Illinois 2023-2024 Regular Session

Illinois House Bill HB4126 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4126 Introduced , by Rep. Sue Scherer SYNOPSIS AS INTRODUCED: See Index Amends the Illinois Insurance Code. Adds provisions concerning market analysis and market conduct actions. Makes changes to provisions concerning market conduct and non-financial examinations, examination reports, insurance compliance self-evaluative privilege, confidentiality, fees and charges, examination, and fiduciary and bonding requirements. Amends the Network Adequacy and Transparency Act. Adds definitions. Establishes minimum ratios of providers to beneficiaries for network plans issued, delivered, amended, or renewed during 2024. Makes changes to provisions concerning network adequacy, notice of nonrenewal or termination, transition of services, network transparency, administration and enforcement, and provider requirements. Amends the Managed Care Reform and Patient Rights Act. Makes changes to provisions concerning notice of nonrenewal or termination and transition of services. Amends the Illinois Administrative Procedure Act to authorize the Department of Insurance to adopt emergency rules implementing federal standards for provider ratios, time and distance, or appointment wait times when such standards apply to health insurance coverage regulated by the Department of Insurance and are more stringent than the State standards extant at the time the final federal standards are published. Effective immediately. LRB103 33572 RJT 63384 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4126 Introduced , by Rep. Sue Scherer SYNOPSIS AS INTRODUCED: See Index See Index Amends the Illinois Insurance Code. Adds provisions concerning market analysis and market conduct actions. Makes changes to provisions concerning market conduct and non-financial examinations, examination reports, insurance compliance self-evaluative privilege, confidentiality, fees and charges, examination, and fiduciary and bonding requirements. Amends the Network Adequacy and Transparency Act. Adds definitions. Establishes minimum ratios of providers to beneficiaries for network plans issued, delivered, amended, or renewed during 2024. Makes changes to provisions concerning network adequacy, notice of nonrenewal or termination, transition of services, network transparency, administration and enforcement, and provider requirements. Amends the Managed Care Reform and Patient Rights Act. Makes changes to provisions concerning notice of nonrenewal or termination and transition of services. Amends the Illinois Administrative Procedure Act to authorize the Department of Insurance to adopt emergency rules implementing federal standards for provider ratios, time and distance, or appointment wait times when such standards apply to health insurance coverage regulated by the Department of Insurance and are more stringent than the State standards extant at the time the final federal standards are published. Effective immediately. LRB103 33572 RJT 63384 b LRB103 33572 RJT 63384 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4126 Introduced , by Rep. Sue Scherer SYNOPSIS AS INTRODUCED:
3	3	See Index See Index
4	4	See Index
5	5	Amends the Illinois Insurance Code. Adds provisions concerning market analysis and market conduct actions. Makes changes to provisions concerning market conduct and non-financial examinations, examination reports, insurance compliance self-evaluative privilege, confidentiality, fees and charges, examination, and fiduciary and bonding requirements. Amends the Network Adequacy and Transparency Act. Adds definitions. Establishes minimum ratios of providers to beneficiaries for network plans issued, delivered, amended, or renewed during 2024. Makes changes to provisions concerning network adequacy, notice of nonrenewal or termination, transition of services, network transparency, administration and enforcement, and provider requirements. Amends the Managed Care Reform and Patient Rights Act. Makes changes to provisions concerning notice of nonrenewal or termination and transition of services. Amends the Illinois Administrative Procedure Act to authorize the Department of Insurance to adopt emergency rules implementing federal standards for provider ratios, time and distance, or appointment wait times when such standards apply to health insurance coverage regulated by the Department of Insurance and are more stringent than the State standards extant at the time the final federal standards are published. Effective immediately.
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8	8	A BILL FOR
9	9	HB4126LRB103 33572 RJT 63384 b HB4126 LRB103 33572 RJT 63384 b
10	10	HB4126 LRB103 33572 RJT 63384 b
11	11	1 AN ACT concerning regulation.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Administrative Procedure Act is
15	15	5 amended by adding Section 5-45.21 as follows:
16	16	6 (5 ILCS 100/5-45.21 new)
17	17	7 Sec. 5-45.21. Emergency rulemaking; Network Adequacy and
18	18	8 Transparency Act. To provide for the expeditious and timely
19	19	9 implementation of the Network Adequacy and Transparency Act,
20	20	10 emergency rules implementing federal standards for provider
21	21	11 ratios, travel time and distance, and appointment wait times
22	22	12 if such standards apply to health insurance coverage regulated
23	23	13 by the Department of Insurance and are more stringent than the
24	24	14 State standards extant at the time the final federal standards
25	25	15 are published may be adopted in accordance with Section 5-45
26	26	16 by the Department of Insurance. The adoption of emergency
27	27	17 rules authorized by Section 5-45 and this Section is deemed to
28	28	18 be necessary for the public interest, safety, and welfare.
29	29	19 Section 10. The Illinois Insurance Code is amended by
30	30	20 changing Sections 132, 132.5, 155.35, 402, 408, 511.109,
31	31	21 512-3, 512-5, and 513b3 and by adding Section 512-11 as
32	32	22 follows:
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36	36	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4126 Introduced , by Rep. Sue Scherer SYNOPSIS AS INTRODUCED:
37	37	See Index See Index
38	38	See Index
39	39	Amends the Illinois Insurance Code. Adds provisions concerning market analysis and market conduct actions. Makes changes to provisions concerning market conduct and non-financial examinations, examination reports, insurance compliance self-evaluative privilege, confidentiality, fees and charges, examination, and fiduciary and bonding requirements. Amends the Network Adequacy and Transparency Act. Adds definitions. Establishes minimum ratios of providers to beneficiaries for network plans issued, delivered, amended, or renewed during 2024. Makes changes to provisions concerning network adequacy, notice of nonrenewal or termination, transition of services, network transparency, administration and enforcement, and provider requirements. Amends the Managed Care Reform and Patient Rights Act. Makes changes to provisions concerning notice of nonrenewal or termination and transition of services. Amends the Illinois Administrative Procedure Act to authorize the Department of Insurance to adopt emergency rules implementing federal standards for provider ratios, time and distance, or appointment wait times when such standards apply to health insurance coverage regulated by the Department of Insurance and are more stringent than the State standards extant at the time the final federal standards are published. Effective immediately.
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42	42	A BILL FOR
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67	67	1 (215 ILCS 5/132) (from Ch. 73, par. 744)
68	68	2 Sec. 132. Market conduct and non-financial examinations.
69	69	3 (a) Definitions.
70	70	4 As used in this Section:
71	71	5 "Desk examination" means an examination conducted by
72	72	6 market conduct surveillance personnel at a location other than
73	73	7 the regulated person's premises. A "desk examination" is
74	74	8 usually performed at the Department's offices with the insurer
75	75	9 providing requested documents by hard copy, microfiche, discs,
76	76	10 or other electronic media for review without an on-site
77	77	11 examination.
78	78	12 "Market analysis" means a process whereby market conduct
79	79	13 surveillance personnel collect and analyze information from
80	80	14 filed schedules, surveys, data calls, required reports, and
81	81	15 other sources in order to develop a baseline understanding of
82	82	16 the marketplace and to identify patterns or practices of
83	83	17 regulated persons that deviate significantly from the norm or
84	84	18 that may pose a potential risk to the insurance consumer.
85	85	19 "Market conduct action" means any of the full range of
86	86	20 activities that the Director may initiate to assess and
87	87	21 address the market practices of regulated persons, including,
88	88	22 but not limited to, market analysis and market conduct
89	89	23 examinations. "Market conduct action" does not include the
90	90	24 Department's consumer complaint process outlined in 50 Ill.
91	91	25 Adm. Code 926; however, the Department may initiate market
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102	102	1 conduct actions based on information gathered during that
103	103	2 process. Examples of "market conduct action" include, but are
104	104	3 not limited to:
105	105	4 (1) correspondence with the company or person;
106	106	5 (2) interviews with the company or person;
107	107	6 (3) information gathering;
108	108	7 (4) reviews of policies and procedures;
109	109	8 (5) interrogatories;
110	110	9 (6) reviews of self-evaluations and voluntary
111	111	10 compliance programs of the person or company;
112	112	11 (7) self-audits; and
113	113	12 (8) market conduct examinations.
114	114	13 "Market conduct examination" or "examination" means any
115	115	14 type of examination described in the NAIC Market Regulation
116	116	15 Handbook that may be used to assess a regulated person's
117	117	16 compliance with the laws, rules, and regulations applicable to
118	118	17 the examinee. "Market conduct examination" includes
119	119	18 comprehensive examinations, targeted examinations, and
120	120	19 follow-up examinations. Market conduct examinations may be
121	121	20 conducted as desk examinations, on-site examinations, or a
122	122	21 combination of those 2 types of examinations.
123	123	22 "Market conduct surveillance" means market analysis or a
124	124	23 market conduct action.
125	125	24 "Market conduct surveillance personnel" means those
126	126	25 individuals employed or retained by the Department and
127	127	26 designated by the Director to collect, analyze, review, or act
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138	138	1 on information in the insurance marketplace that identifies
139	139	2 patterns or practices of insurers. "Market conduct
140	140	3 surveillance personnel" includes all persons identified as an
141	141	4 examiner in the insurance laws or rules of this State if the
142	142	5 Director has designated those persons to assist the Director
143	143	6 in ascertaining the non-financial business practices,
144	144	7 performance, and operations of a company or person subject to
145	145	8 the Director's jurisdiction.
146	146	9 "NAIC" means the National Association of Insurance
147	147	10 Commissioners.
148	148	11 "On-site examination" means an examination conducted at
149	149	12 the insurer's home office or the location where the records
150	150	13 under review are stored.
151	151	14 (b) Examinations. (1)
152	152	15 The Director, for the purposes of ascertaining the
153	153	16 non-financial business practices, performance, and operations
154	154	17 of any company, may make examinations of:
155	155	18 (1) (a) any company transacting or being organized to
156	156	19 transact business in this State;
157	157	20 (2) (b) any person engaged in or proposing to be
158	158	21 engaged in the organization, promotion, or solicitation of
159	159	22 shares or capital contributions to or aiding in the
160	160	23 formation of a company;
161	161	24 (3) (c) any person having a contract, written or oral,
162	162	25 pertaining to the management or control of a company as
163	163	26 general agent, managing agent, or attorney-in-fact;
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174	174	1 (4) (d) any licensed or registered producer, firm, or
175	175	2 administrator, or any person, organization, or corporation
176	176	3 making application for any licenses or registration;
177	177	4 (5) (e) any person engaged in the business of
178	178	5 adjusting losses or financing premiums; or
179	179	6 (6) (f) any person, organization, trust, or
180	180	7 corporation having custody or control of information
181	181	8 reasonably related to the operation, performance, or
182	182	9 conduct of a company or person subject to the jurisdiction
183	183	10 of the Director.
184	184	11 (c) Market analysis and market conduct actions.
185	185	12 (1) The Director may perform market analysis by
186	186	13 gathering and analyzing information from data currently
187	187	14 available to the Director, information from surveys or
188	188	15 reports that are submitted regularly to the Director or
189	189	16 required in a data call, information collected by the
190	190	17 NAIC, and information from a variety of other sources in
191	191	18 both the public and private domain in order to develop a
192	192	19 baseline understanding of the marketplace and to identify
193	193	20 for further review practices that deviate from the norm or
194	194	21 that may pose a potential risk to the insurance consumer.
195	195	22 The Director shall use the NAIC Market Regulation Handbook
196	196	23 as a guide in performing market analysis.
197	197	24 (2) If the Director determines that further inquiry
198	198	25 into a particular person or practice is needed, the
199	199	26 Director may consider one or more market conduct actions.
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210	210	1 The Director shall inform the examinee in writing of the
211	211	2 type of market conduct action selected and shall use the
212	212	3 NAIC Market Regulation Handbook as a guide in performing
213	213	4 the market conduct action. The Director may coordinate a
214	214	5 market conduct action and findings of this State with
215	215	6 market conduct actions and findings of other states.
216	216	7 (3) Nothing in this Section requires the Director to
217	217	8 conduct market analysis prior to initiating any market
218	218	9 conduct action.
219	219	10 (4) Nothing in this Section restricts the Director to
220	220	11 the type of market conduct action initially selected. The
221	221	12 Director shall inform the examinee in writing of any
222	222	13 change in the type of market conduct action being
223	223	14 conducted.
224	224	15 (d) Access to books and records; oaths and examinations.
225	225	16 (2) Every examinee company or person being examined and
226	226	17 its officers, directors, and agents must provide to the
227	227	18 Director convenient and free access at all reasonable hours at
228	228	19 its office or location to all books, records, documents,
229	229	20 including consumer communications, and any or all papers
230	230	21 relating to the business, performance, operations, and affairs
231	231	22 of the examinee company. The officers, directors, and agents
232	232	23 of the examinee company or person must facilitate the market
233	233	24 conduct action examination and aid in the action examination
234	234	25 so far as it is in their power to do so.
235	235	26 The Director and any authorized market conduct
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246	246	1 surveillance personnel examiner have the power to administer
247	247	2 oaths and examine under oath any person relative to the
248	248	3 business of the examinee company being examined. Any delay of
249	249	4 more than 5 business days in the transmission of requested
250	250	5 documents without an extension approved by the Director or
251	251	6 designated market conduct surveillance personnel is a
252	252	7 violation of this Section.
253	253	8 (e) Examination report.
254	254	9 (3) The market conduct surveillance personnel examiners
255	255	10 designated by the Director under Section 402 must make a full
256	256	11 and true report of every examination made by them, which
257	257	12 contains only facts ascertained from the books, papers,
258	258	13 records, or documents, and other evidence obtained by
259	259	14 investigation and examined by them or ascertained from the
260	260	15 testimony of officers or agents or other persons examined
261	261	16 under oath concerning the business, affairs, conduct, and
262	262	17 performance of the examinee company or person. The report of
263	263	18 examination must be verified by the oath of the examiner in
264	264	19 charge thereof, and when so verified is prima facie evidence
265	265	20 in any action or proceeding in the name of the State against
266	266	21 the company, its officers, or agents upon the facts stated
267	267	22 therein.
268	268	23 (f) Examinee acceptance of examination report.
269	269	24 The Department and the examinee shall adhere to the
270	270	25 following timeline, unless a mutual agreement is reached to
271	271	26 modify the timeline:
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282	282	1 (1) The Department shall deliver the draft report to
283	283	2 the examinee within 60 days after completion of the
284	284	3 examination. "Completion of the examination" means the
285	285	4 date the Department confirms in writing that the
286	286	5 examination is completed. Nothing in this Section prevents
287	287	6 the Department from sharing an earlier draft of the report
288	288	7 with the examinee before confirming that the examination
289	289	8 is completed.
290	290	9 (2) If the examinee chooses to respond with written
291	291	10 submissions or rebuttals, the examinee must do so within
292	292	11 30 days after receipt of any draft report delivered after
293	293	12 the completion of the examination.
294	294	13 (3) After receipt of any written submissions or
295	295	14 rebuttals, the Department shall issue a final report. At
296	296	15 any time, the Department may share draft corrections or
297	297	16 changes to the report with the examinee before issuing a
298	298	17 final report, and the examinee shall have 30 days to
299	299	18 respond to the draft.
300	300	19 (4) The examinee shall, within 10 days after the
301	301	20 issuance of the final report, accept the final report or
302	302	21 request a hearing in writing. Failure to take either
303	303	22 action within 10 days shall be deemed an acceptance of the
304	304	23 final report. If the examinee accepts the examination
305	305	24 report, the Director shall continue to hold the content of
306	306	25 the examination report as private and confidential for a
307	307	26 period of 30 days, except to the extent provided for in
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318	318	1 subsection (h) and in paragraph (10) of subsection (g).
319	319	2 Thereafter, the Director shall open the report for public
320	320	3 inspection if no court of competent jurisdiction has
321	321	4 stayed its publication.
322	322	5 (g) Written hearing.
323	323	6 Notwithstanding anything to the contrary in this Code or
324	324	7 Department rules, if the examinee requests a hearing, the
325	325	8 following procedures apply:
326	326	9 (1) The examinee shall request the hearing in writing
327	327	10 and shall specify the issues in the final report that the
328	328	11 examinee is challenging. The examinee is limited to
329	329	12 challenging the issues that were previously challenged in
330	330	13 the examinee's written submission and rebuttal or
331	331	14 supplemental submission and rebuttal as provided pursuant
332	332	15 to paragraphs (2) and (3) of subsection (f).
333	333	16 (2) The hearing shall be conducted by written
334	334	17 arguments submitted to the Director.
335	335	18 (3) Discovery is limited to the market conduct
336	336	19 surveillance personnel's work papers that are relevant to
337	337	20 the issues the examinee is challenging. The relevant
338	338	21 market conduct surveillance personnel's work papers shall
339	339	22 be deemed admitted into and included in the record. No
340	340	23 other forms of discovery, including depositions and
341	341	24 interrogatories, are allowed, except upon written
342	342	25 agreement of the examinee and the Department's counsel.
343	343	26 (4) Only the examinee and the Department's counsel may
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354	354	1 submit written arguments.
355	355	2 (5) The examinee shall submit its written argument
356	356	3 within 30 days after the Department's counsel serves a
357	357	4 formal notice of hearing.
358	358	5 (6) The Department's counsel shall submit its written
359	359	6 response within 30 days after the examinee submits its
360	360	7 written argument.
361	361	8 (7) The Director shall issue a decision accompanied by
362	362	9 findings and conclusions resulting from the Director's
363	363	10 consideration and review of the written arguments, the
364	364	11 final report, relevant market conduct surveillance
365	365	12 personnel work papers, and any written submissions or
366	366	13 rebuttals. The Director's order is a final agency action
367	367	14 and shall be served upon the examinee by electronic mail
368	368	15 together with a copy of the final report pursuant to
369	369	16 Section 10-75 of the Illinois Administrative Procedure
370	370	17 Act.
371	371	18 (8) Any portion of the final examination report that
372	372	19 was not challenged by the examinee is incorporated into
373	373	20 the decision of the Director.
374	374	21 (9) Findings of fact and conclusions of law in the
375	375	22 Director's final agency action are prima facie evidence in
376	376	23 any legal or regulatory action.
377	377	24 (10) If an examinee has requested a hearing, the
378	378	25 Director shall continue to hold the content of any
379	379	26 examination report or other final agency action of a
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390	390	1 market conduct examination as private and confidential for
391	391	2 a period of 49 days after the final agency action. After
392	392	3 the 49-day period expires, the Director shall open the
393	393	4 final agency action for public inspection if a court of
394	394	5 competent jurisdiction has not stayed its publication.
395	395	6 (h) Nothing in this Section prevents the Director from
396	396	7 disclosing at any time the content of an examination report,
397	397	8 preliminary examination report, or results, or any matter
398	398	9 relating to a report or results, to the division or to the
399	399	10 insurance division of any other state or agency or office of
400	400	11 the federal government at any time if the division, agency, or
401	401	12 office receiving the report or related matters agrees and has
402	402	13 the legal authority to hold it confidential in a manner
403	403	14 consistent with this Section.
404	404	15 (i) Confidentiality.
405	405	16 (1) The Director and any other person in the course of
406	406	17 market conduct surveillance shall keep confidential all
407	407	18 documents pertaining to the market conduct surveillance,
408	408	19 including working papers, third-party models, or products,
409	409	20 complaint logs, and copies of any documents created by,
410	410	21 produced by, obtained by, or disclosed to the Director,
411	411	22 market conduct surveillance personnel, or any other person
412	412	23 in the course of market conduct surveillance conducted
413	413	24 pursuant to this Section, and all documents obtained by
414	414	25 the NAIC as a result of this Section. The documents shall
415	415	26 remain confidential after termination of the market
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426	426	1 conduct surveillance, are not subject to subpoena, are not
427	427	2 subject to discovery or admissible as evidence in private
428	428	3 civil litigation, are not subject to disclosure under the
429	429	4 Freedom of Information Act, and shall not be made public
430	430	5 at any time or used by the Director or any other person,
431	431	6 except as provided in paragraphs (3), (4), and (6) of this
432	432	7 subsection and in subsection (l).
433	433	8 (2) The Director, the Department, and any other person
434	434	9 in the course of market conduct surveillance shall keep
435	435	10 confidential any self-evaluation or voluntary compliance
436	436	11 program documents disclosed to the Director or other
437	437	12 person by an examinee and the data collected via the NAIC
438	438	13 market conduct annual statement. The documents are not
439	439	14 subject to subpoena, are not subject to discovery or
440	440	15 admissible as evidence in private civil litigation, are
441	441	16 not subject to disclosure under the Freedom of Information
442	442	17 Act, and shall not be made public or used by the Director
443	443	18 or any other person, except as provided in paragraphs (3),
444	444	19 (4), and (6) of this subsection, in subsection (l), or in
445	445	20 Section 155.35 of this Code.
446	446	21 (3) Notwithstanding paragraphs (1) and (2), and
447	447	22 consistent with paragraph (5), in order to assist in the
448	448	23 performance of the Director's duties, the Director may:
449	449	24 (A) share documents, materials, communications, or
450	450	25 other information, including the confidential and
451	451	26 privileged documents, materials, or information
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462	462	1 described in this subsection, with other State,
463	463	2 federal, alien, and international regulatory agencies
464	464	3 and law enforcement authorities and the NAIC, its
465	465	4 affiliates, and subsidiaries, if the recipient agrees
466	466	5 to and has the legal authority to maintain the
467	467	6 confidentiality and privileged status of the document,
468	468	7 material, communication, or other information;
469	469	8 (B) receive documents, materials, communications,
470	470	9 or information, including otherwise confidential and
471	471	10 privileged documents, materials, or information, from
472	472	11 the NAIC and its affiliates or subsidiaries, and from
473	473	12 regulatory and law enforcement officials of other
474	474	13 domestic, alien, or international jurisdictions,
475	475	14 authorities, and agencies, and shall maintain as
476	476	15 confidential or privileged any document, material,
477	477	16 communication, or information received with notice or
478	478	17 the understanding that it is confidential or
479	479	18 privileged under the laws of the jurisdiction that is
480	480	19 the source of the document, material, communication,
481	481	20 or information;
482	482	21 (C) enter into agreements governing the sharing
483	483	22 and use of information consistent with this Section;
484	484	23 and
485	485	24 (D) when the Director performs any type of market
486	486	25 conduct surveillance that does not rise to the level
487	487	26 of a market conduct examination, make the final
488	488
489	489
490	490
491	491
492	492
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494	494
495	495
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497	497	HB4126 - 14 - LRB103 33572 RJT 63384 b
498	498	1 results of the market conduct surveillance, in an
499	499	2 aggregated format, available for public inspection in
500	500	3 a manner deemed appropriate by the Director.
501	501	4 (4) Nothing in this Section limits:
502	502	5 (A) the Director's authority to use, if consistent
503	503	6 with subsection (5) of Section 188.1, any final or
504	504	7 preliminary examination report, any market conduct
505	505	8 surveillance or examinee work papers or other
506	506	9 documents, or any other information discovered or
507	507	10 developed during the course of any market conduct
508	508	11 surveillance, in the furtherance of any legal or
509	509	12 regulatory action initiated by the Director that the
510	510	13 Director may, in the Director's sole discretion, deem
511	511	14 appropriate; or
512	512	15 (B) the ability of an examinee to conduct
513	513	16 discovery in accordance with paragraph (3) of
514	514	17 subsection (g).
515	515	18 (5) Disclosure to the Director of documents,
516	516	19 materials, communications, or information required as part
517	517	20 of any type of market conduct surveillance does not waive
518	518	21 any applicable privilege or claim of confidentiality in
519	519	22 the documents, materials, communications, or information.
520	520	23 (6) If the Director deems fit, the Director may
521	521	24 publicly acknowledge the existence of an ongoing
522	522	25 examination before filing the examination report but shall
523	523	26 not disclose any other information protected under this
524	524
525	525
526	526
527	527
528	528
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530	530
531	531
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533	533	HB4126 - 15 - LRB103 33572 RJT 63384 b
534	534	1 subsection.
535	535	2 (j) Corrective actions; sanctions.
536	536	3 (1) As a result of any market conduct action other
537	537	4 than market analysis, the Director may order the examinee
538	538	5 to take any action the Director considers necessary or
539	539	6 appropriate in accordance with the report of examination
540	540	7 or any hearing thereon, including, but not limited to,
541	541	8 requiring the regulated person to undertake corrective
542	542	9 actions to cease and desist an identified violation or
543	543	10 institute processes and practices to comply with
544	544	11 applicable standards, requiring reimbursement or
545	545	12 restitution to persons harmed by the regulated person's
546	546	13 violation, or imposing civil penalties, for acts in
547	547	14 violation of any law, rule, or prior lawful order of the
548	548	15 Director. Civil penalties imposed as a result of a market
549	549	16 conduct action shall be consistent, reasonable, and
550	550	17 justifiable.
551	551	18 (2) If any other provision of this Code or any other
552	552	19 law or rule under the Director's jurisdiction prescribes
553	553	20 an amount or range of penalties for a violation of a
554	554	21 particular statute, that provision shall apply. If no
555	555	22 penalty is already provided by law or rule for a violation
556	556	23 and the violation is quantifiable, then the Director may
557	557	24 order a penalty of up to $3,000 for every act in violation
558	558	25 of any law, rule, or prior lawful order of the Director. If
559	559	26 the examination report finds a violation by the examinee
560	560
561	561
562	562
563	563
564	564
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566	566
567	567
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569	569	HB4126 - 16 - LRB103 33572 RJT 63384 b
570	570	1 that the report is unable to quantify, such as, an
571	571	2 operational policy or procedure that conflicts with
572	572	3 applicable law, then the Director may order a penalty of
573	573	4 up to $10,000 for that violation. A violation of
574	574	5 subsection (d) is punishable by a fine of $2,000 per day up
575	575	6 to a maximum of $500,000.
576	576	7 (k) Participation in national market conduct databases.
577	577	8 The Director shall collect and report market data to the
578	578	9 NAIC's market information systems, including, but not limited
579	579	10 to, the Complaint Database System, the Examination Tracking
580	580	11 System, and the Regulatory Information Retrieval System, or
581	581	12 other successor NAIC products as determined by the Director.
582	582	13 Information collected and maintained by the Department for
583	583	14 inclusion in these NAIC market information systems shall be
584	584	15 compiled in a manner that meets the requirements of the NAIC.
585	585	16 (4) The Director must notify the company or person made
586	586	17 the subject of any examination hereunder of the contents of
587	587	18 the verified examination report before filing it and making
588	588	19 the report public of any matters relating thereto, and must
589	589	20 afford the company or person an opportunity to demand a
590	590	21 hearing with reference to the facts and other evidence therein
591	591	22 contained.
592	592	23 The company or person may request a hearing within 10 days
593	593	24 after receipt of the examination report by giving the Director
594	594	25 written notice of that request, together with a statement of
595	595	26 its objections. The Director must then conduct a hearing in
596	596
597	597
598	598
599	599
600	600
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602	602
603	603
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605	605	HB4126 - 17 - LRB103 33572 RJT 63384 b
606	606	1 accordance with Sections 402 and 403. He must issue a written
607	607	2 order based upon the examination report and upon the hearing
608	608	3 within 90 days after the report is filed or within 90 days
609	609	4 after the hearing.
610	610	5 If the examination reveals that the company is operating
611	611	6 in violation of any law, regulation, or prior order, the
612	612	7 Director in the written order may require the company or
613	613	8 person to take any action he considers necessary or
614	614	9 appropriate in accordance with the report of examination or
615	615	10 any hearing thereon. The order is subject to judicial review
616	616	11 under the Administrative Review Law. The Director may withhold
617	617	12 any report from public inspection for such time as he may deem
618	618	13 proper and may, after filing the same, publish any part or all
619	619	14 of the report as he considers to be in the interest of the
620	620	15 public, in one or more newspapers in this State, without
621	621	16 expense to the company.
622	622	17 (5) Any company which or person who violates or aids and
623	623	18 abets any violation of a written order issued under this
624	624	19 Section shall be guilty of a business offense and may be fined
625	625	20 not more than $5,000. The penalty shall be paid into the
626	626	21 General Revenue fund of the State of Illinois.
627	627	22 (Source: P.A. 87-108.)
628	628	23 (215 ILCS 5/132.5) (from Ch. 73, par. 744.5)
629	629	24 Sec. 132.5. Examination reports.
630	630	25 (a) General description. All examination reports shall be
631	631
632	632
633	633
634	634
635	635
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637	637
638	638
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640	640	HB4126 - 18 - LRB103 33572 RJT 63384 b
641	641	1 comprised of only facts appearing upon the books, records, or
642	642	2 other documents of the company, its agents, or other persons
643	643	3 examined or as ascertained from the testimony of its officers,
644	644	4 agents, or other persons examined concerning its affairs and
645	645	5 the conclusions and recommendations as the examiners find
646	646	6 reasonably warranted from those facts.
647	647	7 (b) Filing of examination report. No later than 60 days
648	648	8 following completion of the examination, the examiner in
649	649	9 charge shall file with the Department a verified written
650	650	10 report of examination under oath. Upon receipt of the verified
651	651	11 report, the Department shall transmit the report to the
652	652	12 company examined, together with a notice that affords the
653	653	13 company examined a reasonable opportunity of not more than 30
654	654	14 days to make a written submission or rebuttal with respect to
655	655	15 any matters contained in the examination report.
656	656	16 (c) Adoption of the report on examination. Within 30 days
657	657	17 of the end of the period allowed for the receipt of written
658	658	18 submissions or rebuttals, the Director shall fully consider
659	659	19 and review the report, together with any written submissions
660	660	20 or rebuttals and any relevant portions of the examiners work
661	661	21 papers and enter an order:
662	662	22 (1) Adopting the examination report as filed or with
663	663	23 modification or corrections. If the examination report
664	664	24 reveals that the company is operating in violation of any
665	665	25 law, regulation, or prior order of the Director, the
666	666	26 Director may order the company to take any action the
667	667
668	668
669	669
670	670
671	671
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673	673
674	674
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676	676	HB4126 - 19 - LRB103 33572 RJT 63384 b
677	677	1 Director considers necessary and appropriate to cure the
678	678	2 violation.
679	679	3 (2) Rejecting the examination report with directions
680	680	4 to the examiners to reopen the examination for purposes of
681	681	5 obtaining additional data, documentation, or information
682	682	6 and refiling under subsection (b).
683	683	7 (3) Calling for an investigatory hearing with no less
684	684	8 than 20 days notice to the company for purposes of
685	685	9 obtaining additional documentation, data, information, and
686	686	10 testimony.
687	687	11 (d) Order and procedures. All orders entered under
688	688	12 paragraph (1) of subsection (c) shall be accompanied by
689	689	13 findings and conclusions resulting from the Director's
690	690	14 consideration and review of the examination report, relevant
691	691	15 examiner work papers, and any written submissions or
692	692	16 rebuttals. The order shall be considered a final
693	693	17 administrative decision and may be appealed in accordance with
694	694	18 the Administrative Review Law. The order shall be served upon
695	695	19 the company by certified mail, together with a copy of the
696	696	20 adopted examination report. Within 30 days of the issuance of
697	697	21 the adopted report, the company shall file affidavits executed
698	698	22 by each of its directors stating under oath that they have
699	699	23 received a copy of the adopted report and related orders.
700	700	24 Any hearing conducted under paragraph (3) of subsection
701	701	25 (c) by the Director or an authorized representative shall be
702	702	26 conducted as a nonadversarial confidential investigatory
703	703
704	704
705	705
706	706
707	707
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709	709
710	710
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712	712	HB4126 - 20 - LRB103 33572 RJT 63384 b
713	713	1 proceeding as necessary for the resolution of any
714	714	2 inconsistencies, discrepancies, or disputed issues apparent
715	715	3 upon the face of the filed examination report or raised by or
716	716	4 as a result of the Director's review of relevant work papers or
717	717	5 by the written submission or rebuttal of the company. Within
718	718	6 20 days of the conclusion of any hearing, the Director shall
719	719	7 enter an order under paragraph (1) of subsection (c).
720	720	8 The Director shall not appoint an examiner as an
721	721	9 authorized representative to conduct the hearing. The hearing
722	722	10 shall proceed expeditiously with discovery by the company
723	723	11 limited to the examiner's work papers that tend to
724	724	12 substantiate any assertions set forth in any written
725	725	13 submission or rebuttal. The Director or his representative may
726	726	14 issue subpoenas for the attendance of any witnesses or the
727	727	15 production of any documents deemed relevant to the
728	728	16 investigation, whether under the control of the Department,
729	729	17 the company, or other persons. The documents produced shall be
730	730	18 included in the record, and testimony taken by the Director or
731	731	19 his representative shall be under oath and preserved for the
732	732	20 record. Nothing contained in this Section shall require the
733	733	21 Department to disclose any information or records that would
734	734	22 indicate or show the existence or content of any investigation
735	735	23 or activity of a criminal justice agency.
736	736	24 The hearing shall proceed with the Director or his
737	737	25 representative posing questions to the persons subpoenaed.
738	738	26 Thereafter the company and the Department may present
739	739
740	740
741	741
742	742
743	743
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745	745
746	746
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748	748	HB4126 - 21 - LRB103 33572 RJT 63384 b
749	749	1 testimony relevant to the investigation. Cross-examination
750	750	2 shall be conducted only by the Director or his representative.
751	751	3 The company and the Department shall be permitted to make
752	752	4 closing statements and may be represented by counsel of their
753	753	5 choice.
754	754	6 (e) Publication and use. Upon the adoption of the
755	755	7 examination report under paragraph (1) of subsection (c), the
756	756	8 Director shall continue to hold the content of the examination
757	757	9 report as private and confidential information for a period of
758	758	10 35 days, except to the extent provided in subsection (b).
759	759	11 Thereafter, the Director may open the report for public
760	760	12 inspection so long as no court of competent jurisdiction has
761	761	13 stayed its publication.
762	762	14 Nothing contained in this Code shall prevent or be
763	763	15 construed as prohibiting the Director from disclosing the
764	764	16 content of an examination report, preliminary examination
765	765	17 report or results, or any matter relating thereto, to the
766	766	18 insurance department of any other state or country or to law
767	767	19 enforcement officials of this or any other state or agency of
768	768	20 the federal government at any time, so long as the agency or
769	769	21 office receiving the report or matters relating thereto agrees
770	770	22 in writing to hold it confidential and in a manner consistent
771	771	23 with this Code.
772	772	24 In the event the Director determines that regulatory
773	773	25 action is appropriate as a result of any examination, he may
774	774	26 initiate any proceedings or actions as provided by law.
775	775
776	776
777	777
778	778
779	779
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781	781
782	782
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784	784	HB4126 - 22 - LRB103 33572 RJT 63384 b
785	785	1 (f) Confidentiality of ancillary information. All working
786	786	2 papers, recorded information, documents, and copies thereof
787	787	3 produced by, obtained by, or disclosed to the Director or any
788	788	4 other person in the course of any examination must be given
789	789	5 confidential treatment, are not subject to subpoena, and may
790	790	6 not be made public by the Director or any other persons, except
791	791	7 to the extent provided in subsection (e). Access may also be
792	792	8 granted to the National Association of Insurance
793	793	9 Commissioners. Those parties must agree in writing before
794	794	10 receiving the information to provide to it the same
795	795	11 confidential treatment as required by this Section, unless the
796	796	12 prior written consent of the company to which it pertains has
797	797	13 been obtained.
798	798	14 This subsection (f) applies to market conduct examinations
799	799	15 described in Section 132 of this Code.
800	800	16 (g) Disclosure. Nothing contained in this Code shall
801	801	17 prevent or be construed as prohibiting the Director from
802	802	18 disclosing the information described in subsections (e) and
803	803	19 (f) to the Illinois Insurance Guaranty Fund regarding any
804	804	20 member company defined in Section 534.5 if the member company
805	805	21 has an authorized control level event as defined in Section
806	806	22 35A-25. The Director may disclose the information described in
807	807	23 this subsection so long as the Fund agrees in writing to hold
808	808	24 that information confidential, in a manner consistent with
809	809	25 this Code, and uses that information to prepare for the
810	810	26 possible liquidation of the member company. Access to the
811	811
812	812
813	813
814	814
815	815
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817	817
818	818
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820	820	HB4126 - 23 - LRB103 33572 RJT 63384 b
821	821	1 information disclosed by the Director to the Fund shall be
822	822	2 limited to the Fund's staff and its counsel. The Board of
823	823	3 Directors of the Fund may have access to the information
824	824	4 disclosed by the Director to the Fund once the member company
825	825	5 is subject to a delinquency proceeding under Article XIII
826	826	6 subject to any terms and conditions established by the
827	827	7 Director.
828	828	8 (Source: P.A. 102-929, eff. 5-27-22.)
829	829	9 (215 ILCS 5/155.35)
830	830	10 Sec. 155.35. Insurance compliance self-evaluative
831	831	11 privilege.
832	832	12 (a) To encourage insurance companies and persons
833	833	13 conducting activities regulated under this Code, both to
834	834	14 conduct voluntary internal audits of their compliance programs
835	835	15 and management systems and to assess and improve compliance
836	836	16 with State and federal statutes, rules, and orders, an
837	837	17 insurance compliance self-evaluative privilege is recognized
838	838	18 to protect the confidentiality of communications relating to
839	839	19 voluntary internal compliance audits. The General Assembly
840	840	20 hereby finds and declares that protection of insurance
841	841	21 consumers is enhanced by companies' voluntary compliance with
842	842	22 this State's insurance and other laws and that the public will
843	843	23 benefit from incentives to identify and remedy insurance and
844	844	24 other compliance issues. It is further declared that limited
845	845	25 expansion of the protection against disclosure will encourage
846	846
847	847
848	848
849	849
850	850
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852	852
853	853
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855	855	HB4126 - 24 - LRB103 33572 RJT 63384 b
856	856	1 voluntary compliance and improve insurance market conduct
857	857	2 quality and that the voluntary provisions of this Section will
858	858	3 not inhibit the exercise of the regulatory authority by those
859	859	4 entrusted with protecting insurance consumers.
860	860	5 (b)(1) An insurance compliance self-evaluative audit
861	861	6 document is privileged information and is not admissible as
862	862	7 evidence in any legal action in any civil, criminal, or
863	863	8 administrative proceeding, except as provided in subsections
864	864	9 (c) and (d) of this Section. Documents, communications, data,
865	865	10 reports, or other information created as a result of a claim
866	866	11 involving personal injury or workers' compensation made
867	867	12 against an insurance policy are not insurance compliance
868	868	13 self-evaluative audit documents and are admissible as evidence
869	869	14 in civil proceedings as otherwise provided by applicable rules
870	870	15 of evidence or civil procedure, subject to any applicable
871	871	16 statutory or common law privilege, including but not limited
872	872	17 to the work product doctrine, the attorney-client privilege,
873	873	18 or the subsequent remedial measures exclusion.
874	874	19 (2) If any company, person, or entity performs or directs
875	875	20 the performance of an insurance compliance audit, an officer
876	876	21 or employee involved with the insurance compliance audit, or
877	877	22 any consultant who is hired for the purpose of performing the
878	878	23 insurance compliance audit, may not be examined in any civil,
879	879	24 criminal, or administrative proceeding as to the insurance
880	880	25 compliance audit or any insurance compliance self-evaluative
881	881	26 audit document, as defined in this Section. This subsection
882	882
883	883
884	884
885	885
886	886
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888	888
889	889
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891	891	HB4126 - 25 - LRB103 33572 RJT 63384 b
892	892	1 (b)(2) does not apply if the privilege set forth in subsection
893	893	2 (b)(1) of this Section is determined under subsection (c) or
894	894	3 (d) not to apply.
895	895	4 (3) A company may voluntarily submit, in connection with
896	896	5 examinations conducted under this Article, an insurance
897	897	6 compliance self-evaluative audit document to the Director, or
898	898	7 his or her designee, as a confidential document under
899	899	8 subsection (i) of Section 132 or subsection (f) of Section
900	900	9 132.5 of this Code, as applicable, without waiving the
901	901	10 privilege set forth in this Section to which the company would
902	902	11 otherwise be entitled; provided, however, that the provisions
903	903	12 in Sections 132 and subsection (f) of Section 132.5 permitting
904	904	13 the Director to make confidential documents public pursuant to
905	905	14 subsection (e) of Section 132.5 and grant access to the
906	906	15 National Association of Insurance Commissioners shall not
907	907	16 apply to the insurance compliance self-evaluative audit
908	908	17 document so voluntarily submitted. Nothing contained in this
909	909	18 subsection shall give the Director any authority to compel a
910	910	19 company to disclose involuntarily or otherwise provide an
911	911	20 insurance compliance self-evaluative audit document.
912	912	21 (c)(1) The privilege set forth in subsection (b) of this
913	913	22 Section does not apply to the extent that it is expressly
914	914	23 waived by the company that prepared or caused to be prepared
915	915	24 the insurance compliance self-evaluative audit document.
916	916	25 (2) In a civil or administrative proceeding, a court of
917	917	26 record may, after an in camera review, require disclosure of
918	918
919	919
920	920
921	921
922	922
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924	924
925	925
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927	927	HB4126 - 26 - LRB103 33572 RJT 63384 b
928	928	1 material for which the privilege set forth in subsection (b)
929	929	2 of this Section is asserted, if the court determines one of the
930	930	3 following:
931	931	4 (A) the privilege is asserted for a fraudulent
932	932	5 purpose;
933	933	6 (B) the material is not subject to the privilege; or
934	934	7 (C) even if subject to the privilege, the material
935	935	8 shows evidence of noncompliance with State and federal
936	936	9 statutes, rules and orders and the company failed to
937	937	10 undertake reasonable corrective action or eliminate the
938	938	11 noncompliance within a reasonable time.
939	939	12 (3) In a criminal proceeding, a court of record may, after
940	940	13 an in camera review, require disclosure of material for which
941	941	14 the privilege described in subsection (b) of this Section is
942	942	15 asserted, if the court determines one of the following:
943	943	16 (A) the privilege is asserted for a fraudulent
944	944	17 purpose;
945	945	18 (B) the material is not subject to the privilege;
946	946	19 (C) even if subject to the privilege, the material
947	947	20 shows evidence of noncompliance with State and federal
948	948	21 statutes, rules and orders and the company failed to
949	949	22 undertake reasonable corrective action or eliminate such
950	950	23 noncompliance within a reasonable time; or
951	951	24 (D) the material contains evidence relevant to
952	952	25 commission of a criminal offense under this Code, and all
953	953	26 of the following factors are present:
954	954
955	955
956	956
957	957
958	958
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960	960
961	961
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964	964	1 (i) the Director, State's Attorney, or Attorney
965	965	2 General has a compelling need for the information;
966	966	3 (ii) the information is not otherwise available;
967	967	4 and
968	968	5 (iii) the Director, State's Attorney, or Attorney
969	969	6 General is unable to obtain the substantial equivalent
970	970	7 of the information by any means without incurring
971	971	8 unreasonable cost and delay.
972	972	9 (d)(1) Within 30 days after the Director, State's
973	973	10 Attorney, or Attorney General makes a written request by
974	974	11 certified mail for disclosure of an insurance compliance
975	975	12 self-evaluative audit document under this subsection, the
976	976	13 company that prepared or caused the document to be prepared
977	977	14 may file with the appropriate court a petition requesting an
978	978	15 in camera hearing on whether the insurance compliance
979	979	16 self-evaluative audit document or portions of the document are
980	980	17 privileged under this Section or subject to disclosure. The
981	981	18 court has jurisdiction over a petition filed by a company
982	982	19 under this subsection requesting an in camera hearing on
983	983	20 whether the insurance compliance self-evaluative audit
984	984	21 document or portions of the document are privileged or subject
985	985	22 to disclosure. Failure by the company to file a petition
986	986	23 waives the privilege.
987	987	24 (2) A company asserting the insurance compliance
988	988	25 self-evaluative privilege in response to a request for
989	989	26 disclosure under this subsection shall include in its request
990	990
991	991
992	992
993	993
994	994
995	995	HB4126 - 27 - LRB103 33572 RJT 63384 b
996	996
997	997
998	998	HB4126- 28 -LRB103 33572 RJT 63384 b HB4126 - 28 - LRB103 33572 RJT 63384 b
999	999	HB4126 - 28 - LRB103 33572 RJT 63384 b
1000	1000	1 for an in camera hearing all of the information set forth in
1001	1001	2 subsection (d)(5) of this Section.
1002	1002	3 (3) Upon the filing of a petition under this subsection,
1003	1003	4 the court shall issue an order scheduling, within 45 days
1004	1004	5 after the filing of the petition, an in camera hearing to
1005	1005	6 determine whether the insurance compliance self-evaluative
1006	1006	7 audit document or portions of the document are privileged
1007	1007	8 under this Section or subject to disclosure.
1008	1008	9 (4) The court, after an in camera review, may require
1009	1009	10 disclosure of material for which the privilege in subsection
1010	1010	11 (b) of this Section is asserted if the court determines, based
1011	1011	12 upon its in camera review, that any one of the conditions set
1012	1012	13 forth in subsection (c)(2)(A) through (C) is applicable as to
1013	1013	14 a civil or administrative proceeding or that any one of the
1014	1014	15 conditions set forth in subsection (c)(3)(A) through (D) is
1015	1015	16 applicable as to a criminal proceeding. Upon making such a
1016	1016	17 determination, the court may only compel the disclosure of
1017	1017	18 those portions of an insurance compliance self-evaluative
1018	1018	19 audit document relevant to issues in dispute in the underlying
1019	1019	20 proceeding. Any compelled disclosure will not be considered to
1020	1020	21 be a public document or be deemed to be a waiver of the
1021	1021	22 privilege for any other civil, criminal, or administrative
1022	1022	23 proceeding. A party unsuccessfully opposing disclosure may
1023	1023	24 apply to the court for an appropriate order protecting the
1024	1024	25 document from further disclosure.
1025	1025	26 (5) A company asserting the insurance compliance
1026	1026
1027	1027
1028	1028
1029	1029
1030	1030
1031	1031	HB4126 - 28 - LRB103 33572 RJT 63384 b
1032	1032
1033	1033
1034	1034	HB4126- 29 -LRB103 33572 RJT 63384 b HB4126 - 29 - LRB103 33572 RJT 63384 b
1035	1035	HB4126 - 29 - LRB103 33572 RJT 63384 b
1036	1036	1 self-evaluative privilege in response to a request for
1037	1037	2 disclosure under this subsection (d) shall provide to the
1038	1038	3 Director, State's Attorney, or Attorney General, as the case
1039	1039	4 may be, at the time of filing any objection to the disclosure,
1040	1040	5 all of the following information:
1041	1041	6 (A) The date of the insurance compliance
1042	1042	7 self-evaluative audit document.
1043	1043	8 (B) The identity of the entity conducting the audit.
1044	1044	9 (C) The general nature of the activities covered by
1045	1045	10 the insurance compliance audit.
1046	1046	11 (D) An identification of the portions of the insurance
1047	1047	12 compliance self-evaluative audit document for which the
1048	1048	13 privilege is being asserted.
1049	1049	14 (e) (1) A company asserting the insurance compliance
1050	1050	15 self-evaluative privilege set forth in subsection (b) of this
1051	1051	16 Section has the burden of demonstrating the applicability of
1052	1052	17 the privilege. Once a company has established the
1053	1053	18 applicability of the privilege, a party seeking disclosure
1054	1054	19 under subsections (c)(2)(A) or (C) of this Section has the
1055	1055	20 burden of proving that the privilege is asserted for a
1056	1056	21 fraudulent purpose or that the company failed to undertake
1057	1057	22 reasonable corrective action or eliminate the noncompliance
1058	1058	23 with a reasonable time. The Director, State's Attorney, or
1059	1059	24 Attorney General seeking disclosure under subsection (c)(3) of
1060	1060	25 this Section has the burden of proving the elements set forth
1061	1061	26 in subsection (c)(3) of this Section.
1062	1062
1063	1063
1064	1064
1065	1065
1066	1066
1067	1067	HB4126 - 29 - LRB103 33572 RJT 63384 b
1068	1068
1069	1069
1070	1070	HB4126- 30 -LRB103 33572 RJT 63384 b HB4126 - 30 - LRB103 33572 RJT 63384 b
1071	1071	HB4126 - 30 - LRB103 33572 RJT 63384 b
1072	1072	1 (2) The parties may at any time stipulate in proceedings
1073	1073	2 under subsections (c) or (d) of this Section to entry of an
1074	1074	3 order directing that specific information contained in an
1075	1075	4 insurance compliance self-evaluative audit document is or is
1076	1076	5 not subject to the privilege provided under subsection (b) of
1077	1077	6 this Section.
1078	1078	7 (f) The privilege set forth in subsection (b) of this
1079	1079	8 Section shall not extend to any of the following:
1080	1080	9 (1) documents, communications, data, reports, or other
1081	1081	10 information required to be collected, developed,
1082	1082	11 maintained, reported, or otherwise made available to a
1083	1083	12 regulatory agency pursuant to this Code, or other federal
1084	1084	13 or State law, rule, or order;
1085	1085	14 (2) information obtained by observation or monitoring
1086	1086	15 by any regulatory agency; or
1087	1087	16 (3) information obtained from a source independent of
1088	1088	17 the insurance compliance audit.
1089	1089	18 (g) As used in this Section:
1090	1090	19 (1) "Insurance compliance audit" means a voluntary,
1091	1091	20 internal evaluation, review, assessment, or audit not
1092	1092	21 otherwise expressly required by law of a company or an
1093	1093	22 activity regulated under this Code, or other State or
1094	1094	23 federal law applicable to a company, or of management
1095	1095	24 systems related to the company or activity, that is
1096	1096	25 designed to identify and prevent noncompliance and to
1097	1097	26 improve compliance with those statutes, rules, or orders.
1098	1098
1099	1099
1100	1100
1101	1101
1102	1102
1103	1103	HB4126 - 30 - LRB103 33572 RJT 63384 b
1104	1104
1105	1105
1106	1106	HB4126- 31 -LRB103 33572 RJT 63384 b HB4126 - 31 - LRB103 33572 RJT 63384 b
1107	1107	HB4126 - 31 - LRB103 33572 RJT 63384 b
1108	1108	1 An insurance compliance audit may be conducted by the
1109	1109	2 company, its employees, or by independent contractors.
1110	1110	3 (2) "Insurance compliance self-evaluative audit
1111	1111	4 document" means documents prepared as a result of or in
1112	1112	5 connection with and not prior to an insurance compliance
1113	1113	6 audit. An insurance compliance self-evaluation audit
1114	1114	7 document may include a written response to the findings of
1115	1115	8 an insurance compliance audit. An insurance compliance
1116	1116	9 self-evaluative audit document may include, but is not
1117	1117	10 limited to, as applicable, field notes and records of
1118	1118	11 observations, findings, opinions, suggestions,
1119	1119	12 conclusions, drafts, memoranda, drawings, photographs,
1120	1120	13 computer-generated or electronically recorded
1121	1121	14 information, phone records, maps, charts, graphs, and
1122	1122	15 surveys, provided this supporting information is collected
1123	1123	16 or developed for the primary purpose and in the course of
1124	1124	17 an insurance compliance audit. An insurance compliance
1125	1125	18 self-evaluative audit document may also include any of the
1126	1126	19 following:
1127	1127	20 (A) an insurance compliance audit report prepared
1128	1128	21 by an auditor, who may be an employee of the company or
1129	1129	22 an independent contractor, which may include the scope
1130	1130	23 of the audit, the information gained in the audit, and
1131	1131	24 conclusions and recommendations, with exhibits and
1132	1132	25 appendices;
1133	1133	26 (B) memoranda and documents analyzing portions or
1134	1134
1135	1135
1136	1136
1137	1137
1138	1138
1139	1139	HB4126 - 31 - LRB103 33572 RJT 63384 b
1140	1140
1141	1141
1142	1142	HB4126- 32 -LRB103 33572 RJT 63384 b HB4126 - 32 - LRB103 33572 RJT 63384 b
1143	1143	HB4126 - 32 - LRB103 33572 RJT 63384 b
1144	1144	1 all of the insurance compliance audit report and
1145	1145	2 discussing potential implementation issues;
1146	1146	3 (C) an implementation plan that addresses
1147	1147	4 correcting past noncompliance, improving current
1148	1148	5 compliance, and preventing future noncompliance; or
1149	1149	6 (D) analytic data generated in the course of
1150	1150	7 conducting the insurance compliance audit.
1151	1151	8 (3) "Company" has the same meaning as provided in
1152	1152	9 Section 2 of this Code.
1153	1153	10 (h) Nothing in this Section shall limit, waive, or
1154	1154	11 abrogate the scope or nature of any statutory or common law
1155	1155	12 privilege including, but not limited to, the work product
1156	1156	13 doctrine, the attorney-client privilege, or the subsequent
1157	1157	14 remedial measures exclusion.
1158	1158	15 (Source: P.A. 90-499, eff. 8-19-97; 90-655, eff. 7-30-98.)
1159	1159	16 (215 ILCS 5/402) (from Ch. 73, par. 1014)
1160	1160	17 Sec. 402. Examinations, investigations and hearings. (1)
1161	1161	18 All examinations, investigations and hearings provided for by
1162	1162	19 this Code may be conducted either by the Director personally,
1163	1163	20 or by one or more of the actuaries, technical advisors,
1164	1164	21 deputies, supervisors or examiners employed or retained by the
1165	1165	22 Department and designated by the Director for such purpose.
1166	1166	23 When necessary to supplement its examination procedures, the
1167	1167	24 Department may retain independent actuaries deemed competent
1168	1168	25 by the Director, independent certified public accountants,
1169	1169
1170	1170
1171	1171
1172	1172
1173	1173
1174	1174	HB4126 - 32 - LRB103 33572 RJT 63384 b
1175	1175
1176	1176
1177	1177	HB4126- 33 -LRB103 33572 RJT 63384 b HB4126 - 33 - LRB103 33572 RJT 63384 b
1178	1178	HB4126 - 33 - LRB103 33572 RJT 63384 b
1179	1179	1 attorneys, or qualified examiners of insurance companies
1180	1180	2 deemed competent by the Director, or any combination of the
1181	1181	3 foregoing, the cost of which shall be borne by the company or
1182	1182	4 person being examined. The Director may compensate independent
1183	1183	5 actuaries, certified public accountants and qualified
1184	1184	6 examiners retained for supplementing examination procedures in
1185	1185	7 amounts not to exceed the reasonable and customary charges for
1186	1186	8 such services. The Director may also accept as a part of the
1187	1187	9 Department's examination of any company or person (a) a report
1188	1188	10 by an independent actuary deemed competent by the Director or
1189	1189	11 (b) a report of an audit made by an independent certified
1190	1190	12 public accountant. Neither those persons so designated nor any
1191	1191	13 members of their immediate families shall be officers of,
1192	1192	14 connected with, or financially interested in any company other
1193	1193	15 than as policyholders, nor shall they be financially
1194	1194	16 interested in any other corporation or person affected by the
1195	1195	17 examination, investigation or hearing.
1196	1196	18 (2) All hearings provided for in this Code shall, unless
1197	1197	19 otherwise specially provided, be held at such time and place
1198	1198	20 as shall be designated in a notice which shall be given by the
1199	1199	21 Director in writing to the person or company whose interests
1200	1200	22 are affected, at least 10 days before the date designated
1201	1201	23 therein. The notice shall state the subject of inquiry and the
1202	1202	24 specific charges, if any. The hearings shall be held in the
1203	1203	25 City of Springfield, the City of Chicago, or in the county
1204	1204	26 where the principal business address of the person or company
1205	1205
1206	1206
1207	1207
1208	1208
1209	1209
1210	1210	HB4126 - 33 - LRB103 33572 RJT 63384 b
1211	1211
1212	1212
1213	1213	HB4126- 34 -LRB103 33572 RJT 63384 b HB4126 - 34 - LRB103 33572 RJT 63384 b
1214	1214	HB4126 - 34 - LRB103 33572 RJT 63384 b
1215	1215	1 affected is located.
1216	1216	2 (Source: P.A. 87-757.)
1217	1217	3 (215 ILCS 5/408) (from Ch. 73, par. 1020)
1218	1218	4 Sec. 408. Fees and charges.
1219	1219	5 (1) The Director shall charge, collect and give proper
1220	1220	6 acquittances for the payment of the following fees and
1221	1221	7 charges:
1222	1222	8 (a) For filing all documents submitted for the
1223	1223	9 incorporation or organization or certification of a
1224	1224	10 domestic company, except for a fraternal benefit society,
1225	1225	11 $2,000.
1226	1226	12 (b) For filing all documents submitted for the
1227	1227	13 incorporation or organization of a fraternal benefit
1228	1228	14 society, $500.
1229	1229	15 (c) For filing amendments to articles of incorporation
1230	1230	16 and amendments to declaration of organization, except for
1231	1231	17 a fraternal benefit society, a mutual benefit association,
1232	1232	18 a burial society or a farm mutual, $200.
1233	1233	19 (d) For filing amendments to articles of incorporation
1234	1234	20 of a fraternal benefit society, a mutual benefit
1235	1235	21 association or a burial society, $100.
1236	1236	22 (e) For filing amendments to articles of incorporation
1237	1237	23 of a farm mutual, $50.
1238	1238	24 (f) For filing bylaws or amendments thereto, $50.
1239	1239	25 (g) For filing agreement of merger or consolidation:
1240	1240
1241	1241
1242	1242
1243	1243
1244	1244
1245	1245	HB4126 - 34 - LRB103 33572 RJT 63384 b
1246	1246
1247	1247
1248	1248	HB4126- 35 -LRB103 33572 RJT 63384 b HB4126 - 35 - LRB103 33572 RJT 63384 b
1249	1249	HB4126 - 35 - LRB103 33572 RJT 63384 b
1250	1250	1 (i) for a domestic company, except for a fraternal
1251	1251	2 benefit society, a mutual benefit association, a
1252	1252	3 burial society, or a farm mutual, $2,000.
1253	1253	4 (ii) for a foreign or alien company, except for a
1254	1254	5 fraternal benefit society, $600.
1255	1255	6 (iii) for a fraternal benefit society, a mutual
1256	1256	7 benefit association, a burial society, or a farm
1257	1257	8 mutual, $200.
1258	1258	9 (h) For filing agreements of reinsurance by a domestic
1259	1259	10 company, $200.
1260	1260	11 (i) For filing all documents submitted by a foreign or
1261	1261	12 alien company to be admitted to transact business or
1262	1262	13 accredited as a reinsurer in this State, except for a
1263	1263	14 fraternal benefit society, $5,000.
1264	1264	15 (j) For filing all documents submitted by a foreign or
1265	1265	16 alien fraternal benefit society to be admitted to transact
1266	1266	17 business in this State, $500.
1267	1267	18 (k) For filing declaration of withdrawal of a foreign
1268	1268	19 or alien company, $50.
1269	1269	20 (l) For filing annual statement by a domestic company,
1270	1270	21 except a fraternal benefit society, a mutual benefit
1271	1271	22 association, a burial society, or a farm mutual, $200.
1272	1272	23 (m) For filing annual statement by a domestic
1273	1273	24 fraternal benefit society, $100.
1274	1274	25 (n) For filing annual statement by a farm mutual, a
1275	1275	26 mutual benefit association, or a burial society, $50.
1276	1276
1277	1277
1278	1278
1279	1279
1280	1280
1281	1281	HB4126 - 35 - LRB103 33572 RJT 63384 b
1282	1282
1283	1283
1284	1284	HB4126- 36 -LRB103 33572 RJT 63384 b HB4126 - 36 - LRB103 33572 RJT 63384 b
1285	1285	HB4126 - 36 - LRB103 33572 RJT 63384 b
1286	1286	1 (o) For issuing a certificate of authority or renewal
1287	1287	2 thereof except to a foreign fraternal benefit society,
1288	1288	3 $400.
1289	1289	4 (p) For issuing a certificate of authority or renewal
1290	1290	5 thereof to a foreign fraternal benefit society, $200.
1291	1291	6 (q) For issuing an amended certificate of authority,
1292	1292	7 $50.
1293	1293	8 (r) For each certified copy of certificate of
1294	1294	9 authority, $20.
1295	1295	10 (s) For each certificate of deposit, or valuation, or
1296	1296	11 compliance or surety certificate, $20.
1297	1297	12 (t) For copies of papers or records per page, $1.
1298	1298	13 (u) For each certification to copies of papers or
1299	1299	14 records, $10.
1300	1300	15 (v) For multiple copies of documents or certificates
1301	1301	16 listed in subparagraphs (r), (s), and (u) of paragraph (1)
1302	1302	17 of this Section, $10 for the first copy of a certificate of
1303	1303	18 any type and $5 for each additional copy of the same
1304	1304	19 certificate requested at the same time, unless, pursuant
1305	1305	20 to paragraph (2) of this Section, the Director finds these
1306	1306	21 additional fees excessive.
1307	1307	22 (w) For issuing a permit to sell shares or increase
1308	1308	23 paid-up capital:
1309	1309	24 (i) in connection with a public stock offering,
1310	1310	25 $300;
1311	1311	26 (ii) in any other case, $100.
1312	1312
1313	1313
1314	1314
1315	1315
1316	1316
1317	1317	HB4126 - 36 - LRB103 33572 RJT 63384 b
1318	1318
1319	1319
1320	1320	HB4126- 37 -LRB103 33572 RJT 63384 b HB4126 - 37 - LRB103 33572 RJT 63384 b
1321	1321	HB4126 - 37 - LRB103 33572 RJT 63384 b
1322	1322	1 (x) For issuing any other certificate required or
1323	1323	2 permissible under the law, $50.
1324	1324	3 (y) For filing a plan of exchange of the stock of a
1325	1325	4 domestic stock insurance company, a plan of
1326	1326	5 demutualization of a domestic mutual company, or a plan of
1327	1327	6 reorganization under Article XII, $2,000.
1328	1328	7 (z) For filing a statement of acquisition of a
1329	1329	8 domestic company as defined in Section 131.4 of this Code,
1330	1330	9 $2,000.
1331	1331	10 (aa) For filing an agreement to purchase the business
1332	1332	11 of an organization authorized under the Dental Service
1333	1333	12 Plan Act or the Voluntary Health Services Plans Act or of a
1334	1334	13 health maintenance organization or a limited health
1335	1335	14 service organization, $2,000.
1336	1336	15 (bb) For filing a statement of acquisition of a
1337	1337	16 foreign or alien insurance company as defined in Section
1338	1338	17 131.12a of this Code, $1,000.
1339	1339	18 (cc) For filing a registration statement as required
1340	1340	19 in Sections 131.13 and 131.14, the notification as
1341	1341	20 required by Sections 131.16, 131.20a, or 141.4, or an
1342	1342	21 agreement or transaction required by Sections 124.2(2),
1343	1343	22 141, 141a, or 141.1, $200.
1344	1344	23 (dd) For filing an application for licensing of:
1345	1345	24 (i) a religious or charitable risk pooling trust
1346	1346	25 or a workers' compensation pool, $1,000;
1347	1347	26 (ii) a workers' compensation service company,
1348	1348
1349	1349
1350	1350
1351	1351
1352	1352
1353	1353	HB4126 - 37 - LRB103 33572 RJT 63384 b
1354	1354
1355	1355
1356	1356	HB4126- 38 -LRB103 33572 RJT 63384 b HB4126 - 38 - LRB103 33572 RJT 63384 b
1357	1357	HB4126 - 38 - LRB103 33572 RJT 63384 b
1358	1358	1 $500;
1359	1359	2 (iii) a self-insured automobile fleet, $200; or
1360	1360	3 (iv) a renewal of or amendment of any license
1361	1361	4 issued pursuant to (i), (ii), or (iii) above, $100.
1362	1362	5 (ee) For filing articles of incorporation for a
1363	1363	6 syndicate to engage in the business of insurance through
1364	1364	7 the Illinois Insurance Exchange, $2,000.
1365	1365	8 (ff) For filing amended articles of incorporation for
1366	1366	9 a syndicate engaged in the business of insurance through
1367	1367	10 the Illinois Insurance Exchange, $100.
1368	1368	11 (gg) For filing articles of incorporation for a
1369	1369	12 limited syndicate to join with other subscribers or
1370	1370	13 limited syndicates to do business through the Illinois
1371	1371	14 Insurance Exchange, $1,000.
1372	1372	15 (hh) For filing amended articles of incorporation for
1373	1373	16 a limited syndicate to do business through the Illinois
1374	1374	17 Insurance Exchange, $100.
1375	1375	18 (ii) For a permit to solicit subscriptions to a
1376	1376	19 syndicate or limited syndicate, $100.
1377	1377	20 (jj) For the filing of each form as required in
1378	1378	21 Section 143 of this Code, $50 per form. The fee for
1379	1379	22 advisory and rating organizations shall be $200 per form.
1380	1380	23 (i) For the purposes of the form filing fee,
1381	1381	24 filings made on insert page basis will be considered
1382	1382	25 one form at the time of its original submission.
1383	1383	26 Changes made to a form subsequent to its approval
1384	1384
1385	1385
1386	1386
1387	1387
1388	1388
1389	1389	HB4126 - 38 - LRB103 33572 RJT 63384 b
1390	1390
1391	1391
1392	1392	HB4126- 39 -LRB103 33572 RJT 63384 b HB4126 - 39 - LRB103 33572 RJT 63384 b
1393	1393	HB4126 - 39 - LRB103 33572 RJT 63384 b
1394	1394	1 shall be considered a new filing.
1395	1395	2 (ii) Only one fee shall be charged for a form,
1396	1396	3 regardless of the number of other forms or policies
1397	1397	4 with which it will be used.
1398	1398	5 (iii) Fees charged for a policy filed as it will be
1399	1399	6 issued regardless of the number of forms comprising
1400	1400	7 that policy shall not exceed $1,500. For advisory or
1401	1401	8 rating organizations, fees charged for a policy filed
1402	1402	9 as it will be issued regardless of the number of forms
1403	1403	10 comprising that policy shall not exceed $2,500.
1404	1404	11 (iv) The Director may by rule exempt forms from
1405	1405	12 such fees.
1406	1406	13 (kk) For filing an application for licensing of a
1407	1407	14 reinsurance intermediary, $500.
1408	1408	15 (ll) For filing an application for renewal of a
1409	1409	16 license of a reinsurance intermediary, $200.
1410	1410	17 (mm) For a network adequacy filing required under the
1411	1411	18 Network Adequacy and Transparency Act, $500, except that
1412	1412	19 the fee for a filing required based on a material change is
1413	1413	20 $100.
1414	1414	21 (2) When printed copies or numerous copies of the same
1415	1415	22 paper or records are furnished or certified, the Director may
1416	1416	23 reduce such fees for copies if he finds them excessive. He may,
1417	1417	24 when he considers it in the public interest, furnish without
1418	1418	25 charge to state insurance departments and persons other than
1419	1419	26 companies, copies or certified copies of reports of
1420	1420
1421	1421
1422	1422
1423	1423
1424	1424
1425	1425	HB4126 - 39 - LRB103 33572 RJT 63384 b
1426	1426
1427	1427
1428	1428	HB4126- 40 -LRB103 33572 RJT 63384 b HB4126 - 40 - LRB103 33572 RJT 63384 b
1429	1429	HB4126 - 40 - LRB103 33572 RJT 63384 b
1430	1430	1 examinations and of other papers and records.
1431	1431	2 (3) The expenses incurred in any performance examination
1432	1432	3 authorized by law shall be paid by the company or person being
1433	1433	4 examined. The charge shall be reasonably related to the cost
1434	1434	5 of the examination including but not limited to compensation
1435	1435	6 of examiners, electronic data processing costs, supervision
1436	1436	7 and preparation of an examination report and lodging and
1437	1437	8 travel expenses. All lodging and travel expenses shall be in
1438	1438	9 accord with the applicable travel regulations as published by
1439	1439	10 the Department of Central Management Services and approved by
1440	1440	11 the Governor's Travel Control Board, except that out-of-state
1441	1441	12 lodging and travel expenses related to examinations authorized
1442	1442	13 under Section 132 shall be in accordance with travel rates
1443	1443	14 prescribed under paragraph 301-7.2 of the Federal Travel
1444	1444	15 Regulations, 41 C.F.R. 301-7.2, for reimbursement of
1445	1445	16 subsistence expenses incurred during official travel. All
1446	1446	17 lodging and travel expenses may be reimbursed directly upon
1447	1447	18 authorization of the Director. With the exception of the
1448	1448	19 direct reimbursements authorized by the Director, all
1449	1449	20 performance examination charges collected by the Department
1450	1450	21 shall be paid to the Insurance Producer Administration Fund,
1451	1451	22 however, the electronic data processing costs incurred by the
1452	1452	23 Department in the performance of any examination shall be
1453	1453	24 billed directly to the company being examined for payment to
1454	1454	25 the Technology Management Revolving Fund.
1455	1455	26 (4) At the time of any service of process on the Director
1456	1456
1457	1457
1458	1458
1459	1459
1460	1460
1461	1461	HB4126 - 40 - LRB103 33572 RJT 63384 b
1462	1462
1463	1463
1464	1464	HB4126- 41 -LRB103 33572 RJT 63384 b HB4126 - 41 - LRB103 33572 RJT 63384 b
1465	1465	HB4126 - 41 - LRB103 33572 RJT 63384 b
1466	1466	1 as attorney for such service, the Director shall charge and
1467	1467	2 collect the sum of $20, which may be recovered as taxable costs
1468	1468	3 by the party to the suit or action causing such service to be
1469	1469	4 made if he prevails in such suit or action.
1470	1470	5 (5) (a) The costs incurred by the Department of Insurance
1471	1471	6 in conducting any hearing authorized by law shall be assessed
1472	1472	7 against the parties to the hearing in such proportion as the
1473	1473	8 Director of Insurance may determine upon consideration of all
1474	1474	9 relevant circumstances including: (1) the nature of the
1475	1475	10 hearing; (2) whether the hearing was instigated by, or for the
1476	1476	11 benefit of a particular party or parties; (3) whether there is
1477	1477	12 a successful party on the merits of the proceeding; and (4) the
1478	1478	13 relative levels of participation by the parties.
1479	1479	14 (b) For purposes of this subsection (5) costs incurred
1480	1480	15 shall mean the hearing officer fees, court reporter fees, and
1481	1481	16 travel expenses of Department of Insurance officers and
1482	1482	17 employees; provided however, that costs incurred shall not
1483	1483	18 include hearing officer fees or court reporter fees unless the
1484	1484	19 Department has retained the services of independent
1485	1485	20 contractors or outside experts to perform such functions.
1486	1486	21 (c) The Director shall make the assessment of costs
1487	1487	22 incurred as part of the final order or decision arising out of
1488	1488	23 the proceeding; provided, however, that such order or decision
1489	1489	24 shall include findings and conclusions in support of the
1490	1490	25 assessment of costs. This subsection (5) shall not be
1491	1491	26 construed as permitting the payment of travel expenses unless
1492	1492
1493	1493
1494	1494
1495	1495
1496	1496
1497	1497	HB4126 - 41 - LRB103 33572 RJT 63384 b
1498	1498
1499	1499
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1501	1501	HB4126 - 42 - LRB103 33572 RJT 63384 b
1502	1502	1 calculated in accordance with the applicable travel
1503	1503	2 regulations of the Department of Central Management Services,
1504	1504	3 as approved by the Governor's Travel Control Board. The
1505	1505	4 Director as part of such order or decision shall require all
1506	1506	5 assessments for hearing officer fees and court reporter fees,
1507	1507	6 if any, to be paid directly to the hearing officer or court
1508	1508	7 reporter by the party(s) assessed for such costs. The
1509	1509	8 assessments for travel expenses of Department officers and
1510	1510	9 employees shall be reimbursable to the Director of Insurance
1511	1511	10 for deposit to the fund out of which those expenses had been
1512	1512	11 paid.
1513	1513	12 (d) The provisions of this subsection (5) shall apply in
1514	1514	13 the case of any hearing conducted by the Director of Insurance
1515	1515	14 not otherwise specifically provided for by law.
1516	1516	15 (6) The Director shall charge and collect an annual
1517	1517	16 financial regulation fee from every domestic company for
1518	1518	17 examination and analysis of its financial condition and to
1519	1519	18 fund the internal costs and expenses of the Interstate
1520	1520	19 Insurance Receivership Commission as may be allocated to the
1521	1521	20 State of Illinois and companies doing an insurance business in
1522	1522	21 this State pursuant to Article X of the Interstate Insurance
1523	1523	22 Receivership Compact. The fee shall be the greater fixed
1524	1524	23 amount based upon the combination of nationwide direct premium
1525	1525	24 income and nationwide reinsurance assumed premium income or
1526	1526	25 upon admitted assets calculated under this subsection as
1527	1527	26 follows:
1528	1528
1529	1529
1530	1530
1531	1531
1532	1532
1533	1533	HB4126 - 42 - LRB103 33572 RJT 63384 b
1534	1534
1535	1535
1536	1536	HB4126- 43 -LRB103 33572 RJT 63384 b HB4126 - 43 - LRB103 33572 RJT 63384 b
1537	1537	HB4126 - 43 - LRB103 33572 RJT 63384 b
1538	1538	1 (a) Combination of nationwide direct premium income
1539	1539	2 and nationwide reinsurance assumed premium.
1540	1540	3 (i) $150, if the premium is less than $500,000 and
1541	1541	4 there is no reinsurance assumed premium;
1542	1542	5 (ii) $750, if the premium is $500,000 or more, but
1543	1543	6 less than $5,000,000 and there is no reinsurance
1544	1544	7 assumed premium; or if the premium is less than
1545	1545	8 $5,000,000 and the reinsurance assumed premium is less
1546	1546	9 than $10,000,000;
1547	1547	10 (iii) $3,750, if the premium is less than
1548	1548	11 $5,000,000 and the reinsurance assumed premium is
1549	1549	12 $10,000,000 or more;
1550	1550	13 (iv) $7,500, if the premium is $5,000,000 or more,
1551	1551	14 but less than $10,000,000;
1552	1552	15 (v) $18,000, if the premium is $10,000,000 or
1553	1553	16 more, but less than $25,000,000;
1554	1554	17 (vi) $22,500, if the premium is $25,000,000 or
1555	1555	18 more, but less than $50,000,000;
1556	1556	19 (vii) $30,000, if the premium is $50,000,000 or
1557	1557	20 more, but less than $100,000,000;
1558	1558	21 (viii) $37,500, if the premium is $100,000,000 or
1559	1559	22 more.
1560	1560	23 (b) Admitted assets.
1561	1561	24 (i) $150, if admitted assets are less than
1562	1562	25 $1,000,000;
1563	1563	26 (ii) $750, if admitted assets are $1,000,000 or
1564	1564
1565	1565
1566	1566
1567	1567
1568	1568
1569	1569	HB4126 - 43 - LRB103 33572 RJT 63384 b
1570	1570
1571	1571
1572	1572	HB4126- 44 -LRB103 33572 RJT 63384 b HB4126 - 44 - LRB103 33572 RJT 63384 b
1573	1573	HB4126 - 44 - LRB103 33572 RJT 63384 b
1574	1574	1 more, but less than $5,000,000;
1575	1575	2 (iii) $3,750, if admitted assets are $5,000,000 or
1576	1576	3 more, but less than $25,000,000;
1577	1577	4 (iv) $7,500, if admitted assets are $25,000,000 or
1578	1578	5 more, but less than $50,000,000;
1579	1579	6 (v) $18,000, if admitted assets are $50,000,000 or
1580	1580	7 more, but less than $100,000,000;
1581	1581	8 (vi) $22,500, if admitted assets are $100,000,000
1582	1582	9 or more, but less than $500,000,000;
1583	1583	10 (vii) $30,000, if admitted assets are $500,000,000
1584	1584	11 or more, but less than $1,000,000,000;
1585	1585	12 (viii) $37,500, if admitted assets are
1586	1586	13 $1,000,000,000 or more.
1587	1587	14 (c) The sum of financial regulation fees charged to
1588	1588	15 the domestic companies of the same affiliated group shall
1589	1589	16 not exceed $250,000 in the aggregate in any single year
1590	1590	17 and shall be billed by the Director to the member company
1591	1591	18 designated by the group.
1592	1592	19 (7) The Director shall charge and collect an annual
1593	1593	20 financial regulation fee from every foreign or alien company,
1594	1594	21 except fraternal benefit societies, for the examination and
1595	1595	22 analysis of its financial condition and to fund the internal
1596	1596	23 costs and expenses of the Interstate Insurance Receivership
1597	1597	24 Commission as may be allocated to the State of Illinois and
1598	1598	25 companies doing an insurance business in this State pursuant
1599	1599	26 to Article X of the Interstate Insurance Receivership Compact.
1600	1600
1601	1601
1602	1602
1603	1603
1604	1604
1605	1605	HB4126 - 44 - LRB103 33572 RJT 63384 b
1606	1606
1607	1607
1608	1608	HB4126- 45 -LRB103 33572 RJT 63384 b HB4126 - 45 - LRB103 33572 RJT 63384 b
1609	1609	HB4126 - 45 - LRB103 33572 RJT 63384 b
1610	1610	1 The fee shall be a fixed amount based upon Illinois direct
1611	1611	2 premium income and nationwide reinsurance assumed premium
1612	1612	3 income in accordance with the following schedule:
1613	1613	4 (a) $150, if the premium is less than $500,000 and
1614	1614	5 there is no reinsurance assumed premium;
1615	1615	6 (b) $750, if the premium is $500,000 or more, but less
1616	1616	7 than $5,000,000 and there is no reinsurance assumed
1617	1617	8 premium; or if the premium is less than $5,000,000 and the
1618	1618	9 reinsurance assumed premium is less than $10,000,000;
1619	1619	10 (c) $3,750, if the premium is less than $5,000,000 and
1620	1620	11 the reinsurance assumed premium is $10,000,000 or more;
1621	1621	12 (d) $7,500, if the premium is $5,000,000 or more, but
1622	1622	13 less than $10,000,000;
1623	1623	14 (e) $18,000, if the premium is $10,000,000 or more,
1624	1624	15 but less than $25,000,000;
1625	1625	16 (f) $22,500, if the premium is $25,000,000 or more,
1626	1626	17 but less than $50,000,000;
1627	1627	18 (g) $30,000, if the premium is $50,000,000 or more,
1628	1628	19 but less than $100,000,000;
1629	1629	20 (h) $37,500, if the premium is $100,000,000 or more.
1630	1630	21 The sum of financial regulation fees under this subsection
1631	1631	22 (7) charged to the foreign or alien companies within the same
1632	1632	23 affiliated group shall not exceed $250,000 in the aggregate in
1633	1633	24 any single year and shall be billed by the Director to the
1634	1634	25 member company designated by the group.
1635	1635	26 (8) Beginning January 1, 1992, the financial regulation
1636	1636
1637	1637
1638	1638
1639	1639
1640	1640
1641	1641	HB4126 - 45 - LRB103 33572 RJT 63384 b
1642	1642
1643	1643
1644	1644	HB4126- 46 -LRB103 33572 RJT 63384 b HB4126 - 46 - LRB103 33572 RJT 63384 b
1645	1645	HB4126 - 46 - LRB103 33572 RJT 63384 b
1646	1646	1 fees imposed under subsections (6) and (7) of this Section
1647	1647	2 shall be paid by each company or domestic affiliated group
1648	1648	3 annually. After January 1, 1994, the fee shall be billed by
1649	1649	4 Department invoice based upon the company's premium income or
1650	1650	5 admitted assets as shown in its annual statement for the
1651	1651	6 preceding calendar year. The invoice is due upon receipt and
1652	1652	7 must be paid no later than June 30 of each calendar year. All
1653	1653	8 financial regulation fees collected by the Department shall be
1654	1654	9 paid to the Insurance Financial Regulation Fund. The
1655	1655	10 Department may not collect financial examiner per diem charges
1656	1656	11 from companies subject to subsections (6) and (7) of this
1657	1657	12 Section undergoing financial examination after June 30, 1992.
1658	1658	13 (9) In addition to the financial regulation fee required
1659	1659	14 by this Section, a company undergoing any financial
1660	1660	15 examination authorized by law shall pay the following costs
1661	1661	16 and expenses incurred by the Department: electronic data
1662	1662	17 processing costs, the expenses authorized under Section 131.21
1663	1663	18 and subsection (d) of Section 132.4 of this Code, and lodging
1664	1664	19 and travel expenses.
1665	1665	20 Electronic data processing costs incurred by the
1666	1666	21 Department in the performance of any examination shall be
1667	1667	22 billed directly to the company undergoing examination for
1668	1668	23 payment to the Technology Management Revolving Fund. Except
1669	1669	24 for direct reimbursements authorized by the Director or direct
1670	1670	25 payments made under Section 131.21 or subsection (d) of
1671	1671	26 Section 132.4 of this Code, all financial regulation fees and
1672	1672
1673	1673
1674	1674
1675	1675
1676	1676
1677	1677	HB4126 - 46 - LRB103 33572 RJT 63384 b
1678	1678
1679	1679
1680	1680	HB4126- 47 -LRB103 33572 RJT 63384 b HB4126 - 47 - LRB103 33572 RJT 63384 b
1681	1681	HB4126 - 47 - LRB103 33572 RJT 63384 b
1682	1682	1 all financial examination charges collected by the Department
1683	1683	2 shall be paid to the Insurance Financial Regulation Fund.
1684	1684	3 All lodging and travel expenses shall be in accordance
1685	1685	4 with applicable travel regulations published by the Department
1686	1686	5 of Central Management Services and approved by the Governor's
1687	1687	6 Travel Control Board, except that out-of-state lodging and
1688	1688	7 travel expenses related to examinations authorized under
1689	1689	8 Sections 132.1 through 132.7 shall be in accordance with
1690	1690	9 travel rates prescribed under paragraph 301-7.2 of the Federal
1691	1691	10 Travel Regulations, 41 C.F.R. 301-7.2, for reimbursement of
1692	1692	11 subsistence expenses incurred during official travel. All
1693	1693	12 lodging and travel expenses may be reimbursed directly upon
1694	1694	13 the authorization of the Director.
1695	1695	14 In the case of an organization or person not subject to the
1696	1696	15 financial regulation fee, the expenses incurred in any
1697	1697	16 financial examination authorized by law shall be paid by the
1698	1698	17 organization or person being examined. The charge shall be
1699	1699	18 reasonably related to the cost of the examination including,
1700	1700	19 but not limited to, compensation of examiners and other costs
1701	1701	20 described in this subsection.
1702	1702	21 (10) Any company, person, or entity failing to make any
1703	1703	22 payment of $150 or more as required under this Section shall be
1704	1704	23 subject to the penalty and interest provisions provided for in
1705	1705	24 subsections (4) and (7) of Section 412.
1706	1706	25 (11) Unless otherwise specified, all of the fees collected
1707	1707	26 under this Section shall be paid into the Insurance Financial
1708	1708
1709	1709
1710	1710
1711	1711
1712	1712
1713	1713	HB4126 - 47 - LRB103 33572 RJT 63384 b
1714	1714
1715	1715
1716	1716	HB4126- 48 -LRB103 33572 RJT 63384 b HB4126 - 48 - LRB103 33572 RJT 63384 b
1717	1717	HB4126 - 48 - LRB103 33572 RJT 63384 b
1718	1718	1 Regulation Fund.
1719	1719	2 (12) For purposes of this Section:
1720	1720	3 (a) "Domestic company" means a company as defined in
1721	1721	4 Section 2 of this Code which is incorporated or organized
1722	1722	5 under the laws of this State, and in addition includes a
1723	1723	6 not-for-profit corporation authorized under the Dental
1724	1724	7 Service Plan Act or the Voluntary Health Services Plans
1725	1725	8 Act, a health maintenance organization, and a limited
1726	1726	9 health service organization.
1727	1727	10 (b) "Foreign company" means a company as defined in
1728	1728	11 Section 2 of this Code which is incorporated or organized
1729	1729	12 under the laws of any state of the United States other than
1730	1730	13 this State and in addition includes a health maintenance
1731	1731	14 organization and a limited health service organization
1732	1732	15 which is incorporated or organized under the laws of any
1733	1733	16 state of the United States other than this State.
1734	1734	17 (c) "Alien company" means a company as defined in
1735	1735	18 Section 2 of this Code which is incorporated or organized
1736	1736	19 under the laws of any country other than the United
1737	1737	20 States.
1738	1738	21 (d) "Fraternal benefit society" means a corporation,
1739	1739	22 society, order, lodge or voluntary association as defined
1740	1740	23 in Section 282.1 of this Code.
1741	1741	24 (e) "Mutual benefit association" means a company,
1742	1742	25 association or corporation authorized by the Director to
1743	1743	26 do business in this State under the provisions of Article
1744	1744
1745	1745
1746	1746
1747	1747
1748	1748
1749	1749	HB4126 - 48 - LRB103 33572 RJT 63384 b
1750	1750
1751	1751
1752	1752	HB4126- 49 -LRB103 33572 RJT 63384 b HB4126 - 49 - LRB103 33572 RJT 63384 b
1753	1753	HB4126 - 49 - LRB103 33572 RJT 63384 b
1754	1754	1 XVIII of this Code.
1755	1755	2 (f) "Burial society" means a person, firm,
1756	1756	3 corporation, society or association of individuals
1757	1757	4 authorized by the Director to do business in this State
1758	1758	5 under the provisions of Article XIX of this Code.
1759	1759	6 (g) "Farm mutual" means a district, county and
1760	1760	7 township mutual insurance company authorized by the
1761	1761	8 Director to do business in this State under the provisions
1762	1762	9 of the Farm Mutual Insurance Company Act of 1986.
1763	1763	10 (Source: P.A. 100-23, eff. 7-6-17.)
1764	1764	11 (215 ILCS 5/511.109) (from Ch. 73, par. 1065.58-109)
1765	1765	12 (Section scheduled to be repealed on January 1, 2027)
1766	1766	13 Sec. 511.109. Examination.
1767	1767	14 (a) The Director or the Director's his designee may
1768	1768	15 examine any applicant for or holder of an administrator's
1769	1769	16 license in accordance with Sections 132 through 132.7 of this
1770	1770	17 Code. If the Director or the examiners find that the
1771	1771	18 administrator has violated this Article or any other
1772	1772	19 insurance-related laws or rules under the Director's
1773	1773	20 jurisdiction because of the manner in which the administrator
1774	1774	21 has conducted business on behalf of an insurer or plan
1775	1775	22 sponsor, then, unless the insurer or plan sponsor is included
1776	1776	23 in the examination and has been afforded the same opportunity
1777	1777	24 to request or participate in a hearing on the examination
1778	1778	25 report, the examination report shall not allege a violation by
1779	1779
1780	1780
1781	1781
1782	1782
1783	1783
1784	1784	HB4126 - 49 - LRB103 33572 RJT 63384 b
1785	1785
1786	1786
1787	1787	HB4126- 50 -LRB103 33572 RJT 63384 b HB4126 - 50 - LRB103 33572 RJT 63384 b
1788	1788	HB4126 - 50 - LRB103 33572 RJT 63384 b
1789	1789	1 the insurer or plan sponsor and the Director's order based on
1790	1790	2 the report shall not impose any requirements, prohibitions, or
1791	1791	3 penalties on the insurer or plan sponsor. Nothing in this
1792	1792	4 Section shall prevent the Director from using any information
1793	1793	5 obtained during the examination of an administrator to
1794	1794	6 examine, investigate, or take other appropriate regulatory or
1795	1795	7 legal action with respect to an insurer or plan sponsor.
1796	1796	8 (b) (Blank). Any administrator being examined shall
1797	1797	9 provide to the Director or his designee convenient and free
1798	1798	10 access, at all reasonable hours at their offices, to all
1799	1799	11 books, records, documents and other papers relating to such
1800	1800	12 administrator's business affairs.
1801	1801	13 (c) (Blank). The Director or his designee may administer
1802	1802	14 oaths and thereafter examine any individual about the business
1803	1803	15 of the administrator.
1804	1804	16 (d) (Blank). The examiners designated by the Director
1805	1805	17 pursuant to this Section may make reports to the Director. Any
1806	1806	18 report alleging substantive violations of this Article, any
1807	1807	19 applicable provisions of the Illinois Insurance Code, or any
1808	1808	20 applicable Part of Title 50 of the Illinois Administrative
1809	1809	21 Code shall be in writing and be based upon facts obtained by
1810	1810	22 the examiners. The report shall be verified by the examiners.
1811	1811	23 (e) (Blank). If a report is made, the Director shall
1812	1812	24 either deliver a duplicate thereof to the administrator being
1813	1813	25 examined or send such duplicate by certified or registered
1814	1814	26 mail to the administrator's address specified in the records
1815	1815
1816	1816
1817	1817
1818	1818
1819	1819
1820	1820	HB4126 - 50 - LRB103 33572 RJT 63384 b
1821	1821
1822	1822
1823	1823	HB4126- 51 -LRB103 33572 RJT 63384 b HB4126 - 51 - LRB103 33572 RJT 63384 b
1824	1824	HB4126 - 51 - LRB103 33572 RJT 63384 b
1825	1825	1 of the Department. The Director shall afford the administrator
1826	1826	2 an opportunity to request a hearing to object to the report.
1827	1827	3 The administrator may request a hearing within 30 days after
1828	1828	4 receipt of the duplicate of the examination report by giving
1829	1829	5 the Director written notice of such request together with
1830	1830	6 written objections to the report. Any hearing shall be
1831	1831	7 conducted in accordance with Sections 402 and 403 of this
1832	1832	8 Code. The right to hearing is waived if the delivery of the
1833	1833	9 report is refused or the report is otherwise undeliverable or
1834	1834	10 the administrator does not timely request a hearing. After the
1835	1835	11 hearing or upon expiration of the time period during which an
1836	1836	12 administrator may request a hearing, if the examination
1837	1837	13 reveals that the administrator is operating in violation of
1838	1838	14 any applicable provision of the Illinois Insurance Code, any
1839	1839	15 applicable Part of Title 50 of the Illinois Administrative
1840	1840	16 Code or prior order, the Director, in the written order, may
1841	1841	17 require the administrator to take any action the Director
1842	1842	18 considers necessary or appropriate in accordance with the
1843	1843	19 report or examination hearing. If the Director issues an
1844	1844	20 order, it shall be issued within 90 days after the report is
1845	1845	21 filed, or if there is a hearing, within 90 days after the
1846	1846	22 conclusion of the hearing. The order is subject to review
1847	1847	23 under the Administrative Review Law.
1848	1848	24 (Source: P.A. 84-887.)
1849	1849	25 (215 ILCS 5/512-3) (from Ch. 73, par. 1065.59-3)
1850	1850
1851	1851
1852	1852
1853	1853
1854	1854
1855	1855	HB4126 - 51 - LRB103 33572 RJT 63384 b
1856	1856
1857	1857
1858	1858	HB4126- 52 -LRB103 33572 RJT 63384 b HB4126 - 52 - LRB103 33572 RJT 63384 b
1859	1859	HB4126 - 52 - LRB103 33572 RJT 63384 b
1860	1860	1 Sec. 512-3. Definitions. For the purposes of this Article,
1861	1861	2 unless the context otherwise requires, the terms defined in
1862	1862	3 this Article have the meanings ascribed to them herein:
1863	1863	4 (a) "Third party prescription program" or "program" means
1864	1864	5 any system of providing for the reimbursement of
1865	1865	6 pharmaceutical services and prescription drug products offered
1866	1866	7 or operated in this State under a contractual arrangement or
1867	1867	8 agreement between a provider of such services and another
1868	1868	9 party who is not the consumer of those services and products.
1869	1869	10 Such programs may include, but need not be limited to,
1870	1870	11 employee benefit plans whereby a consumer receives
1871	1871	12 prescription drugs or other pharmaceutical services and those
1872	1872	13 services are paid for by an agent of the employer or others.
1873	1873	14 (b) "Third party program administrator" or "administrator"
1874	1874	15 means any person, partnership or corporation who issues or
1875	1875	16 causes to be issued any payment or reimbursement to a provider
1876	1876	17 for services rendered pursuant to a third party prescription
1877	1877	18 program, but does not include the Director of Healthcare and
1878	1878	19 Family Services or any agent authorized by the Director to
1879	1879	20 reimburse a provider of services rendered pursuant to a
1880	1880	21 program of which the Department of Healthcare and Family
1881	1881	22 Services is the third party.
1882	1882	23 (c) "Health care payer" means an insurance company, health
1883	1883	24 maintenance organization, limited health service organization,
1884	1884	25 health services plan corporation, or dental service plan
1885	1885	26 corporation authorized to do business in this State.
1886	1886
1887	1887
1888	1888
1889	1889
1890	1890
1891	1891	HB4126 - 52 - LRB103 33572 RJT 63384 b
1892	1892
1893	1893
1894	1894	HB4126- 53 -LRB103 33572 RJT 63384 b HB4126 - 53 - LRB103 33572 RJT 63384 b
1895	1895	HB4126 - 53 - LRB103 33572 RJT 63384 b
1896	1896	1 (Source: P.A. 95-331, eff. 8-21-07.)
1897	1897	2 (215 ILCS 5/512-5) (from Ch. 73, par. 1065.59-5)
1898	1898	3 Sec. 512-5. Fiduciary and Bonding Requirements. A third
1899	1899	4 party prescription program administrator shall (1) establish
1900	1900	5 and maintain a fiduciary account, separate and apart from any
1901	1901	6 and all other accounts, for the receipt and disbursement of
1902	1902	7 funds for reimbursement of providers of services under the
1903	1903	8 program, or (2) post, or cause to be posted, a bond of
1904	1904	9 indemnity in an amount equal to not less than 10% of the total
1905	1905	10 estimated annual reimbursements under the program.
1906	1906	11 The establishment of such fiduciary accounts and bonds
1907	1907	12 shall be consistent with applicable State law. If a bond of
1908	1908	13 indemnity is posted, it shall be held by the Director of
1909	1909	14 Insurance for the benefit and indemnification of the providers
1910	1910	15 of services under the third party prescription program.
1911	1911	16 An administrator who operates more than one third party
1912	1912	17 prescription program may establish and maintain a separate
1913	1913	18 fiduciary account or bond of indemnity for each such program,
1914	1914	19 or may operate and maintain a consolidated fiduciary account
1915	1915	20 or bond of indemnity for all such programs.
1916	1916	21 The requirements of this Section do not apply to any third
1917	1917	22 party prescription program administered by or on behalf of any
1918	1918	23 health care payer insurance company, Health Care Service Plan
1919	1919	24 Corporation or Pharmaceutical Service Plan Corporation
1920	1920	25 authorized to do business in the State of Illinois.
1921	1921
1922	1922
1923	1923
1924	1924
1925	1925
1926	1926	HB4126 - 53 - LRB103 33572 RJT 63384 b
1927	1927
1928	1928
1929	1929	HB4126- 54 -LRB103 33572 RJT 63384 b HB4126 - 54 - LRB103 33572 RJT 63384 b
1930	1930	HB4126 - 54 - LRB103 33572 RJT 63384 b
1931	1931	1 (Source: P.A. 82-1005.)
1932	1932	2 (215 ILCS 5/512-11 new)
1933	1933	3 Sec. 512-11. Examination. The Director or the Director's
1934	1934	4 designee may examine any applicant for or holder of an
1935	1935	5 administrator's registration in accordance with Sections 132
1936	1936	6 through 132.7 of this Code. If the Director or the examiners
1937	1937	7 find that the administrator has violated this Article or any
1938	1938	8 other insurance-related laws or rules under the Director's
1939	1939	9 jurisdiction because of the manner in which the administrator
1940	1940	10 has conducted business on behalf of a separately incorporated
1941	1941	11 health care payer, then, unless the health care payer is
1942	1942	12 included in the examination and has been afforded the same
1943	1943	13 opportunity to request or participate in a hearing on the
1944	1944	14 examination report, the examination report shall not allege a
1945	1945	15 violation by the health care payer and the Director's order
1946	1946	16 based on the report shall not impose any requirements,
1947	1947	17 prohibitions, or penalties on the health care payer. Nothing
1948	1948	18 in this Section shall prevent the Director from using any
1949	1949	19 information obtained during the examination of an
1950	1950	20 administrator to examine, investigate, or take other
1951	1951	21 appropriate regulatory or legal action with respect to a
1952	1952	22 health care payer.
1953	1953	23 (215 ILCS 5/513b3)
1954	1954	24 Sec. 513b3. Examination.
1955	1955
1956	1956
1957	1957
1958	1958
1959	1959
1960	1960	HB4126 - 54 - LRB103 33572 RJT 63384 b
1961	1961
1962	1962
1963	1963	HB4126- 55 -LRB103 33572 RJT 63384 b HB4126 - 55 - LRB103 33572 RJT 63384 b
1964	1964	HB4126 - 55 - LRB103 33572 RJT 63384 b
1965	1965	1 (a) The Director, or the Director's his or her designee,
1966	1966	2 may examine a registered pharmacy benefit manager in
1967	1967	3 accordance with Sections 132 through 132.7 of this Code. If
1968	1968	4 the Director or the examiners find that the pharmacy benefit
1969	1969	5 manager has violated this Article or any other
1970	1970	6 insurance-related laws or rules under the Director's
1971	1971	7 jurisdiction because of the manner in which the pharmacy
1972	1972	8 benefit manager has conducted business on behalf of a health
1973	1973	9 insurer or plan sponsor, then, unless the health insurer or
1974	1974	10 plan sponsor is included in the examination and has been
1975	1975	11 afforded the same opportunity to request or participate in a
1976	1976	12 hearing on the examination report, the examination report
1977	1977	13 shall not allege a violation by the health insurer or plan
1978	1978	14 sponsor and the Director's order based on the report shall not
1979	1979	15 impose any requirements, prohibitions, or penalties on the
1980	1980	16 health insurer or plan sponsor. Nothing in this Section shall
1981	1981	17 prevent the Director from using any information obtained
1982	1982	18 during the examination of an administrator to examine,
1983	1983	19 investigate, or take other appropriate regulatory or legal
1984	1984	20 action with respect to a health insurer or plan sponsor.
1985	1985	21 (b) (Blank). Any pharmacy benefit manager being examined
1986	1986	22 shall provide to the Director, or his or her designee,
1987	1987	23 convenient and free access to all books, records, documents,
1988	1988	24 and other papers relating to such pharmacy benefit manager's
1989	1989	25 business affairs at all reasonable hours at its offices.
1990	1990	26 (c) (Blank). The Director, or his or her designee, may
1991	1991
1992	1992
1993	1993
1994	1994
1995	1995
1996	1996	HB4126 - 55 - LRB103 33572 RJT 63384 b
1997	1997
1998	1998
1999	1999	HB4126- 56 -LRB103 33572 RJT 63384 b HB4126 - 56 - LRB103 33572 RJT 63384 b
2000	2000	HB4126 - 56 - LRB103 33572 RJT 63384 b
2001	2001	1 administer oaths and thereafter examine the pharmacy benefit
2002	2002	2 manager's designee, representative, or any officer or senior
2003	2003	3 manager as listed on the license or registration certificate
2004	2004	4 about the business of the pharmacy benefit manager.
2005	2005	5 (d) (Blank). The examiners designated by the Director
2006	2006	6 under this Section may make reports to the Director. Any
2007	2007	7 report alleging substantive violations of this Article, any
2008	2008	8 applicable provisions of this Code, or any applicable Part of
2009	2009	9 Title 50 of the Illinois Administrative Code shall be in
2010	2010	10 writing and be based upon facts obtained by the examiners. The
2011	2011	11 report shall be verified by the examiners.
2012	2012	12 (e) (Blank). If a report is made, the Director shall
2013	2013	13 either deliver a duplicate report to the pharmacy benefit
2014	2014	14 manager being examined or send such duplicate by certified or
2015	2015	15 registered mail to the pharmacy benefit manager's address
2016	2016	16 specified in the records of the Department. The Director shall
2017	2017	17 afford the pharmacy benefit manager an opportunity to request
2018	2018	18 a hearing to object to the report. The pharmacy benefit
2019	2019	19 manager may request a hearing within 30 days after receipt of
2020	2020	20 the duplicate report by giving the Director written notice of
2021	2021	21 such request together with written objections to the report.
2022	2022	22 Any hearing shall be conducted in accordance with Sections 402
2023	2023	23 and 403 of this Code. The right to a hearing is waived if the
2024	2024	24 delivery of the report is refused or the report is otherwise
2025	2025	25 undeliverable or the pharmacy benefit manager does not timely
2026	2026	26 request a hearing. After the hearing or upon expiration of the
2027	2027
2028	2028
2029	2029
2030	2030
2031	2031
2032	2032	HB4126 - 56 - LRB103 33572 RJT 63384 b
2033	2033
2034	2034
2035	2035	HB4126- 57 -LRB103 33572 RJT 63384 b HB4126 - 57 - LRB103 33572 RJT 63384 b
2036	2036	HB4126 - 57 - LRB103 33572 RJT 63384 b
2037	2037	1 time period during which a pharmacy benefit manager may
2038	2038	2 request a hearing, if the examination reveals that the
2039	2039	3 pharmacy benefit manager is operating in violation of any
2040	2040	4 applicable provision of this Code, any applicable Part of
2041	2041	5 Title 50 of the Illinois Administrative Code, a provision of
2042	2042	6 this Article, or prior order, the Director, in the written
2043	2043	7 order, may require the pharmacy benefit manager to take any
2044	2044	8 action the Director considers necessary or appropriate in
2045	2045	9 accordance with the report or examination hearing. If the
2046	2046	10 Director issues an order, it shall be issued within 90 days
2047	2047	11 after the report is filed, or if there is a hearing, within 90
2048	2048	12 days after the conclusion of the hearing. The order is subject
2049	2049	13 to review under the Administrative Review Law.
2050	2050	14 (Source: P.A. 101-452, eff. 1-1-20.)
2051	2051	15 Section 15. The Network Adequacy and Transparency Act is
2052	2052	16 amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and
2053	2053	17 by adding Sections 35 and 40 as follows:
2054	2054	18 (215 ILCS 124/3)
2055	2055	19 Sec. 3. Applicability of Act. This Act applies to an
2056	2056	20 individual or group policy of accident and health insurance
2057	2057	21 coverage with a network plan amended, delivered, issued, or
2058	2058	22 renewed in this State on or after January 1, 2019. This Act
2059	2059	23 does not apply to an individual or group policy for excepted
2060	2060	24 benefits or short-term, limited-duration health insurance
2061	2061
2062	2062
2063	2063
2064	2064
2065	2065
2066	2066	HB4126 - 57 - LRB103 33572 RJT 63384 b
2067	2067
2068	2068
2069	2069	HB4126- 58 -LRB103 33572 RJT 63384 b HB4126 - 58 - LRB103 33572 RJT 63384 b
2070	2070	HB4126 - 58 - LRB103 33572 RJT 63384 b
2071	2071	1 coverage dental or vision insurance or a limited health
2072	2072	2 service organization with a network plan amended, delivered,
2073	2073	3 issued, or renewed in this State on or after January 1, 2019,
2074	2074	4 except to the extent that federal law establishes network
2075	2075	5 adequacy and transparency standards for stand-alone dental
2076	2076	6 plans, which the Department shall enforce.
2077	2077	7 (Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
2078	2078	8 (215 ILCS 124/5)
2079	2079	9 Sec. 5. Definitions. In this Act:
2080	2080	10 "Authorized representative" means a person to whom a
2081	2081	11 beneficiary has given express written consent to represent the
2082	2082	12 beneficiary; a person authorized by law to provide substituted
2083	2083	13 consent for a beneficiary; or the beneficiary's treating
2084	2084	14 provider only when the beneficiary or his or her family member
2085	2085	15 is unable to provide consent.
2086	2086	16 "Beneficiary" means an individual, an enrollee, an
2087	2087	17 insured, a participant, or any other person entitled to
2088	2088	18 reimbursement for covered expenses of or the discounting of
2089	2089	19 provider fees for health care services under a program in
2090	2090	20 which the beneficiary has an incentive to utilize the services
2091	2091	21 of a provider that has entered into an agreement or
2092	2092	22 arrangement with an issuer insurer.
2093	2093	23 "Department" means the Department of Insurance.
2094	2094	24 "Essential community provider" has the meaning ascribed to
2095	2095	25 that term in 45 CFR 156.235.
2096	2096
2097	2097
2098	2098
2099	2099
2100	2100
2101	2101	HB4126 - 58 - LRB103 33572 RJT 63384 b
2102	2102
2103	2103
2104	2104	HB4126- 59 -LRB103 33572 RJT 63384 b HB4126 - 59 - LRB103 33572 RJT 63384 b
2105	2105	HB4126 - 59 - LRB103 33572 RJT 63384 b
2106	2106	1 "Excepted benefits" has the meaning ascribed to that term
2107	2107	2 in 42 U.S.C. 300gg-91(c).
2108	2108	3 "Director" means the Director of Insurance.
2109	2109	4 "Family caregiver" means a relative, partner, friend, or
2110	2110	5 neighbor who has a significant relationship with the patient
2111	2111	6 and administers or assists the patient with activities of
2112	2112	7 daily living, instrumental activities of daily living, or
2113	2113	8 other medical or nursing tasks for the quality and welfare of
2114	2114	9 that patient.
2115	2115	10 "Group health plan" has the meaning ascribed to that term
2116	2116	11 in Section 5 of the Illinois Health Insurance Portability and
2117	2117	12 Accountability Act.
2118	2118	13 "Health insurance coverage" has the meaning ascribed to
2119	2119	14 that term in Section 5 of the Illinois Health Insurance
2120	2120	15 Portability and Accountability Act. "Health insurance
2121	2121	16 coverage" does not include any coverage or benefits under
2122	2122	17 Medicare or under the medical assistance program established
2123	2123	18 under Article V of the Illinois Public Aid Code.
2124	2124	19 "Issuer" means a "health insurance issuer" as defined in
2125	2125	20 Section 5 of the Illinois Health Insurance Portability and
2126	2126	21 Accountability Act.
2127	2127	22 "Insurer" means any entity that offers individual or group
2128	2128	23 accident and health insurance, including, but not limited to,
2129	2129	24 health maintenance organizations, preferred provider
2130	2130	25 organizations, exclusive provider organizations, and other
2131	2131	26 plan structures requiring network participation, excluding the
2132	2132
2133	2133
2134	2134
2135	2135
2136	2136
2137	2137	HB4126 - 59 - LRB103 33572 RJT 63384 b
2138	2138
2139	2139
2140	2140	HB4126- 60 -LRB103 33572 RJT 63384 b HB4126 - 60 - LRB103 33572 RJT 63384 b
2141	2141	HB4126 - 60 - LRB103 33572 RJT 63384 b
2142	2142	1 medical assistance program under the Illinois Public Aid Code,
2143	2143	2 the State employees group health insurance program, workers
2144	2144	3 compensation insurance, and pharmacy benefit managers.
2145	2145	4 "Material change" means a significant reduction in the
2146	2146	5 number of providers available in a network plan, including,
2147	2147	6 but not limited to, a reduction of 10% or more in a specific
2148	2148	7 type of providers within any county, the removal of a major
2149	2149	8 health system that causes a network to be significantly
2150	2150	9 different within any county from the network when the
2151	2151	10 beneficiary purchased the network plan, or any change that
2152	2152	11 would cause the network to no longer satisfy the requirements
2153	2153	12 of this Act or the Department's rules for network adequacy and
2154	2154	13 transparency.
2155	2155	14 "Network" means the group or groups of preferred providers
2156	2156	15 providing services to a network plan.
2157	2157	16 "Network plan" means an individual or group policy of
2158	2158	17 accident and health insurance coverage that either requires a
2159	2159	18 covered person to use or creates incentives, including
2160	2160	19 financial incentives, for a covered person to use providers
2161	2161	20 managed, owned, under contract with, or employed by the issuer
2162	2162	21 or by a third party contracted to arrange, contract for, or
2163	2163	22 administer such provider-related incentives for the issuer
2164	2164	23 insurer.
2165	2165	24 "Ongoing course of treatment" means (1) treatment for a
2166	2166	25 life-threatening condition, which is a disease or condition
2167	2167	26 for which likelihood of death is probable unless the course of
2168	2168
2169	2169
2170	2170
2171	2171
2172	2172
2173	2173	HB4126 - 60 - LRB103 33572 RJT 63384 b
2174	2174
2175	2175
2176	2176	HB4126- 61 -LRB103 33572 RJT 63384 b HB4126 - 61 - LRB103 33572 RJT 63384 b
2177	2177	HB4126 - 61 - LRB103 33572 RJT 63384 b
2178	2178	1 the disease or condition is interrupted; (2) treatment for a
2179	2179	2 serious acute condition, defined as a disease or condition
2180	2180	3 requiring complex ongoing care that the covered person is
2181	2181	4 currently receiving, such as chemotherapy, radiation therapy,
2182	2182	5 or post-operative visits, or a serious and complex condition
2183	2183	6 as defined under 42 U.S.C. 300gg-113(b)(2); (3) a course of
2184	2184	7 treatment for a health condition that a treating provider
2185	2185	8 attests that discontinuing care by that provider would worsen
2186	2186	9 the condition or interfere with anticipated outcomes; or (4)
2187	2187	10 the third trimester of pregnancy through the post-partum
2188	2188	11 period ; (5) undergoing a course of institutional or inpatient
2189	2189	12 care from the provider within the meaning of 42 U.S.C.
2190	2190	13 300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective
2191	2191	14 surgery from the provider, including receipt of postoperative
2192	2192	15 care from such provider with respect to such a surgery; or (7)
2193	2193	16 being determined to be terminally ill, as determined under 42
2194	2194	17 U.S.C. 1395x(dd)(3)(A), and receiving treatment for such
2195	2195	18 illness from such provider.
2196	2196	19 "Preferred provider" means any provider who has entered,
2197	2197	20 either directly or indirectly, into an agreement with an
2198	2198	21 employer or risk-bearing entity relating to health care
2199	2199	22 services that may be rendered to beneficiaries under a network
2200	2200	23 plan.
2201	2201	24 "Providers" means physicians licensed to practice medicine
2202	2202	25 in all its branches, other health care professionals,
2203	2203	26 hospitals, or other health care institutions or facilities
2204	2204
2205	2205
2206	2206
2207	2207
2208	2208
2209	2209	HB4126 - 61 - LRB103 33572 RJT 63384 b
2210	2210
2211	2211
2212	2212	HB4126- 62 -LRB103 33572 RJT 63384 b HB4126 - 62 - LRB103 33572 RJT 63384 b
2213	2213	HB4126 - 62 - LRB103 33572 RJT 63384 b
2214	2214	1 that provide health care services.
2215	2215	2 "Short-term, limited-duration health insurance coverage"
2216	2216	3 has the meaning ascribed to that term in Section 5 of the
2217	2217	4 Short-Term, Limited-Duration Health Insurance Coverage Act.
2218	2218	5 "Stand-alone dental plan" has the meaning ascribed to that
2219	2219	6 term in 45 CFR 156.400.
2220	2220	7 "Telehealth" has the meaning given to that term in Section
2221	2221	8 356z.22 of the Illinois Insurance Code.
2222	2222	9 "Telemedicine" has the meaning given to that term in
2223	2223	10 Section 49.5 of the Medical Practice Act of 1987.
2224	2224	11 "Tiered network" means a network that identifies and
2225	2225	12 groups some or all types of provider and facilities into
2226	2226	13 specific groups to which different provider reimbursement,
2227	2227	14 covered person cost-sharing or provider access requirements,
2228	2228	15 or any combination thereof, apply for the same services.
2229	2229	16 "Woman's principal health care provider" means a physician
2230	2230	17 licensed to practice medicine in all of its branches
2231	2231	18 specializing in obstetrics, gynecology, or family practice.
2232	2232	19 (Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)
2233	2233	20 (215 ILCS 124/10)
2234	2234	21 Sec. 10. Network adequacy.
2235	2235	22 (a) Before issuing, delivering, or renewing a network
2236	2236	23 plan, an issuer An insurer providing a network plan shall file
2237	2237	24 a description of all of the following with the Director:
2238	2238	25 (1) The written policies and procedures for adding
2239	2239
2240	2240
2241	2241
2242	2242
2243	2243
2244	2244	HB4126 - 62 - LRB103 33572 RJT 63384 b
2245	2245
2246	2246
2247	2247	HB4126- 63 -LRB103 33572 RJT 63384 b HB4126 - 63 - LRB103 33572 RJT 63384 b
2248	2248	HB4126 - 63 - LRB103 33572 RJT 63384 b
2249	2249	1 providers to meet patient needs based on increases in the
2250	2250	2 number of beneficiaries, changes in the
2251	2251	3 patient-to-provider ratio, changes in medical and health
2252	2252	4 care capabilities, and increased demand for services.
2253	2253	5 (2) The written policies and procedures for making
2254	2254	6 referrals within and outside the network.
2255	2255	7 (3) The written policies and procedures on how the
2256	2256	8 network plan will provide 24-hour, 7-day per week access
2257	2257	9 to network-affiliated primary care, emergency services,
2258	2258	10 and women's principal health care providers.
2259	2259	11 An issuer insurer shall not prohibit a preferred provider
2260	2260	12 from discussing any specific or all treatment options with
2261	2261	13 beneficiaries irrespective of the insurer's position on those
2262	2262	14 treatment options or from advocating on behalf of
2263	2263	15 beneficiaries within the utilization review, grievance, or
2264	2264	16 appeals processes established by the issuer insurer in
2265	2265	17 accordance with any rights or remedies available under
2266	2266	18 applicable State or federal law.
2267	2267	19 (b) Before issuing, delivering, or renewing a network
2268	2268	20 plan, an issuer Insurers must file for review a description of
2269	2269	21 the services to be offered through a network plan. The
2270	2270	22 description shall include all of the following:
2271	2271	23 (1) A geographic map of the area proposed to be served
2272	2272	24 by the plan by county service area and zip code, including
2273	2273	25 marked locations for preferred providers.
2274	2274	26 (2) As deemed necessary by the Department, the names,
2275	2275
2276	2276
2277	2277
2278	2278
2279	2279
2280	2280	HB4126 - 63 - LRB103 33572 RJT 63384 b
2281	2281
2282	2282
2283	2283	HB4126- 64 -LRB103 33572 RJT 63384 b HB4126 - 64 - LRB103 33572 RJT 63384 b
2284	2284	HB4126 - 64 - LRB103 33572 RJT 63384 b
2285	2285	1 addresses, phone numbers, and specialties of the providers
2286	2286	2 who have entered into preferred provider agreements under
2287	2287	3 the network plan.
2288	2288	4 (3) The number of beneficiaries anticipated to be
2289	2289	5 covered by the network plan.
2290	2290	6 (4) An Internet website and toll-free telephone number
2291	2291	7 for beneficiaries and prospective beneficiaries to access
2292	2292	8 current and accurate lists of preferred providers,
2293	2293	9 additional information about the plan, as well as any
2294	2294	10 other information required by Department rule.
2295	2295	11 (5) A description of how health care services to be
2296	2296	12 rendered under the network plan are reasonably accessible
2297	2297	13 and available to beneficiaries. The description shall
2298	2298	14 address all of the following:
2299	2299	15 (A) the type of health care services to be
2300	2300	16 provided by the network plan;
2301	2301	17 (B) the ratio of physicians and other providers to
2302	2302	18 beneficiaries, by specialty and including primary care
2303	2303	19 physicians and facility-based physicians when
2304	2304	20 applicable under the contract, necessary to meet the
2305	2305	21 health care needs and service demands of the currently
2306	2306	22 enrolled population;
2307	2307	23 (C) the travel and distance standards for plan
2308	2308	24 beneficiaries in county service areas; and
2309	2309	25 (D) a description of how the use of telemedicine,
2310	2310	26 telehealth, or mobile care services may be used to
2311	2311
2312	2312
2313	2313
2314	2314
2315	2315
2316	2316	HB4126 - 64 - LRB103 33572 RJT 63384 b
2317	2317
2318	2318
2319	2319	HB4126- 65 -LRB103 33572 RJT 63384 b HB4126 - 65 - LRB103 33572 RJT 63384 b
2320	2320	HB4126 - 65 - LRB103 33572 RJT 63384 b
2321	2321	1 partially meet the network adequacy standards, if
2322	2322	2 applicable.
2323	2323	3 (6) A provision ensuring that whenever a beneficiary
2324	2324	4 has made a good faith effort, as evidenced by accessing
2325	2325	5 the provider directory, calling the network plan, and
2326	2326	6 calling the provider, to utilize preferred providers for a
2327	2327	7 covered service and it is determined the insurer does not
2328	2328	8 have the appropriate preferred providers due to
2329	2329	9 insufficient number, type, unreasonable travel distance or
2330	2330	10 delay, or preferred providers refusing to provide a
2331	2331	11 covered service because it is contrary to the conscience
2332	2332	12 of the preferred providers, as protected by the Health
2333	2333	13 Care Right of Conscience Act, the issuer insurer shall
2334	2334	14 ensure, directly or indirectly, by terms contained in the
2335	2335	15 payer contract, that the beneficiary will be provided the
2336	2336	16 covered service at no greater cost to the beneficiary than
2337	2337	17 if the service had been provided by a preferred provider.
2338	2338	18 This paragraph (6) does not apply to: (A) a beneficiary
2339	2339	19 who willfully chooses to access a non-preferred provider
2340	2340	20 for health care services available through the panel of
2341	2341	21 preferred providers, or (B) a beneficiary enrolled in a
2342	2342	22 health maintenance organization. In these circumstances,
2343	2343	23 the contractual requirements for non-preferred provider
2344	2344	24 reimbursements shall apply unless Section 356z.3a of the
2345	2345	25 Illinois Insurance Code requires otherwise. In no event
2346	2346	26 shall a beneficiary who receives care at a participating
2347	2347
2348	2348
2349	2349
2350	2350
2351	2351
2352	2352	HB4126 - 65 - LRB103 33572 RJT 63384 b
2353	2353
2354	2354
2355	2355	HB4126- 66 -LRB103 33572 RJT 63384 b HB4126 - 66 - LRB103 33572 RJT 63384 b
2356	2356	HB4126 - 66 - LRB103 33572 RJT 63384 b
2357	2357	1 health care facility be required to search for
2358	2358	2 participating providers under the circumstances described
2359	2359	3 in subsection (b) or (b-5) of Section 356z.3a of the
2360	2360	4 Illinois Insurance Code except under the circumstances
2361	2361	5 described in paragraph (2) of subsection (b-5).
2362	2362	6 (7) A provision that the beneficiary shall receive
2363	2363	7 emergency care coverage such that payment for this
2364	2364	8 coverage is not dependent upon whether the emergency
2365	2365	9 services are performed by a preferred or non-preferred
2366	2366	10 provider and the coverage shall be at the same benefit
2367	2367	11 level as if the service or treatment had been rendered by a
2368	2368	12 preferred provider. For purposes of this paragraph (7),
2369	2369	13 "the same benefit level" means that the beneficiary is
2370	2370	14 provided the covered service at no greater cost to the
2371	2371	15 beneficiary than if the service had been provided by a
2372	2372	16 preferred provider. This provision shall be consistent
2373	2373	17 with Section 356z.3a of the Illinois Insurance Code.
2374	2374	18 (8) A limitation that, if the plan provides that the
2375	2375	19 beneficiary will incur a penalty for failing to
2376	2376	20 pre-certify inpatient hospital treatment, the penalty may
2377	2377	21 not exceed $1,000 per occurrence in addition to the plan
2378	2378	22 cost sharing provisions.
2379	2379	23 (9) For a network plan in the individual or small group
2380	2380	24 market other than a grandfathered health plan, evidence that
2381	2381	25 the network plan:
2382	2382	26 (A) contracts with at least 35% of the essential
2383	2383
2384	2384
2385	2385
2386	2386
2387	2387
2388	2388	HB4126 - 66 - LRB103 33572 RJT 63384 b
2389	2389
2390	2390
2391	2391	HB4126- 67 -LRB103 33572 RJT 63384 b HB4126 - 67 - LRB103 33572 RJT 63384 b
2392	2392	HB4126 - 67 - LRB103 33572 RJT 63384 b
2393	2393	1 community providers in the service area of the network
2394	2394	2 plan that are available to participate in the provider
2395	2395	3 network of the network plan, as calculated using the
2396	2396	4 methodology contained in the most recent Letter to Issuers
2397	2397	5 in the Federally-facilitated Marketplaces issued by the
2398	2398	6 federal Centers for Medicare and Medicaid Services. The
2399	2399	7 Director may specify a different percentage by rule.
2400	2400	8 (B) offers contracts in good faith to all available
2401	2401	9 Indian health care providers in the service area of the
2402	2402	10 network plan, including, without limitation, the Indian
2403	2403	11 Health Service, Indian tribes, tribal organizations, and
2404	2404	12 urban Indian organizations, as defined in 25 U.S.C. 1603,
2405	2405	13 which apply the special terms and conditions necessitated
2406	2406	14 by federal statutes and regulations as referenced in the
2407	2407	15 Model Qualified Health Plan Addendum for Indian Health
2408	2408	16 Care Providers issued by the federal Centers for Medicare
2409	2409	17 and Medicaid Services.
2410	2410	18 (C) offers contracts in good faith to at least one
2411	2411	19 essential community provider in each category of essential
2412	2412	20 community provider, as contained in the most recent Letter
2413	2413	21 to Issuers in the Federally-facilitated Marketplaces, in
2414	2414	22 each county in the service area of the network plan, where
2415	2415	23 an essential community provider in that category is
2416	2416	24 available and provides medical or dental services that are
2417	2417	25 covered by the network plan. To offer a contract in good
2418	2418	26 faith, a network plan must offer contract terms comparable
2419	2419
2420	2420
2421	2421
2422	2422
2423	2423
2424	2424	HB4126 - 67 - LRB103 33572 RJT 63384 b
2425	2425
2426	2426
2427	2427	HB4126- 68 -LRB103 33572 RJT 63384 b HB4126 - 68 - LRB103 33572 RJT 63384 b
2428	2428	HB4126 - 68 - LRB103 33572 RJT 63384 b
2429	2429	1 to the terms that an issuer would offer to a similarly
2430	2430	2 situated provider that is not an essential community
2431	2431	3 provider, except for terms that would not be applicable to
2432	2432	4 an essential community provider, including, without
2433	2433	5 limitation, because of the type of services that an
2434	2434	6 essential community provider provides. A network plan must
2435	2435	7 be able to provide verification of such offers if the
2436	2436	8 Centers for Medicare and Medicaid Services of the United
2437	2437	9 States Department of Health and Human Services requests to
2438	2438	10 verify compliance with this policy.
2439	2439	11 (c) The issuer network plan shall demonstrate to the
2440	2440	12 Director a minimum ratio of providers to plan beneficiaries as
2441	2441	13 required by the Department for each network plan.
2442	2442	14 (1) The minimum ratio of physicians or other providers
2443	2443	15 to plan beneficiaries shall be established annually by the
2444	2444	16 Department in consultation with the Department of Public
2445	2445	17 Health based upon the guidance from the federal Centers
2446	2446	18 for Medicare and Medicaid Services. The Department shall
2447	2447	19 not establish ratios for vision or dental providers who
2448	2448	20 provide services under dental-specific or vision-specific
2449	2449	21 benefits, except to the extent provided under federal law
2450	2450	22 for stand-alone dental plans. The Department shall
2451	2451	23 consider establishing ratios for the following physicians
2452	2452	24 or other providers:
2453	2453	25 (A) Primary Care;
2454	2454	26 (B) Pediatrics;
2455	2455
2456	2456
2457	2457
2458	2458
2459	2459
2460	2460	HB4126 - 68 - LRB103 33572 RJT 63384 b
2461	2461
2462	2462
2463	2463	HB4126- 69 -LRB103 33572 RJT 63384 b HB4126 - 69 - LRB103 33572 RJT 63384 b
2464	2464	HB4126 - 69 - LRB103 33572 RJT 63384 b
2465	2465	1 (C) Cardiology;
2466	2466	2 (D) Gastroenterology;
2467	2467	3 (E) General Surgery;
2468	2468	4 (F) Neurology;
2469	2469	5 (G) OB/GYN;
2470	2470	6 (H) Oncology/Radiation;
2471	2471	7 (I) Ophthalmology;
2472	2472	8 (J) Urology;
2473	2473	9 (K) Behavioral Health;
2474	2474	10 (L) Allergy/Immunology;
2475	2475	11 (M) Chiropractic;
2476	2476	12 (N) Dermatology;
2477	2477	13 (O) Endocrinology;
2478	2478	14 (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
2479	2479	15 (Q) Infectious Disease;
2480	2480	16 (R) Nephrology;
2481	2481	17 (S) Neurosurgery;
2482	2482	18 (T) Orthopedic Surgery;
2483	2483	19 (U) Physiatry/Rehabilitative;
2484	2484	20 (V) Plastic Surgery;
2485	2485	21 (W) Pulmonary;
2486	2486	22 (X) Rheumatology;
2487	2487	23 (Y) Anesthesiology;
2488	2488	24 (Z) Pain Medicine;
2489	2489	25 (AA) Pediatric Specialty Services;
2490	2490	26 (BB) Outpatient Dialysis; and
2491	2491
2492	2492
2493	2493
2494	2494
2495	2495
2496	2496	HB4126 - 69 - LRB103 33572 RJT 63384 b
2497	2497
2498	2498
2499	2499	HB4126- 70 -LRB103 33572 RJT 63384 b HB4126 - 70 - LRB103 33572 RJT 63384 b
2500	2500	HB4126 - 70 - LRB103 33572 RJT 63384 b
2501	2501	1 (CC) HIV.
2502	2502	2 (2) The Director shall establish a process for the
2503	2503	3 review of the adequacy of these standards, along with an
2504	2504	4 assessment of additional specialties to be included in the
2505	2505	5 list under this subsection (c).
2506	2506	6 (3) Notwithstanding any other law or rule, the minimum
2507	2507	7 ratio for each provider type shall be no less than any such
2508	2508	8 ratio established for qualified health plans in
2509	2509	9 Federally-Facilitated Exchanges by federal law or by the
2510	2510	10 federal Centers for Medicare and Medicaid Services, even
2511	2511	11 if the network plan is issued in the large group market or
2512	2512	12 is otherwise not issued through an exchange. Federal
2513	2513	13 standards for stand-alone dental plans shall only apply to
2514	2514	14 such network plans. In the absence of an applicable
2515	2515	15 Department rule, the federal standards shall apply for the
2516	2516	16 time period specified in the federal law, regulation, or
2517	2517	17 guidance. If the Centers for Medicare and Medicaid
2518	2518	18 Services establish standards that are more stringent than
2519	2519	19 the standards in effect under any Department rule, the
2520	2520	20 Department may amend its rules to conform to the more
2521	2521	21 stringent federal standards.
2522	2522	22 (4) Prior to the enactment of an applicable Department
2523	2523	23 rule or the promulgation of federal standards for
2524	2524	24 qualified health plans or stand-alone dental plans, the
2525	2525	25 minimum ratios for any network plan issued, delivered,
2526	2526	26 amended, or renewed during 2024 shall be the following,
2527	2527
2528	2528
2529	2529
2530	2530
2531	2531
2532	2532	HB4126 - 70 - LRB103 33572 RJT 63384 b
2533	2533
2534	2534
2535	2535	HB4126- 71 -LRB103 33572 RJT 63384 b HB4126 - 71 - LRB103 33572 RJT 63384 b
2536	2536	HB4126 - 71 - LRB103 33572 RJT 63384 b
2537	2537	1 expressed in terms of providers to beneficiaries for
2538	2538	2 health care professionals and in terms of providers per
2539	2539	3 county for facilities:
2540	2540	4 (A) primary care physician, general practice,
2541	2541	5 family practice, internal medicine, pediatrician,
2542	2542	6 primary care physician assistant, or primary care
2543	2543	7 nurse practitioner - 1:500;
2544	2544	8 (B) allergy/immunology - 1:15,000;
2545	2545	9 (C) cardiology - 1:10,000;
2546	2546	10 (D) chiropractic - 1:10,000;
2547	2547	11 (E) dermatology - 1:10,000;
2548	2548	12 (F) endocrinology - 1:10,000;
2549	2549	13 (G) ENT/otolaryngology - 1:15,000;
2550	2550	14 (H) gastroenterology - 1:10,000;
2551	2551	15 (I) general surgery - 1:5,000;
2552	2552	16 (J) gynecology or OB/GYN - 1:2,500;
2553	2553	17 (K) infectious diseases - 1:15,000;
2554	2554	18 (L) nephrology - 1:10,000;
2555	2555	19 (M) neurology - 1:20,000;
2556	2556	20 (N) oncology/radiation - 1:15,000;
2557	2557	21 (O) ophthalmology - 1:10,000;
2558	2558	22 (P) orthopedic surgery - 1:10,000;
2559	2559	23 (Q) physiatry/rehabilitative medicine - 1:15,000;
2560	2560	24 (R) plastic surgery - 1:20,000;
2561	2561	25 (S) behavioral health - 1:5,000;
2562	2562	26 (T) pulmonology - 1:10,000;
2563	2563
2564	2564
2565	2565
2566	2566
2567	2567
2568	2568	HB4126 - 71 - LRB103 33572 RJT 63384 b
2569	2569
2570	2570
2571	2571	HB4126- 72 -LRB103 33572 RJT 63384 b HB4126 - 72 - LRB103 33572 RJT 63384 b
2572	2572	HB4126 - 72 - LRB103 33572 RJT 63384 b
2573	2573	1 (U) rheumatology - 1:10,000;
2574	2574	2 (V) urology - 1:10,000;
2575	2575	3 (W) acute inpatient hospital with emergency
2576	2576	4 services available 24 hours a day, 7 days a week - one
2577	2577	5 per county; and
2578	2578	6 (X) inpatient or residential behavioral health
2579	2579	7 facility - one per county.
2580	2580	8 (d) The network plan shall demonstrate to the Director
2581	2581	9 maximum travel and distance standards and appointment wait
2582	2582	10 time standards for plan beneficiaries, which shall be
2583	2583	11 established annually by the Department in consultation with
2584	2584	12 the Department of Public Health based upon the guidance from
2585	2585	13 the federal Centers for Medicare and Medicaid Services. These
2586	2586	14 standards shall consist of the maximum minutes or miles to be
2587	2587	15 traveled by a plan beneficiary for each county type, such as
2588	2588	16 large counties, metro counties, or rural counties as defined
2589	2589	17 by Department rule.
2590	2590	18 The maximum travel time and distance standards must
2591	2591	19 include standards for each physician and other provider
2592	2592	20 category listed for which ratios have been established.
2593	2593	21 The Director shall establish a process for the review of
2594	2594	22 the adequacy of these standards along with an assessment of
2595	2595	23 additional specialties to be included in the list under this
2596	2596	24 subsection (d).
2597	2597	25 Notwithstanding any other law or Department rule, the
2598	2598	26 maximum travel and distance standards and appointment wait
2599	2599
2600	2600
2601	2601
2602	2602
2603	2603
2604	2604	HB4126 - 72 - LRB103 33572 RJT 63384 b
2605	2605
2606	2606
2607	2607	HB4126- 73 -LRB103 33572 RJT 63384 b HB4126 - 73 - LRB103 33572 RJT 63384 b
2608	2608	HB4126 - 73 - LRB103 33572 RJT 63384 b
2609	2609	1 time standards shall be no greater than any such standards
2610	2610	2 established for qualified health plans in
2611	2611	3 Federally-Facilitated Exchanges by federal law or by the
2612	2612	4 federal Centers for Medicare and Medicaid Services, even if
2613	2613	5 the network plan is issued in the large group market or is
2614	2614	6 otherwise not issued through an exchange. Federal standards
2615	2615	7 for stand-alone dental plans shall only apply to such network
2616	2616	8 plans. In the absence of an applicable Department rule, the
2617	2617	9 federal standards shall apply for the time period specified in
2618	2618	10 the federal law, regulation, or guidance. If the Centers for
2619	2619	11 Medicare and Medicaid Services establish standards that are
2620	2620	12 more stringent than the standards in effect under any
2621	2621	13 Department rule, the Department may amend its rules to conform
2622	2622	14 to the more stringent federal standards.
2623	2623	15 If the federal area designations for the maximum time or
2624	2624	16 distance or appointment wait time standards required are
2625	2625	17 changed by the most recent Letter to Issuers in the
2626	2626	18 Federally-facilitated Marketplaces, the Department shall post
2627	2627	19 on its website notice of such changes and may amend its rules
2628	2628	20 to conform to those designations if the Director deems
2629	2629	21 appropriate.
2630	2630	22 (d-5)(1) Every issuer insurer shall ensure that
2631	2631	23 beneficiaries have timely and proximate access to treatment
2632	2632	24 for mental, emotional, nervous, or substance use disorders or
2633	2633	25 conditions in accordance with the provisions of paragraph (4)
2634	2634	26 of subsection (a) of Section 370c of the Illinois Insurance
2635	2635
2636	2636
2637	2637
2638	2638
2639	2639
2640	2640	HB4126 - 73 - LRB103 33572 RJT 63384 b
2641	2641
2642	2642
2643	2643	HB4126- 74 -LRB103 33572 RJT 63384 b HB4126 - 74 - LRB103 33572 RJT 63384 b
2644	2644	HB4126 - 74 - LRB103 33572 RJT 63384 b
2645	2645	1 Code. Issuers Insurers shall use a comparable process,
2646	2646	2 strategy, evidentiary standard, and other factors in the
2647	2647	3 development and application of the network adequacy standards
2648	2648	4 for timely and proximate access to treatment for mental,
2649	2649	5 emotional, nervous, or substance use disorders or conditions
2650	2650	6 and those for the access to treatment for medical and surgical
2651	2651	7 conditions. As such, the network adequacy standards for timely
2652	2652	8 and proximate access shall equally be applied to treatment
2653	2653	9 facilities and providers for mental, emotional, nervous, or
2654	2654	10 substance use disorders or conditions and specialists
2655	2655	11 providing medical or surgical benefits pursuant to the parity
2656	2656	12 requirements of Section 370c.1 of the Illinois Insurance Code
2657	2657	13 and the federal Paul Wellstone and Pete Domenici Mental Health
2658	2658	14 Parity and Addiction Equity Act of 2008. Notwithstanding the
2659	2659	15 foregoing, the network adequacy standards for timely and
2660	2660	16 proximate access to treatment for mental, emotional, nervous,
2661	2661	17 or substance use disorders or conditions shall, at a minimum,
2662	2662	18 satisfy the following requirements:
2663	2663	19 (A) For beneficiaries residing in the metropolitan
2664	2664	20 counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
2665	2665	21 network adequacy standards for timely and proximate access
2666	2666	22 to treatment for mental, emotional, nervous, or substance
2667	2667	23 use disorders or conditions means a beneficiary shall not
2668	2668	24 have to travel longer than 30 minutes or 30 miles from the
2669	2669	25 beneficiary's residence to receive outpatient treatment
2670	2670	26 for mental, emotional, nervous, or substance use disorders
2671	2671
2672	2672
2673	2673
2674	2674
2675	2675
2676	2676	HB4126 - 74 - LRB103 33572 RJT 63384 b
2677	2677
2678	2678
2679	2679	HB4126- 75 -LRB103 33572 RJT 63384 b HB4126 - 75 - LRB103 33572 RJT 63384 b
2680	2680	HB4126 - 75 - LRB103 33572 RJT 63384 b
2681	2681	1 or conditions. Beneficiaries shall not be required to wait
2682	2682	2 longer than 10 business days between requesting an initial
2683	2683	3 appointment and being seen by the facility or provider of
2684	2684	4 mental, emotional, nervous, or substance use disorders or
2685	2685	5 conditions for outpatient treatment or to wait longer than
2686	2686	6 20 business days between requesting a repeat or follow-up
2687	2687	7 appointment and being seen by the facility or provider of
2688	2688	8 mental, emotional, nervous, or substance use disorders or
2689	2689	9 conditions for outpatient treatment; however, subject to
2690	2690	10 the protections of paragraph (3) of this subsection, a
2691	2691	11 network plan shall not be held responsible if the
2692	2692	12 beneficiary or provider voluntarily chooses to schedule an
2693	2693	13 appointment outside of these required time frames.
2694	2694	14 (B) For beneficiaries residing in Illinois counties
2695	2695	15 other than those counties listed in subparagraph (A) of
2696	2696	16 this paragraph, network adequacy standards for timely and
2697	2697	17 proximate access to treatment for mental, emotional,
2698	2698	18 nervous, or substance use disorders or conditions means a
2699	2699	19 beneficiary shall not have to travel longer than 60
2700	2700	20 minutes or 60 miles from the beneficiary's residence to
2701	2701	21 receive outpatient treatment for mental, emotional,
2702	2702	22 nervous, or substance use disorders or conditions.
2703	2703	23 Beneficiaries shall not be required to wait longer than 10
2704	2704	24 business days between requesting an initial appointment
2705	2705	25 and being seen by the facility or provider of mental,
2706	2706	26 emotional, nervous, or substance use disorders or
2707	2707
2708	2708
2709	2709
2710	2710
2711	2711
2712	2712	HB4126 - 75 - LRB103 33572 RJT 63384 b
2713	2713
2714	2714
2715	2715	HB4126- 76 -LRB103 33572 RJT 63384 b HB4126 - 76 - LRB103 33572 RJT 63384 b
2716	2716	HB4126 - 76 - LRB103 33572 RJT 63384 b
2717	2717	1 conditions for outpatient treatment or to wait longer than
2718	2718	2 20 business days between requesting a repeat or follow-up
2719	2719	3 appointment and being seen by the facility or provider of
2720	2720	4 mental, emotional, nervous, or substance use disorders or
2721	2721	5 conditions for outpatient treatment; however, subject to
2722	2722	6 the protections of paragraph (3) of this subsection, a
2723	2723	7 network plan shall not be held responsible if the
2724	2724	8 beneficiary or provider voluntarily chooses to schedule an
2725	2725	9 appointment outside of these required time frames.
2726	2726	10 (2) For beneficiaries residing in all Illinois counties,
2727	2727	11 network adequacy standards for timely and proximate access to
2728	2728	12 treatment for mental, emotional, nervous, or substance use
2729	2729	13 disorders or conditions means a beneficiary shall not have to
2730	2730	14 travel longer than 60 minutes or 60 miles from the
2731	2731	15 beneficiary's residence to receive inpatient or residential
2732	2732	16 treatment for mental, emotional, nervous, or substance use
2733	2733	17 disorders or conditions.
2734	2734	18 (3) If there is no in-network facility or provider
2735	2735	19 available for a beneficiary to receive timely and proximate
2736	2736	20 access to treatment for mental, emotional, nervous, or
2737	2737	21 substance use disorders or conditions in accordance with the
2738	2738	22 network adequacy standards outlined in this subsection, the
2739	2739	23 issuer insurer shall provide necessary exceptions to its
2740	2740	24 network to ensure admission and treatment with a provider or
2741	2741	25 at a treatment facility in accordance with the network
2742	2742	26 adequacy standards in this subsection.
2743	2743
2744	2744
2745	2745
2746	2746
2747	2747
2748	2748	HB4126 - 76 - LRB103 33572 RJT 63384 b
2749	2749
2750	2750
2751	2751	HB4126- 77 -LRB103 33572 RJT 63384 b HB4126 - 77 - LRB103 33572 RJT 63384 b
2752	2752	HB4126 - 77 - LRB103 33572 RJT 63384 b
2753	2753	1 (4) If the federal Centers for Medicare and Medicaid
2754	2754	2 Services establish or law requires more stringent standards
2755	2755	3 for qualified health plans in the Federally-Facilitated
2756	2756	4 Exchanges, the federal standards shall control for the time
2757	2757	5 period specified in the federal law, regulation, or guidance,
2758	2758	6 even if the network plan is issued in the large group market or
2759	2759	7 is otherwise not issued through an exchange.
2760	2760	8 (e) Except for network plans solely offered as a group
2761	2761	9 health plan, these ratio and time and distance standards apply
2762	2762	10 to the lowest cost-sharing tier of any tiered network.
2763	2763	11 (f) The network plan may consider use of other health care
2764	2764	12 service delivery options, such as telemedicine or telehealth,
2765	2765	13 mobile clinics, and centers of excellence, or other ways of
2766	2766	14 delivering care to partially meet the requirements set under
2767	2767	15 this Section.
2768	2768	16 (g) Except for the requirements set forth in subsection
2769	2769	17 (d-5), issuers insurers who are not able to comply with the
2770	2770	18 provider ratios and time and distance or appointment wait time
2771	2771	19 standards established under this Act by the Department may
2772	2772	20 request an exception to these requirements from the
2773	2773	21 Department. The Department may grant an exception in the
2774	2774	22 following circumstances:
2775	2775	23 (1) if no providers or facilities meet the specific
2776	2776	24 time and distance standard in a specific service area and
2777	2777	25 the issuer insurer (i) discloses information on the
2778	2778	26 distance and travel time points that beneficiaries would
2779	2779
2780	2780
2781	2781
2782	2782
2783	2783
2784	2784	HB4126 - 77 - LRB103 33572 RJT 63384 b
2785	2785
2786	2786
2787	2787	HB4126- 78 -LRB103 33572 RJT 63384 b HB4126 - 78 - LRB103 33572 RJT 63384 b
2788	2788	HB4126 - 78 - LRB103 33572 RJT 63384 b
2789	2789	1 have to travel beyond the required criterion to reach the
2790	2790	2 next closest contracted provider outside of the service
2791	2791	3 area and (ii) provides contact information, including
2792	2792	4 names, addresses, and phone numbers for the next closest
2793	2793	5 contracted provider or facility;
2794	2794	6 (2) if patterns of care in the service area do not
2795	2795	7 support the need for the requested number of provider or
2796	2796	8 facility type and the issuer insurer provides data on
2797	2797	9 local patterns of care, such as claims data, referral
2798	2798	10 patterns, or local provider interviews, indicating where
2799	2799	11 the beneficiaries currently seek this type of care or
2800	2800	12 where the physicians currently refer beneficiaries, or
2801	2801	13 both; or
2802	2802	14 (3) other circumstances deemed appropriate by the
2803	2803	15 Department consistent with the requirements of this Act.
2804	2804	16 (h) Issuers Insurers are required to report to the
2805	2805	17 Director any material change to an approved network plan
2806	2806	18 within 15 days after the change occurs and any change that
2807	2807	19 would result in failure to meet the requirements of this Act.
2808	2808	20 The issuer shall submit a revised version of the complete
2809	2809	21 network adequacy filing based on the material change, and the
2810	2810	22 issuer shall attach versions with the changes indicated for
2811	2811	23 each document that was revised from the previous version of
2812	2812	24 the filing. Upon notice from the issuer insurer, the Director
2813	2813	25 shall reevaluate the network plan's compliance with the
2814	2814	26 network adequacy and transparency standards of this Act. For
2815	2815
2816	2816
2817	2817
2818	2818
2819	2819
2820	2820	HB4126 - 78 - LRB103 33572 RJT 63384 b
2821	2821
2822	2822
2823	2823	HB4126- 79 -LRB103 33572 RJT 63384 b HB4126 - 79 - LRB103 33572 RJT 63384 b
2824	2824	HB4126 - 79 - LRB103 33572 RJT 63384 b
2825	2825	1 every day past 15 days that the issuer fails to submit a
2826	2826	2 revised network adequacy filing to the Director, the Director
2827	2827	3 shall order a fine of $1,000 per day.
2828	2828	4 (i) If a network plan is inadequate under this Act with
2829	2829	5 respect to a provider type in a county, and if the network plan
2830	2830	6 does not have an approved exception for that provider type in
2831	2831	7 that county pursuant to subsection (g), an issuer shall
2832	2832	8 process out-of-network claims for covered health care services
2833	2833	9 received from that provider type within that county at the
2834	2834	10 in-network benefit level and shall retroactively adjudicate
2835	2835	11 and reimburse beneficiaries to achieve that objective if their
2836	2836	12 claims were processed at the out-of-network level contrary to
2837	2837	13 this subsection.
2838	2838	14 (j) If the Director determines that a network is
2839	2839	15 inadequate in any county and no exception has been granted
2840	2840	16 under subsection (g) and the issuer does not have a process in
2841	2841	17 place to comply with subsection (d-5), the Director may
2842	2842	18 prohibit the network plan from being issued or renewed within
2843	2843	19 that county until the Director determines that the network is
2844	2844	20 adequate apart from processes and exceptions described in
2845	2845	21 subsections (d-5) and (g). Nothing in this subsection shall be
2846	2846	22 construed to terminate any beneficiary's health insurance
2847	2847	23 coverage under a network plan before the expiration of the
2848	2848	24 beneficiary's policy period if the Director makes a
2849	2849	25 determination under this subsection after the issuance or
2850	2850	26 renewal of the beneficiary's policy or certificate because of
2851	2851
2852	2852
2853	2853
2854	2854
2855	2855
2856	2856	HB4126 - 79 - LRB103 33572 RJT 63384 b
2857	2857
2858	2858
2859	2859	HB4126- 80 -LRB103 33572 RJT 63384 b HB4126 - 80 - LRB103 33572 RJT 63384 b
2860	2860	HB4126 - 80 - LRB103 33572 RJT 63384 b
2861	2861	1 a material change. Policies or certificates issued or renewed
2862	2862	2 in violation of this subsection shall subject the issuer to a
2863	2863	3 civil penalty of $1,000 per policy.
2864	2864	4 (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
2865	2865	5 102-1117, eff. 1-13-23.)
2866	2866	6 (215 ILCS 124/15)
2867	2867	7 Sec. 15. Notice of nonrenewal or termination.
2868	2868	8 (a) A network plan must give at least 60 days' notice of
2869	2869	9 nonrenewal or termination of a provider to the provider and to
2870	2870	10 the beneficiaries served by the provider. The notice shall
2871	2871	11 include a name and address to which a beneficiary or provider
2872	2872	12 may direct comments and concerns regarding the nonrenewal or
2873	2873	13 termination and the telephone number maintained by the
2874	2874	14 Department for consumer complaints. Immediate written notice
2875	2875	15 may be provided without 60 days' notice when a provider's
2876	2876	16 license has been disciplined by a State licensing board or
2877	2877	17 when the network plan reasonably believes direct imminent
2878	2878	18 physical harm to patients under the provider's providers care
2879	2879	19 may occur. The notice to the beneficiary shall provide the
2880	2880	20 individual with an opportunity to notify the issuer of the
2881	2881	21 individual's need for transitional care.
2882	2882	22 (b) Primary care providers must notify active affected
2883	2883	23 patients of nonrenewal or termination of the provider from the
2884	2884	24 network plan, except in the case of incapacitation.
2885	2885	25 (Source: P.A. 100-502, eff. 9-15-17.)
2886	2886
2887	2887
2888	2888
2889	2889
2890	2890
2891	2891	HB4126 - 80 - LRB103 33572 RJT 63384 b
2892	2892
2893	2893
2894	2894	HB4126- 81 -LRB103 33572 RJT 63384 b HB4126 - 81 - LRB103 33572 RJT 63384 b
2895	2895	HB4126 - 81 - LRB103 33572 RJT 63384 b
2896	2896	1 (215 ILCS 124/20)
2897	2897	2 Sec. 20. Transition of services.
2898	2898	3 (a) A network plan shall provide for continuity of care
2899	2899	4 for its beneficiaries as follows:
2900	2900	5 (1) If a beneficiary's physician or hospital provider
2901	2901	6 leaves the network plan's network of providers for reasons
2902	2902	7 other than termination of a contract in situations
2903	2903	8 involving imminent harm to a patient or a final
2904	2904	9 disciplinary action by a State licensing board and the
2905	2905	10 provider remains within the network plan's service area,
2906	2906	11 if benefits provided under such network plan with respect
2907	2907	12 to such provider or facility are terminated because of a
2908	2908	13 change in the terms of the participation of such provider
2909	2909	14 or facility in such plan, or if a contract between a group
2910	2910	15 health plan and a health insurance issuer offering a
2911	2911	16 network plan in connection with the group health plan is
2912	2912	17 terminated and results in a loss of benefits provided
2913	2913	18 under such plan with respect to such provider, then the
2914	2914	19 network plan shall permit the beneficiary to continue an
2915	2915	20 ongoing course of treatment with that provider during a
2916	2916	21 transitional period for the following duration:
2917	2917	22 (A) 90 days from the date of the notice to the
2918	2918	23 beneficiary of the provider's disaffiliation from the
2919	2919	24 network plan if the beneficiary has an ongoing course
2920	2920	25 of treatment; or
2921	2921
2922	2922
2923	2923
2924	2924
2925	2925
2926	2926	HB4126 - 81 - LRB103 33572 RJT 63384 b
2927	2927
2928	2928
2929	2929	HB4126- 82 -LRB103 33572 RJT 63384 b HB4126 - 82 - LRB103 33572 RJT 63384 b
2930	2930	HB4126 - 82 - LRB103 33572 RJT 63384 b
2931	2931	1 (B) if the beneficiary has entered the third
2932	2932	2 trimester of pregnancy at the time of the provider's
2933	2933	3 disaffiliation, a period that includes the provision
2934	2934	4 of post-partum care directly related to the delivery.
2935	2935	5 (2) Notwithstanding the provisions of paragraph (1) of
2936	2936	6 this subsection (a), such care shall be authorized by the
2937	2937	7 network plan during the transitional period in accordance
2938	2938	8 with the following:
2939	2939	9 (A) the provider receives continued reimbursement
2940	2940	10 from the network plan at the rates and terms and
2941	2941	11 conditions applicable under the terminated contract
2942	2942	12 prior to the start of the transitional period;
2943	2943	13 (B) the provider adheres to the network plan's
2944	2944	14 quality assurance requirements, including provision to
2945	2945	15 the network plan of necessary medical information
2946	2946	16 related to such care; and
2947	2947	17 (C) the provider otherwise adheres to the network
2948	2948	18 plan's policies and procedures, including, but not
2949	2949	19 limited to, procedures regarding referrals and
2950	2950	20 obtaining preauthorizations for treatment.
2951	2951	21 (3) The provisions of this Section governing health
2952	2952	22 care provided during the transition period do not apply if
2953	2953	23 the beneficiary has successfully transitioned to another
2954	2954	24 provider participating in the network plan, if the
2955	2955	25 beneficiary has already met or exceeded the benefit
2956	2956	26 limitations of the plan, or if the care provided is not
2957	2957
2958	2958
2959	2959
2960	2960
2961	2961
2962	2962	HB4126 - 82 - LRB103 33572 RJT 63384 b
2963	2963
2964	2964
2965	2965	HB4126- 83 -LRB103 33572 RJT 63384 b HB4126 - 83 - LRB103 33572 RJT 63384 b
2966	2966	HB4126 - 83 - LRB103 33572 RJT 63384 b
2967	2967	1 medically necessary.
2968	2968	2 (b) A network plan shall provide for continuity of care
2969	2969	3 for new beneficiaries as follows:
2970	2970	4 (1) If a new beneficiary whose provider is not a
2971	2971	5 member of the network plan's provider network, but is
2972	2972	6 within the network plan's service area, enrolls in the
2973	2973	7 network plan, the network plan shall permit the
2974	2974	8 beneficiary to continue an ongoing course of treatment
2975	2975	9 with the beneficiary's current physician during a
2976	2976	10 transitional period:
2977	2977	11 (A) of 90 days from the effective date of
2978	2978	12 enrollment if the beneficiary has an ongoing course of
2979	2979	13 treatment; or
2980	2980	14 (B) if the beneficiary has entered the third
2981	2981	15 trimester of pregnancy at the effective date of
2982	2982	16 enrollment, that includes the provision of post-partum
2983	2983	17 care directly related to the delivery.
2984	2984	18 (2) If a beneficiary, or a beneficiary's authorized
2985	2985	19 representative, elects in writing to continue to receive
2986	2986	20 care from such provider pursuant to paragraph (1) of this
2987	2987	21 subsection (b), such care shall be authorized by the
2988	2988	22 network plan for the transitional period in accordance
2989	2989	23 with the following:
2990	2990	24 (A) the provider receives reimbursement from the
2991	2991	25 network plan at rates established by the network plan;
2992	2992	26 (B) the provider adheres to the network plan's
2993	2993
2994	2994
2995	2995
2996	2996
2997	2997
2998	2998	HB4126 - 83 - LRB103 33572 RJT 63384 b
2999	2999
3000	3000
3001	3001	HB4126- 84 -LRB103 33572 RJT 63384 b HB4126 - 84 - LRB103 33572 RJT 63384 b
3002	3002	HB4126 - 84 - LRB103 33572 RJT 63384 b
3003	3003	1 quality assurance requirements, including provision to
3004	3004	2 the network plan of necessary medical information
3005	3005	3 related to such care; and
3006	3006	4 (C) the provider otherwise adheres to the network
3007	3007	5 plan's policies and procedures, including, but not
3008	3008	6 limited to, procedures regarding referrals and
3009	3009	7 obtaining preauthorization for treatment.
3010	3010	8 (3) The provisions of this Section governing health
3011	3011	9 care provided during the transition period do not apply if
3012	3012	10 the beneficiary has successfully transitioned to another
3013	3013	11 provider participating in the network plan, if the
3014	3014	12 beneficiary has already met or exceeded the benefit
3015	3015	13 limitations of the plan, or if the care provided is not
3016	3016	14 medically necessary.
3017	3017	15 (c) In no event shall this Section be construed to require
3018	3018	16 a network plan to provide coverage for benefits not otherwise
3019	3019	17 covered or to diminish or impair preexisting condition
3020	3020	18 limitations contained in the beneficiary's contract.
3021	3021	19 (d) A provider shall comply with the requirements of 42
3022	3022	20 U.S.C. 300gg-138.
3023	3023	21 (Source: P.A. 100-502, eff. 9-15-17.)
3024	3024	22 (215 ILCS 124/25)
3025	3025	23 Sec. 25. Network transparency.
3026	3026	24 (a) A network plan shall post electronically an
3027	3027	25 up-to-date, accurate, and complete provider directory for each
3028	3028
3029	3029
3030	3030
3031	3031
3032	3032
3033	3033	HB4126 - 84 - LRB103 33572 RJT 63384 b
3034	3034
3035	3035
3036	3036	HB4126- 85 -LRB103 33572 RJT 63384 b HB4126 - 85 - LRB103 33572 RJT 63384 b
3037	3037	HB4126 - 85 - LRB103 33572 RJT 63384 b
3038	3038	1 of its network plans, with the information and search
3039	3039	2 functions, as described in this Section.
3040	3040	3 (1) In making the directory available electronically,
3041	3041	4 the network plans shall ensure that the general public is
3042	3042	5 able to view all of the current providers for a plan
3043	3043	6 through a clearly identifiable link or tab and without
3044	3044	7 creating or accessing an account or entering a policy or
3045	3045	8 contract number.
3046	3046	9 (2) The network plan shall update the online provider
3047	3047	10 directory at least monthly. An issuer's failure to update
3048	3048	11 a network plan's directory shall subject the issuer to a
3049	3049	12 civil penalty of $5,000 per month. Providers shall notify
3050	3050	13 the network plan electronically or in writing of any
3051	3051	14 changes to their information as listed in the provider
3052	3052	15 directory, including the information required in
3053	3053	16 subparagraph (K) of paragraph (1) of subsection (b). If a
3054	3054	17 provider is no longer accepting new patients, the provider
3055	3055	18 must give notice to the issuer within 5 business days
3056	3056	19 after deciding to cease accepting new patients, or within
3057	3057	20 5 business days after the effective date of this
3058	3058	21 amendatory Act of the 103rd General Assembly, whichever is
3059	3059	22 later. The network plan shall update its online provider
3060	3060	23 directory in a manner consistent with the information
3061	3061	24 provided by the provider within 2 10 business days after
3062	3062	25 being notified of the change by the provider. Nothing in
3063	3063	26 this paragraph (2) shall void any contractual relationship
3064	3064
3065	3065
3066	3066
3067	3067
3068	3068
3069	3069	HB4126 - 85 - LRB103 33572 RJT 63384 b
3070	3070
3071	3071
3072	3072	HB4126- 86 -LRB103 33572 RJT 63384 b HB4126 - 86 - LRB103 33572 RJT 63384 b
3073	3073	HB4126 - 86 - LRB103 33572 RJT 63384 b
3074	3074	1 between the provider and the plan.
3075	3075	2 (3) At least once every 90 days, the The network plan
3076	3076	3 shall audit each periodically at least 25% of its print
3077	3077	4 and online provider directories for accuracy, make any
3078	3078	5 corrections necessary, and retain documentation of the
3079	3079	6 audit. The network plan shall submit the audit to the
3080	3080	7 Director upon request. As part of these audits, the
3081	3081	8 network plan shall contact any provider in its network
3082	3082	9 that has not submitted a claim to the plan or otherwise
3083	3083	10 communicated his or her intent to continue participation
3084	3084	11 in the plan's network. The audits shall comply with 42
3085	3085	12 U.S.C. 300gg-115(a)(2), except that "provider directory
3086	3086	13 information" shall include all information required to be
3087	3087	14 included in a provider directory pursuant to this Act.
3088	3088	15 (4) A network plan shall provide a print copy of a
3089	3089	16 current provider directory or a print copy of the
3090	3090	17 requested directory information upon request of a
3091	3091	18 beneficiary or a prospective beneficiary. Print copies
3092	3092	19 must be updated quarterly and an errata that reflects
3093	3093	20 changes in the provider network must be updated quarterly.
3094	3094	21 (5) For each network plan, a network plan shall
3095	3095	22 include, in plain language in both the electronic and
3096	3096	23 print directory, the following general information:
3097	3097	24 (A) in plain language, a description of the
3098	3098	25 criteria the plan has used to build its provider
3099	3099	26 network;
3100	3100
3101	3101
3102	3102
3103	3103
3104	3104
3105	3105	HB4126 - 86 - LRB103 33572 RJT 63384 b
3106	3106
3107	3107
3108	3108	HB4126- 87 -LRB103 33572 RJT 63384 b HB4126 - 87 - LRB103 33572 RJT 63384 b
3109	3109	HB4126 - 87 - LRB103 33572 RJT 63384 b
3110	3110	1 (B) if applicable, in plain language, a
3111	3111	2 description of the criteria the issuer insurer or
3112	3112	3 network plan has used to create tiered networks;
3113	3113	4 (C) if applicable, in plain language, how the
3114	3114	5 network plan designates the different provider tiers
3115	3115	6 or levels in the network and identifies for each
3116	3116	7 specific provider, hospital, or other type of facility
3117	3117	8 in the network which tier each is placed, for example,
3118	3118	9 by name, symbols, or grouping, in order for a
3119	3119	10 beneficiary-covered person or a prospective
3120	3120	11 beneficiary-covered person to be able to identify the
3121	3121	12 provider tier; and
3122	3122	13 (D) if applicable, a notation that authorization
3123	3123	14 or referral may be required to access some providers.
3124	3124	15 (6) A network plan shall make it clear for both its
3125	3125	16 electronic and print directories what provider directory
3126	3126	17 applies to which network plan, such as including the
3127	3127	18 specific name of the network plan as marketed and issued
3128	3128	19 in this State. The network plan shall include in both its
3129	3129	20 electronic and print directories a customer service email
3130	3130	21 address and telephone number or electronic link that
3131	3131	22 beneficiaries or the general public may use to notify the
3132	3132	23 network plan of inaccurate provider directory information
3133	3133	24 and contact information for the Department's Office of
3134	3134	25 Consumer Health Insurance.
3135	3135	26 (7) A provider directory, whether in electronic or
3136	3136
3137	3137
3138	3138
3139	3139
3140	3140
3141	3141	HB4126 - 87 - LRB103 33572 RJT 63384 b
3142	3142
3143	3143
3144	3144	HB4126- 88 -LRB103 33572 RJT 63384 b HB4126 - 88 - LRB103 33572 RJT 63384 b
3145	3145	HB4126 - 88 - LRB103 33572 RJT 63384 b
3146	3146	1 print format, shall accommodate the communication needs of
3147	3147	2 individuals with disabilities, and include a link to or
3148	3148	3 information regarding available assistance for persons
3149	3149	4 with limited English proficiency.
3150	3150	5 (b) For each network plan, a network plan shall make
3151	3151	6 available through an electronic provider directory the
3152	3152	7 following information in a searchable format:
3153	3153	8 (1) for health care professionals:
3154	3154	9 (A) name;
3155	3155	10 (B) gender;
3156	3156	11 (C) participating office locations;
3157	3157	12 (D) specialty, if applicable;
3158	3158	13 (E) medical group affiliations, if applicable;
3159	3159	14 (F) facility affiliations, if applicable;
3160	3160	15 (G) participating facility affiliations, if
3161	3161	16 applicable;
3162	3162	17 (H) languages spoken other than English, if
3163	3163	18 applicable;
3164	3164	19 (I) whether accepting new patients;
3165	3165	20 (J) board certifications, if applicable; and
3166	3166	21 (K) use of telehealth or telemedicine, including,
3167	3167	22 but not limited to:
3168	3168	23 (i) whether the provider offers the use of
3169	3169	24 telehealth or telemedicine to deliver services to
3170	3170	25 patients for whom it would be clinically
3171	3171	26 appropriate;
3172	3172
3173	3173
3174	3174
3175	3175
3176	3176
3177	3177	HB4126 - 88 - LRB103 33572 RJT 63384 b
3178	3178
3179	3179
3180	3180	HB4126- 89 -LRB103 33572 RJT 63384 b HB4126 - 89 - LRB103 33572 RJT 63384 b
3181	3181	HB4126 - 89 - LRB103 33572 RJT 63384 b
3182	3182	1 (ii) what modalities are used and what types
3183	3183	2 of services may be provided via telehealth or
3184	3184	3 telemedicine; and
3185	3185	4 (iii) whether the provider has the ability and
3186	3186	5 willingness to include in a telehealth or
3187	3187	6 telemedicine encounter a family caregiver who is
3188	3188	7 in a separate location than the patient if the
3189	3189	8 patient wishes and provides his or her consent;
3190	3190	9 (2) for hospitals:
3191	3191	10 (A) hospital name;
3192	3192	11 (B) hospital type (such as acute, rehabilitation,
3193	3193	12 children's, or cancer);
3194	3194	13 (C) participating hospital location; and
3195	3195	14 (D) hospital accreditation status; and
3196	3196	15 (3) for facilities, other than hospitals, by type:
3197	3197	16 (A) facility name;
3198	3198	17 (B) facility type;
3199	3199	18 (C) types of services performed; and
3200	3200	19 (D) participating facility location or locations,
3201	3201	20 including for each location where the health care
3202	3202	21 professional is at the location at least 3 days per
3203	3203	22 week.
3204	3204	23 (c) For the electronic provider directories, for each
3205	3205	24 network plan, a network plan shall make available all of the
3206	3206	25 following information in addition to the searchable
3207	3207	26 information required in this Section:
3208	3208
3209	3209
3210	3210
3211	3211
3212	3212
3213	3213	HB4126 - 89 - LRB103 33572 RJT 63384 b
3214	3214
3215	3215
3216	3216	HB4126- 90 -LRB103 33572 RJT 63384 b HB4126 - 90 - LRB103 33572 RJT 63384 b
3217	3217	HB4126 - 90 - LRB103 33572 RJT 63384 b
3218	3218	1 (1) for health care professionals:
3219	3219	2 (A) contact information, including both a
3220	3220	3 telephone number and digital contact information if
3221	3221	4 the provider has supplied digital contact information;
3222	3222	5 and
3223	3223	6 (B) languages spoken other than English by
3224	3224	7 clinical staff, if applicable;
3225	3225	8 (2) for hospitals, telephone number and digital
3226	3226	9 contact information; and
3227	3227	10 (3) for facilities other than hospitals, telephone
3228	3228	11 number.
3229	3229	12 (d) The issuer insurer or network plan shall make
3230	3230	13 available in print, upon request, the following provider
3231	3231	14 directory information for the applicable network plan:
3232	3232	15 (1) for health care professionals:
3233	3233	16 (A) name;
3234	3234	17 (B) contact information, including telephone
3235	3235	18 number and digital contact information if the provider
3236	3236	19 has supplied digital contact information;
3237	3237	20 (C) participating office location or locations,
3238	3238	21 including for each location where the health care
3239	3239	22 professional is at the location at least 3 days per
3240	3240	23 week;
3241	3241	24 (D) specialty, if applicable;
3242	3242	25 (E) languages spoken other than English, if
3243	3243	26 applicable;
3244	3244
3245	3245
3246	3246
3247	3247
3248	3248
3249	3249	HB4126 - 90 - LRB103 33572 RJT 63384 b
3250	3250
3251	3251
3252	3252	HB4126- 91 -LRB103 33572 RJT 63384 b HB4126 - 91 - LRB103 33572 RJT 63384 b
3253	3253	HB4126 - 91 - LRB103 33572 RJT 63384 b
3254	3254	1 (F) whether accepting new patients; and
3255	3255	2 (G) use of telehealth or telemedicine, including,
3256	3256	3 but not limited to:
3257	3257	4 (i) whether the provider offers the use of
3258	3258	5 telehealth or telemedicine to deliver services to
3259	3259	6 patients for whom it would be clinically
3260	3260	7 appropriate;
3261	3261	8 (ii) what modalities are used and what types
3262	3262	9 of services may be provided via telehealth or
3263	3263	10 telemedicine; and
3264	3264	11 (iii) whether the provider has the ability and
3265	3265	12 willingness to include in a telehealth or
3266	3266	13 telemedicine encounter a family caregiver who is
3267	3267	14 in a separate location than the patient if the
3268	3268	15 patient wishes and provides his or her consent;
3269	3269	16 (2) for hospitals:
3270	3270	17 (A) hospital name;
3271	3271	18 (B) hospital type (such as acute, rehabilitation,
3272	3272	19 children's, or cancer); and
3273	3273	20 (C) participating hospital location, and telephone
3274	3274	21 number, and digital contact information; and
3275	3275	22 (3) for facilities, other than hospitals, by type:
3276	3276	23 (A) facility name;
3277	3277	24 (B) facility type;
3278	3278	25 (C) types of services performed; and
3279	3279	26 (D) participating facility location or locations,
3280	3280
3281	3281
3282	3282
3283	3283
3284	3284
3285	3285	HB4126 - 91 - LRB103 33572 RJT 63384 b
3286	3286
3287	3287
3288	3288	HB4126- 92 -LRB103 33572 RJT 63384 b HB4126 - 92 - LRB103 33572 RJT 63384 b
3289	3289	HB4126 - 92 - LRB103 33572 RJT 63384 b
3290	3290	1 and telephone numbers, and digital contact information
3291	3291	2 for each location.
3292	3292	3 (e) The network plan shall include a disclosure in the
3293	3293	4 print format provider directory that the information included
3294	3294	5 in the directory is accurate as of the date of printing and
3295	3295	6 that beneficiaries or prospective beneficiaries should consult
3296	3296	7 the issuer's insurer's electronic provider directory on its
3297	3297	8 website and contact the provider. The network plan shall also
3298	3298	9 include a telephone number in the print format provider
3299	3299	10 directory for a customer service representative where the
3300	3300	11 beneficiary can obtain current provider directory information.
3301	3301	12 (f) The Director may conduct periodic audits of the
3302	3302	13 accuracy of provider directories. A network plan shall not be
3303	3303	14 subject to any fines or penalties for information required in
3304	3304	15 this Section that a provider submits that is inaccurate or
3305	3305	16 incomplete.
3306	3306	17 (g) To the extent not otherwise provided in this Act, an
3307	3307	18 issuer shall comply with the requirements of 42 U.S.C.
3308	3308	19 300gg-115, except that "provider directory information" shall
3309	3309	20 include all information required to be included in a provider
3310	3310	21 directory pursuant to this Section.
3311	3311	22 (Source: P.A. 102-92, eff. 7-9-21.)
3312	3312	23 (215 ILCS 124/30)
3313	3313	24 Sec. 30. Administration and enforcement.
3314	3314	25 (a) Issuers Insurers, as defined in this Act, have a
3315	3315
3316	3316
3317	3317
3318	3318
3319	3319
3320	3320	HB4126 - 92 - LRB103 33572 RJT 63384 b
3321	3321
3322	3322
3323	3323	HB4126- 93 -LRB103 33572 RJT 63384 b HB4126 - 93 - LRB103 33572 RJT 63384 b
3324	3324	HB4126 - 93 - LRB103 33572 RJT 63384 b
3325	3325	1 continuing obligation to comply with the requirements of this
3326	3326	2 Act. Other than the duties specifically created in this Act,
3327	3327	3 nothing in this Act is intended to preclude, prevent, or
3328	3328	4 require the adoption, modification, or termination of any
3329	3329	5 utilization management, quality management, or claims
3330	3330	6 processing methodologies of an issuer insurer.
3331	3331	7 (b) Nothing in this Act precludes, prevents, or requires
3332	3332	8 the adoption, modification, or termination of any network plan
3333	3333	9 term, benefit, coverage or eligibility provision, or payment
3334	3334	10 methodology.
3335	3335	11 (c) The Director shall enforce the provisions of this Act
3336	3336	12 pursuant to the enforcement powers granted to it by law.
3337	3337	13 (d) The Department shall adopt rules to enforce compliance
3338	3338	14 with this Act to the extent necessary.
3339	3339	15 (e) In accordance with Section 5-45.21 of the Illinois
3340	3340	16 Administrative Procedure Act, the Department may adopt
3341	3341	17 emergency rules to implement federal standards for provider
3342	3342	18 ratios, travel time and distance, and appointment wait times
3343	3343	19 if such standards apply to health insurance coverage regulated
3344	3344	20 by the Department and are more stringent than the State
3345	3345	21 standards extant at the time the final federal standards are
3346	3346	22 published.
3347	3347	23 (Source: P.A. 100-502, eff. 9-15-17.)
3348	3348	24 (215 ILCS 124/35 new)
3349	3349	25 Sec. 35. Provider requirements. Providers shall comply
3350	3350
3351	3351
3352	3352
3353	3353
3354	3354
3355	3355	HB4126 - 93 - LRB103 33572 RJT 63384 b
3356	3356
3357	3357
3358	3358	HB4126- 94 -LRB103 33572 RJT 63384 b HB4126 - 94 - LRB103 33572 RJT 63384 b
3359	3359	HB4126 - 94 - LRB103 33572 RJT 63384 b
3360	3360	1 with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations
3361	3361	2 promulgated thereunder, as well as Section 20 and paragraph
3362	3362	3 (2) of subsection (a) of Section 25 of this Act, except that
3363	3363	4 "provider directory information" includes all information
3364	3364	5 required to be included in a provider directory pursuant to
3365	3365	6 Section 25 of this Act. To the extent a provider is licensed by
3366	3366	7 the Department of Financial and Professional Regulation or by
3367	3367	8 the Department of Public Health, that agency shall have the
3368	3368	9 authority to investigate, examine, process complaints, issue
3369	3369	10 subpoenas, examine witnesses under oath, issue a fine, or take
3370	3370	11 disciplinary action against the provider's license for
3371	3371	12 violations of these requirements in accordance with the
3372	3372	13 provider's applicable licensing statute.
3373	3373	14 (215 ILCS 124/40 new)
3374	3374	15 Sec. 40. Confidentiality.
3375	3375	16 (a) All records in the custody or possession of the
3376	3376	17 Department are presumed to be open to public inspection or
3377	3377	18 copying unless exempt from disclosure by Section 7 or 7.5 of
3378	3378	19 the Freedom of Information Act. Except as otherwise provided
3379	3379	20 in this Section or other applicable law, the filings required
3380	3380	21 under this Act shall be open to public inspection or copying.
3381	3381	22 (b) The following information shall not be deemed
3382	3382	23 confidential:
3383	3383	24 (1) actual or projected ratios of providers to
3384	3384	25 beneficiaries;
3385	3385
3386	3386
3387	3387
3388	3388
3389	3389
3390	3390	HB4126 - 94 - LRB103 33572 RJT 63384 b
3391	3391
3392	3392
3393	3393	HB4126- 95 -LRB103 33572 RJT 63384 b HB4126 - 95 - LRB103 33572 RJT 63384 b
3394	3394	HB4126 - 95 - LRB103 33572 RJT 63384 b
3395	3395	1 (2) actual or projected time and distance between
3396	3396	2 network providers and beneficiaries or actual or projected
3397	3397	3 waiting times for a beneficiary to see a network provider;
3398	3398	4 (3) geographic maps of network providers;
3399	3399	5 (4) requests for exceptions under subsection (g) of
3400	3400	6 Section 10, except with respect to any discussion of
3401	3401	7 ongoing or planned contractual negotiations with providers
3402	3402	8 that the issuer requests to be treated as confidential;
3403	3403	9 and
3404	3404	10 (5) provider directories.
3405	3405	11 (c) An issuer's work papers and reports on the results of a
3406	3406	12 self-audit of its provider directories shall remain
3407	3407	13 confidential unless expressly waived by the insurer or unless
3408	3408	14 deemed public information under federal law.
3409	3409	15 (d) The filings required under Section 10 of this Act
3410	3410	16 shall be confidential while they remain under the Department's
3411	3411	17 review but shall become open to public inspection and copying
3412	3412	18 upon completion of the review, except as provided in this
3413	3413	19 Section or under other applicable law.
3414	3414	20 (e) Nothing in this Section shall supersede the statutory
3415	3415	21 requirement that work papers obtained during a market conduct
3416	3416	22 examination be deemed confidential.
3417	3417	23 Section 20. The Managed Care Reform and Patient Rights Act
3418	3418	24 is amended by changing Sections 20 and 25 as follows:
3419	3419
3420	3420
3421	3421
3422	3422
3423	3423
3424	3424	HB4126 - 95 - LRB103 33572 RJT 63384 b
3425	3425
3426	3426
3427	3427	HB4126- 96 -LRB103 33572 RJT 63384 b HB4126 - 96 - LRB103 33572 RJT 63384 b
3428	3428	HB4126 - 96 - LRB103 33572 RJT 63384 b
3429	3429	1 (215 ILCS 134/20)
3430	3430	2 Sec. 20. Notice of nonrenewal or termination. A health
3431	3431	3 care plan must give at least 60 days notice of nonrenewal or
3432	3432	4 termination of a health care provider to the health care
3433	3433	5 provider and to the enrollees served by the health care
3434	3434	6 provider. The notice shall include a name and address to which
3435	3435	7 an enrollee or health care provider may direct comments and
3436	3436	8 concerns regarding the nonrenewal or termination. Immediate
3437	3437	9 written notice may be provided without 60 days notice when a
3438	3438	10 health care provider's license has been disciplined by a State
3439	3439	11 licensing board. The notice to the enrollee shall provide the
3440	3440	12 individual with an opportunity to notify the health care plan
3441	3441	13 of the individual's need for transitional care.
3442	3442	14 (Source: P.A. 91-617, eff. 1-1-00.)
3443	3443	15 (215 ILCS 134/25)
3444	3444	16 Sec. 25. Transition of services.
3445	3445	17 (a) A health care plan shall provide for continuity of
3446	3446	18 care for its enrollees as follows:
3447	3447	19 (1) If an enrollee's health care provider physician
3448	3448	20 leaves the health care plan's network of health care
3449	3449	21 providers for reasons other than termination of a contract
3450	3450	22 in situations involving imminent harm to a patient or a
3451	3451	23 final disciplinary action by a State licensing board and
3452	3452	24 the provider physician remains within the health care
3453	3453	25 plan's service area, or if benefits provided under such
3454	3454
3455	3455
3456	3456
3457	3457
3458	3458
3459	3459	HB4126 - 96 - LRB103 33572 RJT 63384 b
3460	3460
3461	3461
3462	3462	HB4126- 97 -LRB103 33572 RJT 63384 b HB4126 - 97 - LRB103 33572 RJT 63384 b
3463	3463	HB4126 - 97 - LRB103 33572 RJT 63384 b
3464	3464	1 health care plan with respect to such provider are
3465	3465	2 terminated because of a change in the terms of the
3466	3466	3 participation of such provider in such plan, or if a
3467	3467	4 contract between a group health plan, as defined in
3468	3468	5 Section 5 of the Illinois Health Insurance Portability and
3469	3469	6 Accountability Act, and a health care plan offered
3470	3470	7 connection with the group health plan is terminated and
3471	3471	8 results in a loss of benefits provided under such plan
3472	3472	9 with respect to such provider, the health care plan shall
3473	3473	10 permit the enrollee to continue an ongoing course of
3474	3474	11 treatment with that provider physician during a
3475	3475	12 transitional period:
3476	3476	13 (A) of 90 days from the date of the notice of
3477	3477	14 provider's physician's termination from the health
3478	3478	15 care plan to the enrollee of the provider's
3479	3479	16 physician's disaffiliation from the health care plan
3480	3480	17 if the enrollee has an ongoing course of treatment; or
3481	3481	18 (B) if the enrollee has entered the third
3482	3482	19 trimester of pregnancy at the time of the provider's
3483	3483	20 physician's disaffiliation, that includes the
3484	3484	21 provision of post-partum care directly related to the
3485	3485	22 delivery.
3486	3486	23 (2) Notwithstanding the provisions in item (1) of this
3487	3487	24 subsection, such care shall be authorized by the health
3488	3488	25 care plan during the transitional period only if the
3489	3489	26 provider physician agrees:
3490	3490
3491	3491
3492	3492
3493	3493
3494	3494
3495	3495	HB4126 - 97 - LRB103 33572 RJT 63384 b
3496	3496
3497	3497
3498	3498	HB4126- 98 -LRB103 33572 RJT 63384 b HB4126 - 98 - LRB103 33572 RJT 63384 b
3499	3499	HB4126 - 98 - LRB103 33572 RJT 63384 b
3500	3500	1 (A) to continue to accept reimbursement from the
3501	3501	2 health care plan at the rates applicable prior to the
3502	3502	3 start of the transitional period;
3503	3503	4 (B) to adhere to the health care plan's quality
3504	3504	5 assurance requirements and to provide to the health
3505	3505	6 care plan necessary medical information related to
3506	3506	7 such care; and
3507	3507	8 (C) to otherwise adhere to the health care plan's
3508	3508	9 policies and procedures, including but not limited to
3509	3509	10 procedures regarding referrals and obtaining
3510	3510	11 preauthorizations for treatment.
3511	3511	12 (3) During an enrollee's plan year, a health care plan
3512	3512	13 shall not remove a drug from its formulary or negatively
3513	3513	14 change its preferred or cost-tier sharing unless, at least
3514	3514	15 60 days before making the formulary change, the health
3515	3515	16 care plan:
3516	3516	17 (A) provides general notification of the change in
3517	3517	18 its formulary to current and prospective enrollees;
3518	3518	19 (B) directly notifies enrollees currently
3519	3519	20 receiving coverage for the drug, including information
3520	3520	21 on the specific drugs involved and the steps they may
3521	3521	22 take to request coverage determinations and
3522	3522	23 exceptions, including a statement that a certification
3523	3523	24 of medical necessity by the enrollee's prescribing
3524	3524	25 provider will result in continuation of coverage at
3525	3525	26 the existing level; and
3526	3526
3527	3527
3528	3528
3529	3529
3530	3530
3531	3531	HB4126 - 98 - LRB103 33572 RJT 63384 b
3532	3532
3533	3533
3534	3534	HB4126- 99 -LRB103 33572 RJT 63384 b HB4126 - 99 - LRB103 33572 RJT 63384 b
3535	3535	HB4126 - 99 - LRB103 33572 RJT 63384 b
3536	3536	1 (C) directly notifies by first class mail and
3537	3537	2 through an electronic transmission, if available, the
3538	3538	3 prescribing provider of all health care plan enrollees
3539	3539	4 currently prescribed the drug affected by the proposed
3540	3540	5 change; the notice shall include a one-page form by
3541	3541	6 which the prescribing provider can notify the health
3542	3542	7 care plan by first class mail that coverage of the drug
3543	3543	8 for the enrollee is medically necessary.
3544	3544	9 The notification in paragraph (C) may direct the
3545	3545	10 prescribing provider to an electronic portal through which
3546	3546	11 the prescribing provider may electronically file a
3547	3547	12 certification to the health care plan that coverage of the
3548	3548	13 drug for the enrollee is medically necessary. The
3549	3549	14 prescribing provider may make a secure electronic
3550	3550	15 signature beside the words "certification of medical
3551	3551	16 necessity", and this certification shall authorize
3552	3552	17 continuation of coverage for the drug.
3553	3553	18 If the prescribing provider certifies to the health
3554	3554	19 care plan either in writing or electronically that the
3555	3555	20 drug is medically necessary for the enrollee as provided
3556	3556	21 in paragraph (C), a health care plan shall authorize
3557	3557	22 coverage for the drug prescribed based solely on the
3558	3558	23 prescribing provider's assertion that coverage is
3559	3559	24 medically necessary, and the health care plan is
3560	3560	25 prohibited from making modifications to the coverage
3561	3561	26 related to the covered drug, including, but not limited
3562	3562
3563	3563
3564	3564
3565	3565
3566	3566
3567	3567	HB4126 - 99 - LRB103 33572 RJT 63384 b
3568	3568
3569	3569
3570	3570	HB4126- 100 -LRB103 33572 RJT 63384 b HB4126 - 100 - LRB103 33572 RJT 63384 b
3571	3571	HB4126 - 100 - LRB103 33572 RJT 63384 b
3572	3572	1 to:
3573	3573	2 (i) increasing the out-of-pocket costs for the
3574	3574	3 covered drug;
3575	3575	4 (ii) moving the covered drug to a more restrictive
3576	3576	5 tier; or
3577	3577	6 (iii) denying an enrollee coverage of the drug for
3578	3578	7 which the enrollee has been previously approved for
3579	3579	8 coverage by the health care plan.
3580	3580	9 Nothing in this item (3) prevents a health care plan
3581	3581	10 from removing a drug from its formulary or denying an
3582	3582	11 enrollee coverage if the United States Food and Drug
3583	3583	12 Administration has issued a statement about the drug that
3584	3584	13 calls into question the clinical safety of the drug, the
3585	3585	14 drug manufacturer has notified the United States Food and
3586	3586	15 Drug Administration of a manufacturing discontinuance or
3587	3587	16 potential discontinuance of the drug as required by
3588	3588	17 Section 506C of the Federal Food, Drug, and Cosmetic Act,
3589	3589	18 as codified in 21 U.S.C. 356c, or the drug manufacturer
3590	3590	19 has removed the drug from the market.
3591	3591	20 Nothing in this item (3) prohibits a health care plan,
3592	3592	21 by contract, written policy or procedure, or any other
3593	3593	22 agreement or course of conduct, from requiring a
3594	3594	23 pharmacist to effect substitutions of prescription drugs
3595	3595	24 consistent with Section 19.5 of the Pharmacy Practice Act,
3596	3596	25 under which a pharmacist may substitute an interchangeable
3597	3597	26 biologic for a prescribed biologic product, and Section 25
3598	3598
3599	3599
3600	3600
3601	3601
3602	3602
3603	3603	HB4126 - 100 - LRB103 33572 RJT 63384 b
3604	3604
3605	3605
3606	3606	HB4126- 101 -LRB103 33572 RJT 63384 b HB4126 - 101 - LRB103 33572 RJT 63384 b
3607	3607	HB4126 - 101 - LRB103 33572 RJT 63384 b
3608	3608	1 of the Pharmacy Practice Act, under which a pharmacist may
3609	3609	2 select a generic drug determined to be therapeutically
3610	3610	3 equivalent by the United States Food and Drug
3611	3611	4 Administration and in accordance with the Illinois Food,
3612	3612	5 Drug and Cosmetic Act.
3613	3613	6 This item (3) applies to a policy or contract that is
3614	3614	7 amended, delivered, issued, or renewed on or after January
3615	3615	8 1, 2019. This item (3) does not apply to a health plan as
3616	3616	9 defined in the State Employees Group Insurance Act of 1971
3617	3617	10 or medical assistance under Article V of the Illinois
3618	3618	11 Public Aid Code.
3619	3619	12 (b) A health care plan shall provide for continuity of
3620	3620	13 care for new enrollees as follows:
3621	3621	14 (1) If a new enrollee whose physician is not a member
3622	3622	15 of the health care plan's provider network, but is within
3623	3623	16 the health care plan's service area, enrolls in the health
3624	3624	17 care plan, the health care plan shall permit the enrollee
3625	3625	18 to continue an ongoing course of treatment with the
3626	3626	19 enrollee's current physician during a transitional period:
3627	3627	20 (A) of 90 days from the effective date of
3628	3628	21 enrollment if the enrollee has an ongoing course of
3629	3629	22 treatment; or
3630	3630	23 (B) if the enrollee has entered the third
3631	3631	24 trimester of pregnancy at the effective date of
3632	3632	25 enrollment, that includes the provision of post-partum
3633	3633	26 care directly related to the delivery.
3634	3634
3635	3635
3636	3636
3637	3637
3638	3638
3639	3639	HB4126 - 101 - LRB103 33572 RJT 63384 b
3640	3640
3641	3641
3642	3642	HB4126- 102 -LRB103 33572 RJT 63384 b HB4126 - 102 - LRB103 33572 RJT 63384 b
3643	3643	HB4126 - 102 - LRB103 33572 RJT 63384 b
3644	3644	1 (2) If an enrollee elects to continue to receive care
3645	3645	2 from such physician pursuant to item (1) of this
3646	3646	3 subsection, such care shall be authorized by the health
3647	3647	4 care plan for the transitional period only if the
3648	3648	5 physician agrees:
3649	3649	6 (A) to accept reimbursement from the health care
3650	3650	7 plan at rates established by the health care plan;
3651	3651	8 such rates shall be the level of reimbursement
3652	3652	9 applicable to similar physicians within the health
3653	3653	10 care plan for such services;
3654	3654	11 (B) to adhere to the health care plan's quality
3655	3655	12 assurance requirements and to provide to the health
3656	3656	13 care plan necessary medical information related to
3657	3657	14 such care; and
3658	3658	15 (C) to otherwise adhere to the health care plan's
3659	3659	16 policies and procedures including, but not limited to
3660	3660	17 procedures regarding referrals and obtaining
3661	3661	18 preauthorization for treatment.
3662	3662	19 (c) In no event shall this Section be construed to require
3663	3663	20 a health care plan to provide coverage for benefits not
3664	3664	21 otherwise covered or to diminish or impair preexisting
3665	3665	22 condition limitations contained in the enrollee's contract. In
3666	3666	23 no event shall this Section be construed to prohibit the
3667	3667	24 addition of prescription drugs to a health care plan's list of
3668	3668	25 covered drugs during the coverage year.
3669	3669	26 (d) In this Section, "ongoing course of treatment" has the
3670	3670
3671	3671
3672	3672
3673	3673
3674	3674
3675	3675	HB4126 - 102 - LRB103 33572 RJT 63384 b
3676	3676
3677	3677
3678	3678	HB4126- 103 -LRB103 33572 RJT 63384 b HB4126 - 103 - LRB103 33572 RJT 63384 b
3679	3679	HB4126 - 103 - LRB103 33572 RJT 63384 b
3680	3680	1 meaning ascribed to that term in Section 5 of the Network
3681	3681	2 Adequacy and Transparency Act.
3682	3682	3 (Source: P.A. 100-1052, eff. 8-24-18.)
3683	3683	4 Section 99. Effective date. This Act takes effect upon
3684	3684	5 becoming law.
3685	3685	HB4126- 104 -LRB103 33572 RJT 63384 b 1 INDEX 2 Statutes amended in order of appearance HB4126- 104 -LRB103 33572 RJT 63384 b HB4126 - 104 - LRB103 33572 RJT 63384 b 1 INDEX 2 Statutes amended in order of appearance
3686	3686	HB4126- 104 -LRB103 33572 RJT 63384 b HB4126 - 104 - LRB103 33572 RJT 63384 b
3687	3687	HB4126 - 104 - LRB103 33572 RJT 63384 b
3688	3688	1 INDEX
3689	3689	2 Statutes amended in order of appearance
3690	3690
3691	3691
3692	3692
3693	3693
3694	3694
3695	3695	HB4126 - 103 - LRB103 33572 RJT 63384 b
3696	3696
3697	3697
3698	3698
3699	3699	HB4126- 104 -LRB103 33572 RJT 63384 b HB4126 - 104 - LRB103 33572 RJT 63384 b
3700	3700	HB4126 - 104 - LRB103 33572 RJT 63384 b
3701	3701	1 INDEX
3702	3702	2 Statutes amended in order of appearance
3703	3703
3704	3704
3705	3705
3706	3706
3707	3707
3708	3708	HB4126 - 104 - LRB103 33572 RJT 63384 b