Provides that the Department shall conduct periodic audits of health care network plan to verify compliance with network adequacy standards. Establishes certain notice requirements. Provides that a health care network plan shall provide for continuity of care for its beneficiaries based on certain circumstances. Provides that a health care network plan shall post electronically a current and accurate provider directory and make available in print, upon request, a provider directory each subject to the provision's specifications. Provides that the provisions of the Act are deemed incorporated into the health care providers service contracts entered into on or before the effective date of the Act. Provides that the Department is granted specific authority to issue a cease and desist order against, fine, or otherwise penalize any insurer or administrator for violations of any provision of the Act. Effective January 1, 2017.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB6562LRB099 21532 EGJ 47840 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 1. Short title. This Act may be cited as the
5Network Adequacy and Transparency Act.
 
6    Section 5. Definitions. In this Act:
7    "Active course of treatment" means (1) ongoing treatment
8for a life threatening condition, which is a disease or
9condition for which likelihood of death is probable unless the
10course of the disease or condition is interrupted; (2) ongoing
11treatment for a serious acute condition, defined as a disease
12or condition requiring complex ongoing care that the covered
13person is currently receiving, such as chemotherapy, radiation
14therapy, or post-operative visits; or (3) ongoing course of
15treatment for a health condition that a treating physician or
16health care provider attests that discontinuing care by that
17physician or health care provider would worsen the condition or
18interfere with anticipated outcomes; or
19    "Administrator" means any third party administrator
20regulated by the Department.
21    "Beneficiary" means an insured, enrollee, or covered
22person participating in a health care network plan.
23    "County type" means population and density parameters as

 

 

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1established by the designations of large, metro, micro, or
2rural.
3    "Large" means a county that meets the following population
4and density thresholds:
5        (1) a population greater than or equal to 1,000,000
6    persons and a population density of greater than or equal
7    to 1000 persons per square mile;
8        (2) a population between 500,000 and 999,999 persons
9    and a population density of greater than or equal to 1500
10    persons per square mile; or
11        (3) a population of any number of persons and a
12    population density of greater than or equal to 5000 persons
13    per square mile.
14    "Metro" means a county that meets the following population
15and density thresholds:
16        (1) a population greater than or equal to 1,000,000
17    persons and a population density of 10 to 999.9 persons per
18    square mile;
19        (2) a population of between 500,000 to 999,999 persons
20    and a population density of 10 to 1,499.9 persons per
21    square mile;
22        (3) a population of between 200,000 to 499,999 persons
23    and a population density of 10 to 4999.9 persons per square
24    mile;
25        (4) a population of between 50,000 and 199,999 persons
26    and a population density of 100 to 4,999.9 persons per

 

 

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1    square mile; or
2        (5) a population of between 10,000 to 49,999 persons
3    and a population density of 1,000 to 4,999.9 persons per
4    square mile.
5    "Micro" means a county that meets the following population
6and density thresholds:
7        (1) a population of between 50,000 and 199,999 persons
8    and a population density of 10 to 99.9 persons per square
9    mile; or
10        (2) a population between 10,000 and 49,999 persons and
11    a population density of 50 to 999.99 persons per square
12    mile.
13    "Rural" means a county that meets the following population
14and density thresholds:
15        (1) a population between 10,000 and 49,999 persons and
16    a population density of 10 to 49.9 persons per square mile;
17    or
18        (2) a population less than 10,000 persons and a
19    population density of 10 to 4,999.9 persons per square
20    mile.
21    "Department" means the Department of Insurance.
22    "Health care network plan" means an individual or group
23policy of accident and health insurance that either requires a
24beneficiary to use, or creates incentives, including financial
25incentives, for a beneficiary to use providers managed, owned,
26under contract with, or employed by any insurer or

 

 

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1administrator.
2    "Insurer" means any entity that offers individual or group
3accident and health insurance, including, but not limited to,
4Health Maintenance Organizations, Preferred Provider
5Organizations, exclusive provider organizations, Accountable
6Care Organizations, and other plan structures, excluding the
7medical assistance program and the state employees' health
8insurance program.
9    "Providers" means physicians licensed to practice medicine
10in all its branches, other health care professionals,
11hospitals, or other health care institutions that provide
12health care services.
13    "Material change" means a significant reduction in the
14number of providers or hospitals available in a health care
15network plan, including, but not limited to, a reduction in a
16specific type of providers, or a change in inclusion of a major
17health system that causes a network to be significantly
18different from the network when the beneficiary purchased the
19health care network plan.
20    "Tiered network" means a network that identifies and groups
21some or all types of providers and facilities into specific
22groups to which different provider reimbursement, covered
23person cost-sharing or provider access requirements, or any
24combination thereof, apply for the same services.
 
25    Section 10. Network adequacy.

 

 

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1    (a) Prior to going to market, administrators and insurers
2must file with the Department for review and approval a
3description of the services to be offered through a health care
4network plan. The description shall include all of the
5following:
6        (1) The method of marketing the health care network
7    plan;
8        (2) A geographic map of the area proposed to be served
9    by the plan by county and zip code, including marked
10    locations for preferred providers;
11        (3) The names, addresses, and specialties of the
12    providers who have entered into preferred provider
13    agreements under the program;
14        (4) The number of beneficiaries anticipated to be
15    covered by the providers listed under paragraph (3);
16        (5) An Internet website and toll-free telephone number
17    for beneficiaries and prospective beneficiaries to access
18    current and accurate lists of preferred providers,
19    additional information about the plan, as well as any other
20    information necessary established by the Department rule;
21        (6) A description of how health care services to be
22    rendered under the health care network plan are reasonably
23    accessible and available to beneficiaries. The description
24    shall address all of the following:
25            (A) The type of health care services to be provided
26        by the health care network plan;

 

 

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1            (B) The ratio of full-time equivalent physicians
2        and other providers to beneficiaries, by specialty and
3        including primary care physicians and facility-based
4        physicians when applicable under the contract,
5        necessary to meet the health care needs and service
6        demands of the currently enrolled population; and
7            (C) The travel and distance burdens for plan
8        beneficiaries.
9        (7) The written policies and procedures for
10    determining when the plan is closed to new providers
11    desiring to enter into a health care network plan;
12        (8) The written policies and procedures for adding
13    providers to meet patient needs based on increases in the
14    number of beneficiaries, changes in the patient to provider
15    ratio, changes in medical and health care capabilities, and
16    increased demand for services;
17        (9) The procedures for making referrals within and
18    outside the network;
19        (10) How the health care network plan will provide 24
20    hour, 7 day per week access to network affiliated primary
21    care and women's principal health care providers;
22        (11) A provision ensuring that whenever a beneficiary
23    has made a good faith effort to utilize preferred providers
24    for a covered service and it is determined the
25    administrator does not have the appropriate preferred
26    providers due to insufficient numbers, type, or distance,

 

 

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1    the administrator or insurer shall ensure, directly or
2    indirectly, by terms contained in the payor contract, that
3    the beneficiary will be provided the covered service at no
4    greater cost to the beneficiary than if the service had
5    been provided by a preferred provider;
6        (12) The procedures for paying benefits when
7    particular physician specialties are not represented
8    within the provider network, or the services of such
9    providers are not available at the time care is sought;
10        (13) A provision that the beneficiary shall receive
11    emergency care coverage such that payment for this coverage
12    is not dependent upon whether the services are performed by
13    a preferred or non-preferred provider and the coverage
14    shall be at the same benefit level as if the service or
15    treatment had been rendered by a preferred provider. For
16    purposes of this paragraph (13), "the same benefit level"
17    means that the beneficiary will be provided the covered
18    service at no greater cost to the beneficiary than if the
19    service had been provided by a preferred provider; and
20        (14) A limitation that, if the plan provides that the
21    beneficiary will incur a penalty for failing to pre-certify
22    inpatient hospital treatment, the penalty may not exceed
23    $1,000 per occurrence.
24    (b) The health care network plan shall demonstrate to the
25Department, prior to approval, a minimum ratio of full-time
26equivalent providers to plan beneficiaries.

 

 

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1        (1) The ratio of full-time equivalent physician
2    providers to plan beneficiaries shall be as follows:
3            (A) Primary Care Physician: 1 per 1,000
4            (B) Pediatrician: 1 per 1,000
5            (C) Cardiology: 1 per 10,000
6            (D) Gastroenterology: 1 per 10,000
7            (E) General Surgery: 1 per 5,000
8            (F) Neurology: 1 per 20,000
9            (G) OB/GYN: 1 per 2,500
10            (H) Oncology/Radiation: 1 per 15,000
11            (I) Ophthalmology: 1 per 10,000
12            (J) Urology: 1 per 10,000
13            (K) Behavioral Health: 1 per 5,000
14            (L) Allergy/Immunology: 1 per 15,000
15            (M) Chiropractor: 1 per 10,000
16            (N) Dermatology: 1 per 10,000
17            (O) Endocrinology: 1 per 10,000
18            (P) Ears, Nose, and Throat (ENT)/Otolaryngology: 1
19        per 15,000
20            (Q) Infectious Disease: 1 per 15,000
21            (R) Nephrology: 1 per 10,000
22            (S) Neurosurgery: 1 per 20,000
23            (T) Orthopedic Surgery: 1 per 10,000
24            (U) Physiatry/Rehabilitative: 1 per 15,000
25            (V) Plastic Surgery: 1 per 20,000
26            (W) Pulmonary: 1 per 10,000

 

 

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1            (X) Rheumatology: 1 per 10,000
2        (2) The health care network plan shall also demonstrate
3    the ratio of full-time equivalent physician providers to
4    plan beneficiaries related to pediatrics specialty care.
5    The ratio of full-time equivalent pediatric specialty
6    providers to plan beneficiaries shall be calculated
7    separately from ratio requirements set forth in paragraph
8    (1) of this subsection (b). The ratio of full-time
9    equivalent pediatric specialty providers to plan
10    beneficiaries shall be the same as those set forth in
11    paragraph (1) of this subsection (b) as related to each
12    applicable pediatric specialty.
13        (3) The Department shall establish a process for the
14    annual review of the adequacy of these standards, along
15    with an assessment of additional specialties to be included
16    in the list under this subsection.
17    (c) The health care network plan shall demonstrate to the
18Department, prior to approval, maximum travel and distance
19burdens for plan beneficiaries based on the maximum minutes or
20miles to be traveled by a plan beneficiary for each county type
21as defined in this Act.
22        (1) The maximum travel time and distance burdens for
23    each provider specialty are as follows:
24            (A) Primary Care:
25            Large: 10 minutes or 5 miles
26            Metro: 15 minutes or 10 miles

 

 

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1            Micro: 30 minutes or 20 miles
2            Rural 40 minutes or 30 miles
3            (B) OB/GYN/Pediatrics
4            Large 10 minutes or 5 miles
5            Metro 15 minutes or 10 miles
6            Micro 30 minutes or 20 miles
7            Rural40 minutes or 30 miles
8            (C) Dental
9            Large: 30 minutes or 15 miles
10            Metro: 45 minutes or 30 miles
11            Micro: 80 minutes or 60 miles
12            Rural: 90 minutes or 75 miles
13            (D) Endocrinology
14            Large: 30 minutes or 15 miles
15            Metro: 60 minutes or 40 miles
16            Micro: 100 minutes or 75 miles
17            Rural: 110 minutes or 90 miles
18            (E) Infectious Diseases
19            Large: 30 minutes or 15 miles
20            Metro: 60 minutes or 40 miles
21            Micro: 100 minutes or 75 miles
22            Rural: 110 minutes or 90 miles
23            (F) Oncology - Surgical
24            Large: 20 minutes or 10 miles
25            Metro: 45 minutes or 30 miles
26            Micro: 60 minutes or 45 miles

 

 

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1            Rural: 75 minutes or 60 miles
2            (G) Oncology - Radiology
3            Large: 30 minutes or 15 miles
4            Metro: 60 minutes or 40 miles
5            Micro: 100 minutes or 75 miles
6            Rural: 110 minutes or 90 miles
7            (H) Mental Health
8            Large: 20 minutes or 10 miles
9            Metro: 45 minutes or 30 miles
10            Micro: 60 minutes or 45 miles
11            Rural: 75 minutes or 60 miles
12            (I) Cardiology
13            Large: 20 minutes or 10 miles
14            Metro: 30 minutes or 20 miles
15            Micro: 50 minutes or 35 miles
16            Rural: 75 minutes or 60 miles
17            (J) Rheumatology
18            Large: 30 minutes or 15 miles
19            Metro: 60 minutes or 40 miles
20            Micro: 100 minutes or 75 miles
21            Rural: 110 minutes or 90 miles
22            (K) Outpatient Dialysis
23            Large: 30 minutes or 15 miles
24            Metro: 45 minutes or 30 miles
25            Micro: 80 minutes or 60 miles
26            Rural: 90 minutes or 75 miles

 

 

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1            (L) Inpatient Psychiatry
2            Large: 30 minutes or 15 miles
3            Metro: 70 minutes or 45 miles
4            Micro: 100 minutes or 75 miles
5            Rural: 90 minutes or 75 miles
6            (M) Hospital-based services, including, but not
7        limited to, emergency medicine, radiology, pathology,
8        anesthesiology, trauma surgery, and other hospital
9        based specialties, shall demonstrate the following
10        travel and distance burdens:
11            Large: 20 minutes or 10 miles
12            Metro: 45 minutes or 30 miles
13            Micro: 80 minutes or 60 miles
14            Rural: 75 minutes or 60 miles
15        (2) The health care network plan must be able to
16    demonstrate the maximum travel and distance burdens for
17    plan beneficiaries related to pediatric care. The maximum
18    travel and distance burdens for plan beneficiaries related
19    to pediatric specialties shall be calculated separately
20    from the travel and distance burdens set forth in paragraph
21    (1) of this subsection (c). The maximum travel time and
22    distance burdens related to pediatric specialties shall be
23    the same as those set forth in paragraph (1) of this
24    subsection (c) as related to each applicable pediatric
25    specialty.
26        (3) The Department shall establish a process for the

 

 

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1    annual review of the adequacy of these standards along with
2    an assessment of additional specialties to be included in
3    the list under this subsection.
4    (d) These ratio and time and distance standards apply
5separately to each cost-sharing tier of any tiered network.
6    (e) Insurers and administrators are required to report to
7the Department when any material change is made to any approved
8health care network plan within 15 days after the change
9occurs. Upon such notice from the carrier, the Department must
10reevaluate the health care network plan's ability to meet
11network adequacy standards.
12    (f) The Department shall conduct periodic audits of health
13care network plan to verify compliance with network adequacy
14standards. These audits shall include surveys to be sent to
15plan beneficiaries and providers for the purpose of assessing
16health care network plan compliance with the provisions of this
17Section.
 
18    Section 20. Notice of nonrenewal or termination. A health
19care network plan must give at least 60 days' notice of
20nonrenewal or termination of a health care provider to the
21health care provider and to the beneficiaries served by the
22health care provider. The notice shall include a name and
23address to which a beneficiary or health care provider may
24direct comments and concerns regarding the nonrenewal or
25termination and the telephone number maintained by the

 

 

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1Department for consumer complaints. Immediate written notice
2may be provided without 60 days' notice when a health care
3provider's license has been disciplined by a State licensing
4board.
 
5    Section 25. Transition of services.
6    (a) A health care network plan shall provide for continuity
7of care for its beneficiaries as follows:
8        (1) If a beneficiary's provider leaves the health care
9    network plan's network of health care providers for reasons
10    other than termination of a contract in situations
11    involving imminent harm to a patient or a final
12    disciplinary action by a State licensing board and the
13    provider remains within the healthcare network plan's
14    service area, the healthcare network plan shall permit the
15    beneficiary to continue an ongoing course of treatment with
16    that provider during a transitional period for the
17    following duration:
18            (A) 90 days from the date of the notice of
19        provider's termination from the healthcare network
20        plan to the beneficiary of the provider's
21        disaffiliation from the healthcare network plan if the
22        beneficiary has an active course of treatment; or
23            (B) if the beneficiary has entered the third
24        trimester of pregnancy at the time of the provider's
25        disaffiliation, that includes the provision of

 

 

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1        post-partum care directly related to the delivery.
2        (2) Notwithstanding the provisions in paragraph (1) of
3    this subsection (a), such care shall be authorized by the
4    health care network plan during the transitional period
5    only if the provider agrees to all the following
6    provisions:
7            (A) to continue to accept reimbursement from the
8        health care network plan at the rates and terms and
9        conditions, applicable prior to the start of the
10        transitional period;
11            (B) to adhere to the health care network plan's
12        quality assurance requirements and to provide to the
13        health care network plan necessary medical information
14        related to such care; and
15            (C) to otherwise adhere to the healthcare network
16        plan's policies and procedures, including, but not
17        limited to, procedures regarding referrals and
18        obtaining preauthorizations for treatment.
19        (3) The provisions of this Section governing health
20    care provided during the transition period do not apply if
21    the beneficiary has successfully transitioned to another
22    provider participating in the health care network plan, if
23    the beneficiary has already met or exceeded the benefit
24    limitations of the plan, or if the care provided is not
25    medically necessary.
26    (b) The termination or departure of a beneficiary's primary

 

 

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1care provider from a health care network plan shall constitute
2a qualifying event, allowing beneficiaries to select a new
3health care network plan outside of a standard open enrollment
4period within 60 days of notice of termination or departure.
5    (c) A health care network plan shall provide for continuity
6of care for new beneficiaries as follows:
7        (1) If a new beneficiary whose provider is not a member
8    of the health care network plan's provider network, but is
9    within the health care network plan's service area, enrolls
10    in the healthcare network plan, the health care network
11    plan shall permit the beneficiary to continue an ongoing
12    course of treatment with the beneficiary's current
13    physician during a transitional period:
14            (A) of 90 days from the effective date of
15        enrollment if the beneficiary has an ongoing active
16        course of treatment; or
17            (B) if the beneficiary has entered the third
18        trimester of pregnancy at the effective date of
19        enrollment, that includes the provision of post-partum
20        care directly related to the delivery.
21        (2) If a beneficiary elects to continue to receive care
22    from such provider pursuant to paragraph (1) of this
23    subsection (c), such care shall be authorized by the health
24    care network plan for the transitional period only if the
25    physician agrees to all of the following provisions:
26            (A) to accept reimbursement from the healthcare

 

 

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1        network plan at rates established by the healthcare
2        network plan;
3            (B) to adhere to the health care network plan's
4        quality assurance requirements and to provide to the
5        health care network plan necessary medical information
6        related to such care; and
7            (C) to otherwise adhere to the health care network
8        plan's policies and procedures, including, but not
9        limited to, procedures regarding referrals and
10        obtaining preauthorization for treatment.
11        (3) The provisions of this Section governing health
12    care provided during the transition period do not apply if
13    the beneficiary has successfully transitioned to another
14    provider participating in the health care network plan, if
15    the beneficiary has already met or exceeded the benefit
16    limitations of the plan, or the care provided is not
17    medically necessary.
18    (d) In no event shall this Section be construed to require
19a healthcare network plan to provide coverage for benefits not
20otherwise covered or to diminish or impair preexisting
21condition limitations contained in the beneficiary's contract.
 
22    Section 30. Network transparency.
23    (a) A health care network plan shall post electronically a
24current and accurate provider directory for each of its health
25care network plans with the information and search functions,

 

 

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1as described in this Section.
2    In making the directory available electronically, the
3health care network plan shall ensure that the general public
4is able to view all of the current providers for a plan through
5a clearly identifiable link or tab and without creating or
6accessing an account or entering a policy or contract number.
7    The health care network plan shall provide real time
8updates to the online provider directory.
9    The health care network plan shall audit monthly at least a
10reasonable sample size of its provider directories for accuracy
11and retain documentation of such an audit to be made available
12to the Department upon request.
13    A health care network plan shall provide a print copy, or a
14print copy of the requested directory information, of a current
15provider directory with the information upon request of a
16beneficiary or a prospective beneficiary. Print copies must be
17updated monthly or provide an errata that reflects changes in
18the provider network, to be updated monthly.
19    For each health care network plan, a healthcare network
20plan shall include in plain language in both the electronic and
21print directory, the following general information:
22        (1) In plain language, a description of the criteria
23    the plan has used to build its provider network;
24        (2) If applicable, in plain language, a description of
25    the criteria the administrator, insurer, or health care
26    network plan has used to create tiered networks;

 

 

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1        (3) If applicable, in plain language, how the health
2    care network plan designates the different provider tiers
3    or levels in the network and identifies for each specific
4    provider, hospital or other type of facility in the network
5    which tier each is placed, for example by name, symbols or
6    grouping, in order for a beneficiary covered person or a
7    prospective beneficiary covered person to be able to
8    identify the provider tier; and
9        (4) If applicable, note that authorization or referral
10    may be required to access some providers.
11    A health care network plan shall make it clear for both its
12electronic and print directories what provider directory
13applies to which health care network plan, such as including
14the specific name of the health care network plan as marketed
15and issued in this State. The healthcare network plan shall
16include in both its electronic and print directories a customer
17service email address and telephone number or electronic link
18that beneficiaries or the general public may use to notify the
19health care network plan of inaccurate provider directory
20information.
21    For the pieces of information required in a provider
22directory pertaining to a health care professional, a hospital
23or a facility other than a hospital, the health care network
24plan shall make available through the directory the source of
25the information and any limitations, if applicable.
26    A provider directory, whether in electronic or print

 

 

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1format, shall accommodate the communication needs of
2individuals with disabilities, and include a link to or
3information regarding available assistance for persons with
4limited English proficiency.
5    (b) The health care network plan shall make available
6through an electronic provider directory, for each health care
7network plan, the information under this subsection (b) in a
8searchable format:
9        (1) For health care professionals:
10            (A) Name;
11            (B) Gender;
12            (C) Participating office locations;
13            (D) Specialty, if applicable;
14            (E) Medical group affiliations, if applicable;
15            (F) Facility affiliations, if applicable;
16            (G) Participating facility affiliations, if
17        applicable;
18            (H) Languages spoken other than English, if
19        applicable; and
20            (I) Whether accepting new patients.
21        (2) For hospitals:
22            (A) Hospital name;
23            (B) Hospital type (such as acute, rehabilitation,
24        children's, cancer);
25            (C) Participating hospital location; and
26            (D) Hospital accreditation status; and

 

 

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1        (3) For facilities, other than hospitals, by type:
2            (A) Facility name;
3            (B) Facility type;
4            (C) Types of services performed; and
5            (D) Participating facility locations.
6    (c) For the electronic provider directories, for each
7health care network plan, a healthcare network plan shall make
8available the following information all of the information:
9        (1) For health care professionals:
10            (A) Contact information;
11            (B) Board certifications; and
12            (C) Languages spoken other than English by
13        clinical staff, if applicable;
14        (2) For hospitals: Telephone number; and
15        (3) For facilities other than hospitals: Telephone
16    number.
17    (d) The administrator, insurer, or health care network plan
18shall make available in print, upon request, the following
19provider directory information for the applicable health care
20network plan:
21        (1) For health care professionals:
22            (A) Name;
23            (B) Contact information;
24            (C) Participating office location(s);
25            (D) Specialty, if applicable;
26            (E) Languages spoken other than English, if

 

 

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1        applicable; and
2            (F) Whether accepting new patients.
3        (2) For hospitals:
4            (A) Hospital name;
5            (B) Hospital type (such as acute, rehabilitation,
6        children's, cancer); and
7            (C) Participating hospital location and telephone
8        number; and
9        (3) For facilities, other than hospitals, by type:
10            (A) Facility name;
11            (B) Facility type;
12            (C) Types of services performed; and
13            (D) Participating facility locations and telephone
14        number.
15    (e) The health care network plan shall include a disclosure
16in the print format provider directory that the information
17included in the directory is accurate as of the date of
18printing and that covered persons or prospective covered
19persons should consult the carrier's electronic provider
20directory on its website. The health care network plan shall
21also include a telephone number in the print format provider
22directory for a customer service representative or serve where
23the beneficiary can obtain current provider directory
24information.
25    (f) Where the violation results in an enrollee's use of an
26out-of-network provider despite the enrollee's reasonable

 

 

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1efforts to remain in network, require the health insurer to:
2        (1) pay the non-contracted provider's charge as stated
3    on the claim form;
4        (2) ensure that the enrollee's financial obligations
5    are no greater than if the service had provided by an
6    in-network provider; and
7        (3) apply the enrollee's out-of-pocket expenses to any
8    out-of-pocket maximum under his or her health insurance
9    plan.
10    (g) The Department shall conduct periodic audits of the
11accuracy of provider directories to ensure health plan
12compliance.
 
13    Section 40. Administration and enforcement.
14    (a) Insurers and administrators have a continuing
15obligation to comply with the requirements of this Act. Other
16than the duties specifically created in this Act, nothing in
17this Act is intended to preclude, prevent, or require the
18adoption, modification, or termination of any utilization
19management, quality management, or claims processing
20methodologies or other provisions of a contract applicable to
21services provided under a contract between an insurer, health
22care network plan, or physician hospital organization and a
23health care professional or health care provider.
24    (b) Nothing in this Act precludes, prevents, or requires
25the adoption, modification, or termination of any health care

 

 

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1network plan term, benefit, coverage or eligibility provision,
2or payment methodology.
3    (c) The provisions of this Act are deemed incorporated into
4health care provider service contracts entered into on or
5before the effective date of this Act and do not require a
6health care network plan to renew or renegotiate the contracts
7with a health care provider.
8    (d) The Department shall enforce the provisions of this Act
9pursuant to the enforcement powers granted to it by law.
10    (e) The Department is hereby granted specific authority to
11issue a cease and desist order against, fine, or otherwise
12penalize any insurer or administrator for violations of any
13provision of this Act.
14    (f) The Department shall adopt rules to enforce compliance
15with this Act.
 
16    Section 99. Effective date. This Act takes effect January
171, 2017.