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
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4126 Introduced , by Rep. Sue Scherer SYNOPSIS AS INTRODUCED:
See Index 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.
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A BILL FOR
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1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Administrative Procedure Act is
5 amended by adding Section 5-45.21 as follows:
6 (5 ILCS 100/5-45.21 new)
7 Sec. 5-45.21. Emergency rulemaking; Network Adequacy and
8 Transparency Act. To provide for the expeditious and timely
9 implementation of the Network Adequacy and Transparency Act,
10 emergency rules implementing federal standards for provider
11 ratios, travel time and distance, and appointment wait times
12 if such standards apply to health insurance coverage regulated
13 by the Department of Insurance and are more stringent than the
14 State standards extant at the time the final federal standards
15 are published may be adopted in accordance with Section 5-45
16 by the Department of Insurance. The adoption of emergency
17 rules authorized by Section 5-45 and this Section is deemed to
18 be necessary for the public interest, safety, and welfare.
19 Section 10. The Illinois Insurance Code is amended by
20 changing Sections 132, 132.5, 155.35, 402, 408, 511.109,
21 512-3, 512-5, and 513b3 and by adding Section 512-11 as
22 follows:
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4126 Introduced , by Rep. Sue Scherer SYNOPSIS AS INTRODUCED:
See Index 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.
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A BILL FOR
See Index
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1 (215 ILCS 5/132) (from Ch. 73, par. 744)
2 Sec. 132. Market conduct and non-financial examinations.
3 (a) Definitions.
4 As used in this Section:
5 "Desk examination" means an examination conducted by
6 market conduct surveillance personnel at a location other than
7 the regulated person's premises. A "desk examination" is
8 usually performed at the Department's offices with the insurer
9 providing requested documents by hard copy, microfiche, discs,
10 or other electronic media for review without an on-site
11 examination.
12 "Market analysis" means a process whereby market conduct
13 surveillance personnel collect and analyze information from
14 filed schedules, surveys, data calls, required reports, and
15 other sources in order to develop a baseline understanding of
16 the marketplace and to identify patterns or practices of
17 regulated persons that deviate significantly from the norm or
18 that may pose a potential risk to the insurance consumer.
19 "Market conduct action" means any of the full range of
20 activities that the Director may initiate to assess and
21 address the market practices of regulated persons, including,
22 but not limited to, market analysis and market conduct
23 examinations. "Market conduct action" does not include the
24 Department's consumer complaint process outlined in 50 Ill.
25 Adm. Code 926; however, the Department may initiate market
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1 conduct actions based on information gathered during that
2 process. Examples of "market conduct action" include, but are
3 not limited to:
4 (1) correspondence with the company or person;
5 (2) interviews with the company or person;
6 (3) information gathering;
7 (4) reviews of policies and procedures;
8 (5) interrogatories;
9 (6) reviews of self-evaluations and voluntary
10 compliance programs of the person or company;
11 (7) self-audits; and
12 (8) market conduct examinations.
13 "Market conduct examination" or "examination" means any
14 type of examination described in the NAIC Market Regulation
15 Handbook that may be used to assess a regulated person's
16 compliance with the laws, rules, and regulations applicable to
17 the examinee. "Market conduct examination" includes
18 comprehensive examinations, targeted examinations, and
19 follow-up examinations. Market conduct examinations may be
20 conducted as desk examinations, on-site examinations, or a
21 combination of those 2 types of examinations.
22 "Market conduct surveillance" means market analysis or a
23 market conduct action.
24 "Market conduct surveillance personnel" means those
25 individuals employed or retained by the Department and
26 designated by the Director to collect, analyze, review, or act
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1 on information in the insurance marketplace that identifies
2 patterns or practices of insurers. "Market conduct
3 surveillance personnel" includes all persons identified as an
4 examiner in the insurance laws or rules of this State if the
5 Director has designated those persons to assist the Director
6 in ascertaining the non-financial business practices,
7 performance, and operations of a company or person subject to
8 the Director's jurisdiction.
9 "NAIC" means the National Association of Insurance
10 Commissioners.
11 "On-site examination" means an examination conducted at
12 the insurer's home office or the location where the records
13 under review are stored.
14 (b) Examinations. (1)
15 The Director, for the purposes of ascertaining the
16 non-financial business practices, performance, and operations
17 of any company, may make examinations of:
18 (1) (a) any company transacting or being organized to
19 transact business in this State;
20 (2) (b) any person engaged in or proposing to be
21 engaged in the organization, promotion, or solicitation of
22 shares or capital contributions to or aiding in the
23 formation of a company;
24 (3) (c) any person having a contract, written or oral,
25 pertaining to the management or control of a company as
26 general agent, managing agent, or attorney-in-fact;
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1 (4) (d) any licensed or registered producer, firm, or
2 administrator, or any person, organization, or corporation
3 making application for any licenses or registration;
4 (5) (e) any person engaged in the business of
5 adjusting losses or financing premiums; or
6 (6) (f) any person, organization, trust, or
7 corporation having custody or control of information
8 reasonably related to the operation, performance, or
9 conduct of a company or person subject to the jurisdiction
10 of the Director.
11 (c) Market analysis and market conduct actions.
12 (1) The Director may perform market analysis by
13 gathering and analyzing information from data currently
14 available to the Director, information from surveys or
15 reports that are submitted regularly to the Director or
16 required in a data call, information collected by the
17 NAIC, and information from a variety of other sources in
18 both the public and private domain in order to develop a
19 baseline understanding of the marketplace and to identify
20 for further review practices that deviate from the norm or
21 that may pose a potential risk to the insurance consumer.
22 The Director shall use the NAIC Market Regulation Handbook
23 as a guide in performing market analysis.
24 (2) If the Director determines that further inquiry
25 into a particular person or practice is needed, the
26 Director may consider one or more market conduct actions.
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1 The Director shall inform the examinee in writing of the
2 type of market conduct action selected and shall use the
3 NAIC Market Regulation Handbook as a guide in performing
4 the market conduct action. The Director may coordinate a
5 market conduct action and findings of this State with
6 market conduct actions and findings of other states.
7 (3) Nothing in this Section requires the Director to
8 conduct market analysis prior to initiating any market
9 conduct action.
10 (4) Nothing in this Section restricts the Director to
11 the type of market conduct action initially selected. The
12 Director shall inform the examinee in writing of any
13 change in the type of market conduct action being
14 conducted.
15 (d) Access to books and records; oaths and examinations.
16 (2) Every examinee company or person being examined and
17 its officers, directors, and agents must provide to the
18 Director convenient and free access at all reasonable hours at
19 its office or location to all books, records, documents,
20 including consumer communications, and any or all papers
21 relating to the business, performance, operations, and affairs
22 of the examinee company. The officers, directors, and agents
23 of the examinee company or person must facilitate the market
24 conduct action examination and aid in the action examination
25 so far as it is in their power to do so.
26 The Director and any authorized market conduct
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1 surveillance personnel examiner have the power to administer
2 oaths and examine under oath any person relative to the
3 business of the examinee company being examined. Any delay of
4 more than 5 business days in the transmission of requested
5 documents without an extension approved by the Director or
6 designated market conduct surveillance personnel is a
7 violation of this Section.
8 (e) Examination report.
9 (3) The market conduct surveillance personnel examiners
10 designated by the Director under Section 402 must make a full
11 and true report of every examination made by them, which
12 contains only facts ascertained from the books, papers,
13 records, or documents, and other evidence obtained by
14 investigation and examined by them or ascertained from the
15 testimony of officers or agents or other persons examined
16 under oath concerning the business, affairs, conduct, and
17 performance of the examinee company or person. The report of
18 examination must be verified by the oath of the examiner in
19 charge thereof, and when so verified is prima facie evidence
20 in any action or proceeding in the name of the State against
21 the company, its officers, or agents upon the facts stated
22 therein.
23 (f) Examinee acceptance of examination report.
24 The Department and the examinee shall adhere to the
25 following timeline, unless a mutual agreement is reached to
26 modify the timeline:
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1 (1) The Department shall deliver the draft report to
2 the examinee within 60 days after completion of the
3 examination. "Completion of the examination" means the
4 date the Department confirms in writing that the
5 examination is completed. Nothing in this Section prevents
6 the Department from sharing an earlier draft of the report
7 with the examinee before confirming that the examination
8 is completed.
9 (2) If the examinee chooses to respond with written
10 submissions or rebuttals, the examinee must do so within
11 30 days after receipt of any draft report delivered after
12 the completion of the examination.
13 (3) After receipt of any written submissions or
14 rebuttals, the Department shall issue a final report. At
15 any time, the Department may share draft corrections or
16 changes to the report with the examinee before issuing a
17 final report, and the examinee shall have 30 days to
18 respond to the draft.
19 (4) The examinee shall, within 10 days after the
20 issuance of the final report, accept the final report or
21 request a hearing in writing. Failure to take either
22 action within 10 days shall be deemed an acceptance of the
23 final report. If the examinee accepts the examination
24 report, the Director shall continue to hold the content of
25 the examination report as private and confidential for a
26 period of 30 days, except to the extent provided for in
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1 subsection (h) and in paragraph (10) of subsection (g).
2 Thereafter, the Director shall open the report for public
3 inspection if no court of competent jurisdiction has
4 stayed its publication.
5 (g) Written hearing.
6 Notwithstanding anything to the contrary in this Code or
7 Department rules, if the examinee requests a hearing, the
8 following procedures apply:
9 (1) The examinee shall request the hearing in writing
10 and shall specify the issues in the final report that the
11 examinee is challenging. The examinee is limited to
12 challenging the issues that were previously challenged in
13 the examinee's written submission and rebuttal or
14 supplemental submission and rebuttal as provided pursuant
15 to paragraphs (2) and (3) of subsection (f).
16 (2) The hearing shall be conducted by written
17 arguments submitted to the Director.
18 (3) Discovery is limited to the market conduct
19 surveillance personnel's work papers that are relevant to
20 the issues the examinee is challenging. The relevant
21 market conduct surveillance personnel's work papers shall
22 be deemed admitted into and included in the record. No
23 other forms of discovery, including depositions and
24 interrogatories, are allowed, except upon written
25 agreement of the examinee and the Department's counsel.
26 (4) Only the examinee and the Department's counsel may
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1 submit written arguments.
2 (5) The examinee shall submit its written argument
3 within 30 days after the Department's counsel serves a
4 formal notice of hearing.
5 (6) The Department's counsel shall submit its written
6 response within 30 days after the examinee submits its
7 written argument.
8 (7) The Director shall issue a decision accompanied by
9 findings and conclusions resulting from the Director's
10 consideration and review of the written arguments, the
11 final report, relevant market conduct surveillance
12 personnel work papers, and any written submissions or
13 rebuttals. The Director's order is a final agency action
14 and shall be served upon the examinee by electronic mail
15 together with a copy of the final report pursuant to
16 Section 10-75 of the Illinois Administrative Procedure
17 Act.
18 (8) Any portion of the final examination report that
19 was not challenged by the examinee is incorporated into
20 the decision of the Director.
21 (9) Findings of fact and conclusions of law in the
22 Director's final agency action are prima facie evidence in
23 any legal or regulatory action.
24 (10) If an examinee has requested a hearing, the
25 Director shall continue to hold the content of any
26 examination report or other final agency action of a
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1 market conduct examination as private and confidential for
2 a period of 49 days after the final agency action. After
3 the 49-day period expires, the Director shall open the
4 final agency action for public inspection if a court of
5 competent jurisdiction has not stayed its publication.
6 (h) Nothing in this Section prevents the Director from
7 disclosing at any time the content of an examination report,
8 preliminary examination report, or results, or any matter
9 relating to a report or results, to the division or to the
10 insurance division of any other state or agency or office of
11 the federal government at any time if the division, agency, or
12 office receiving the report or related matters agrees and has
13 the legal authority to hold it confidential in a manner
14 consistent with this Section.
15 (i) Confidentiality.
16 (1) The Director and any other person in the course of
17 market conduct surveillance shall keep confidential all
18 documents pertaining to the market conduct surveillance,
19 including working papers, third-party models, or products,
20 complaint logs, and copies of any documents created by,
21 produced by, obtained by, or disclosed to the Director,
22 market conduct surveillance personnel, or any other person
23 in the course of market conduct surveillance conducted
24 pursuant to this Section, and all documents obtained by
25 the NAIC as a result of this Section. The documents shall
26 remain confidential after termination of the market
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1 conduct surveillance, are not subject to subpoena, are not
2 subject to discovery or admissible as evidence in private
3 civil litigation, are not subject to disclosure under the
4 Freedom of Information Act, and shall not be made public
5 at any time or used by the Director or any other person,
6 except as provided in paragraphs (3), (4), and (6) of this
7 subsection and in subsection (l).
8 (2) The Director, the Department, and any other person
9 in the course of market conduct surveillance shall keep
10 confidential any self-evaluation or voluntary compliance
11 program documents disclosed to the Director or other
12 person by an examinee and the data collected via the NAIC
13 market conduct annual statement. The documents are not
14 subject to subpoena, are not subject to discovery or
15 admissible as evidence in private civil litigation, are
16 not subject to disclosure under the Freedom of Information
17 Act, and shall not be made public or used by the Director
18 or any other person, except as provided in paragraphs (3),
19 (4), and (6) of this subsection, in subsection (l), or in
20 Section 155.35 of this Code.
21 (3) Notwithstanding paragraphs (1) and (2), and
22 consistent with paragraph (5), in order to assist in the
23 performance of the Director's duties, the Director may:
24 (A) share documents, materials, communications, or
25 other information, including the confidential and
26 privileged documents, materials, or information
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1 described in this subsection, with other State,
2 federal, alien, and international regulatory agencies
3 and law enforcement authorities and the NAIC, its
4 affiliates, and subsidiaries, if the recipient agrees
5 to and has the legal authority to maintain the
6 confidentiality and privileged status of the document,
7 material, communication, or other information;
8 (B) receive documents, materials, communications,
9 or information, including otherwise confidential and
10 privileged documents, materials, or information, from
11 the NAIC and its affiliates or subsidiaries, and from
12 regulatory and law enforcement officials of other
13 domestic, alien, or international jurisdictions,
14 authorities, and agencies, and shall maintain as
15 confidential or privileged any document, material,
16 communication, or information received with notice or
17 the understanding that it is confidential or
18 privileged under the laws of the jurisdiction that is
19 the source of the document, material, communication,
20 or information;
21 (C) enter into agreements governing the sharing
22 and use of information consistent with this Section;
23 and
24 (D) when the Director performs any type of market
25 conduct surveillance that does not rise to the level
26 of a market conduct examination, make the final
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1 results of the market conduct surveillance, in an
2 aggregated format, available for public inspection in
3 a manner deemed appropriate by the Director.
4 (4) Nothing in this Section limits:
5 (A) the Director's authority to use, if consistent
6 with subsection (5) of Section 188.1, any final or
7 preliminary examination report, any market conduct
8 surveillance or examinee work papers or other
9 documents, or any other information discovered or
10 developed during the course of any market conduct
11 surveillance, in the furtherance of any legal or
12 regulatory action initiated by the Director that the
13 Director may, in the Director's sole discretion, deem
14 appropriate; or
15 (B) the ability of an examinee to conduct
16 discovery in accordance with paragraph (3) of
17 subsection (g).
18 (5) Disclosure to the Director of documents,
19 materials, communications, or information required as part
20 of any type of market conduct surveillance does not waive
21 any applicable privilege or claim of confidentiality in
22 the documents, materials, communications, or information.
23 (6) If the Director deems fit, the Director may
24 publicly acknowledge the existence of an ongoing
25 examination before filing the examination report but shall
26 not disclose any other information protected under this
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1 subsection.
2 (j) Corrective actions; sanctions.
3 (1) As a result of any market conduct action other
4 than market analysis, the Director may order the examinee
5 to take any action the Director considers necessary or
6 appropriate in accordance with the report of examination
7 or any hearing thereon, including, but not limited to,
8 requiring the regulated person to undertake corrective
9 actions to cease and desist an identified violation or
10 institute processes and practices to comply with
11 applicable standards, requiring reimbursement or
12 restitution to persons harmed by the regulated person's
13 violation, or imposing civil penalties, for acts in
14 violation of any law, rule, or prior lawful order of the
15 Director. Civil penalties imposed as a result of a market
16 conduct action shall be consistent, reasonable, and
17 justifiable.
18 (2) If any other provision of this Code or any other
19 law or rule under the Director's jurisdiction prescribes
20 an amount or range of penalties for a violation of a
21 particular statute, that provision shall apply. If no
22 penalty is already provided by law or rule for a violation
23 and the violation is quantifiable, then the Director may
24 order a penalty of up to $3,000 for every act in violation
25 of any law, rule, or prior lawful order of the Director. If
26 the examination report finds a violation by the examinee
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1 that the report is unable to quantify, such as, an
2 operational policy or procedure that conflicts with
3 applicable law, then the Director may order a penalty of
4 up to $10,000 for that violation. A violation of
5 subsection (d) is punishable by a fine of $2,000 per day up
6 to a maximum of $500,000.
7 (k) Participation in national market conduct databases.
8 The Director shall collect and report market data to the
9 NAIC's market information systems, including, but not limited
10 to, the Complaint Database System, the Examination Tracking
11 System, and the Regulatory Information Retrieval System, or
12 other successor NAIC products as determined by the Director.
13 Information collected and maintained by the Department for
14 inclusion in these NAIC market information systems shall be
15 compiled in a manner that meets the requirements of the NAIC.
16 (4) The Director must notify the company or person made
17 the subject of any examination hereunder of the contents of
18 the verified examination report before filing it and making
19 the report public of any matters relating thereto, and must
20 afford the company or person an opportunity to demand a
21 hearing with reference to the facts and other evidence therein
22 contained.
23 The company or person may request a hearing within 10 days
24 after receipt of the examination report by giving the Director
25 written notice of that request, together with a statement of
26 its objections. The Director must then conduct a hearing in
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1 accordance with Sections 402 and 403. He must issue a written
2 order based upon the examination report and upon the hearing
3 within 90 days after the report is filed or within 90 days
4 after the hearing.
5 If the examination reveals that the company is operating
6 in violation of any law, regulation, or prior order, the
7 Director in the written order may require the company or
8 person to take any action he considers necessary or
9 appropriate in accordance with the report of examination or
10 any hearing thereon. The order is subject to judicial review
11 under the Administrative Review Law. The Director may withhold
12 any report from public inspection for such time as he may deem
13 proper and may, after filing the same, publish any part or all
14 of the report as he considers to be in the interest of the
15 public, in one or more newspapers in this State, without
16 expense to the company.
17 (5) Any company which or person who violates or aids and
18 abets any violation of a written order issued under this
19 Section shall be guilty of a business offense and may be fined
20 not more than $5,000. The penalty shall be paid into the
21 General Revenue fund of the State of Illinois.
22 (Source: P.A. 87-108.)
23 (215 ILCS 5/132.5) (from Ch. 73, par. 744.5)
24 Sec. 132.5. Examination reports.
25 (a) General description. All examination reports shall be
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1 comprised of only facts appearing upon the books, records, or
2 other documents of the company, its agents, or other persons
3 examined or as ascertained from the testimony of its officers,
4 agents, or other persons examined concerning its affairs and
5 the conclusions and recommendations as the examiners find
6 reasonably warranted from those facts.
7 (b) Filing of examination report. No later than 60 days
8 following completion of the examination, the examiner in
9 charge shall file with the Department a verified written
10 report of examination under oath. Upon receipt of the verified
11 report, the Department shall transmit the report to the
12 company examined, together with a notice that affords the
13 company examined a reasonable opportunity of not more than 30
14 days to make a written submission or rebuttal with respect to
15 any matters contained in the examination report.
16 (c) Adoption of the report on examination. Within 30 days
17 of the end of the period allowed for the receipt of written
18 submissions or rebuttals, the Director shall fully consider
19 and review the report, together with any written submissions
20 or rebuttals and any relevant portions of the examiners work
21 papers and enter an order:
22 (1) Adopting the examination report as filed or with
23 modification or corrections. If the examination report
24 reveals that the company is operating in violation of any
25 law, regulation, or prior order of the Director, the
26 Director may order the company to take any action the
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1 Director considers necessary and appropriate to cure the
2 violation.
3 (2) Rejecting the examination report with directions
4 to the examiners to reopen the examination for purposes of
5 obtaining additional data, documentation, or information
6 and refiling under subsection (b).
7 (3) Calling for an investigatory hearing with no less
8 than 20 days notice to the company for purposes of
9 obtaining additional documentation, data, information, and
10 testimony.
11 (d) Order and procedures. All orders entered under
12 paragraph (1) of subsection (c) shall be accompanied by
13 findings and conclusions resulting from the Director's
14 consideration and review of the examination report, relevant
15 examiner work papers, and any written submissions or
16 rebuttals. The order shall be considered a final
17 administrative decision and may be appealed in accordance with
18 the Administrative Review Law. The order shall be served upon
19 the company by certified mail, together with a copy of the
20 adopted examination report. Within 30 days of the issuance of
21 the adopted report, the company shall file affidavits executed
22 by each of its directors stating under oath that they have
23 received a copy of the adopted report and related orders.
24 Any hearing conducted under paragraph (3) of subsection
25 (c) by the Director or an authorized representative shall be
26 conducted as a nonadversarial confidential investigatory
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1 proceeding as necessary for the resolution of any
2 inconsistencies, discrepancies, or disputed issues apparent
3 upon the face of the filed examination report or raised by or
4 as a result of the Director's review of relevant work papers or
5 by the written submission or rebuttal of the company. Within
6 20 days of the conclusion of any hearing, the Director shall
7 enter an order under paragraph (1) of subsection (c).
8 The Director shall not appoint an examiner as an
9 authorized representative to conduct the hearing. The hearing
10 shall proceed expeditiously with discovery by the company
11 limited to the examiner's work papers that tend to
12 substantiate any assertions set forth in any written
13 submission or rebuttal. The Director or his representative may
14 issue subpoenas for the attendance of any witnesses or the
15 production of any documents deemed relevant to the
16 investigation, whether under the control of the Department,
17 the company, or other persons. The documents produced shall be
18 included in the record, and testimony taken by the Director or
19 his representative shall be under oath and preserved for the
20 record. Nothing contained in this Section shall require the
21 Department to disclose any information or records that would
22 indicate or show the existence or content of any investigation
23 or activity of a criminal justice agency.
24 The hearing shall proceed with the Director or his
25 representative posing questions to the persons subpoenaed.
26 Thereafter the company and the Department may present
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1 testimony relevant to the investigation. Cross-examination
2 shall be conducted only by the Director or his representative.
3 The company and the Department shall be permitted to make
4 closing statements and may be represented by counsel of their
5 choice.
6 (e) Publication and use. Upon the adoption of the
7 examination report under paragraph (1) of subsection (c), the
8 Director shall continue to hold the content of the examination
9 report as private and confidential information for a period of
10 35 days, except to the extent provided in subsection (b).
11 Thereafter, the Director may open the report for public
12 inspection so long as no court of competent jurisdiction has
13 stayed its publication.
14 Nothing contained in this Code shall prevent or be
15 construed as prohibiting the Director from disclosing the
16 content of an examination report, preliminary examination
17 report or results, or any matter relating thereto, to the
18 insurance department of any other state or country or to law
19 enforcement officials of this or any other state or agency of
20 the federal government at any time, so long as the agency or
21 office receiving the report or matters relating thereto agrees
22 in writing to hold it confidential and in a manner consistent
23 with this Code.
24 In the event the Director determines that regulatory
25 action is appropriate as a result of any examination, he may
26 initiate any proceedings or actions as provided by law.
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1 (f) Confidentiality of ancillary information. All working
2 papers, recorded information, documents, and copies thereof
3 produced by, obtained by, or disclosed to the Director or any
4 other person in the course of any examination must be given
5 confidential treatment, are not subject to subpoena, and may
6 not be made public by the Director or any other persons, except
7 to the extent provided in subsection (e). Access may also be
8 granted to the National Association of Insurance
9 Commissioners. Those parties must agree in writing before
10 receiving the information to provide to it the same
11 confidential treatment as required by this Section, unless the
12 prior written consent of the company to which it pertains has
13 been obtained.
14 This subsection (f) applies to market conduct examinations
15 described in Section 132 of this Code.
16 (g) Disclosure. Nothing contained in this Code shall
17 prevent or be construed as prohibiting the Director from
18 disclosing the information described in subsections (e) and
19 (f) to the Illinois Insurance Guaranty Fund regarding any
20 member company defined in Section 534.5 if the member company
21 has an authorized control level event as defined in Section
22 35A-25. The Director may disclose the information described in
23 this subsection so long as the Fund agrees in writing to hold
24 that information confidential, in a manner consistent with
25 this Code, and uses that information to prepare for the
26 possible liquidation of the member company. Access to the
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1 information disclosed by the Director to the Fund shall be
2 limited to the Fund's staff and its counsel. The Board of
3 Directors of the Fund may have access to the information
4 disclosed by the Director to the Fund once the member company
5 is subject to a delinquency proceeding under Article XIII
6 subject to any terms and conditions established by the
7 Director.
8 (Source: P.A. 102-929, eff. 5-27-22.)
9 (215 ILCS 5/155.35)
10 Sec. 155.35. Insurance compliance self-evaluative
11 privilege.
12 (a) To encourage insurance companies and persons
13 conducting activities regulated under this Code, both to
14 conduct voluntary internal audits of their compliance programs
15 and management systems and to assess and improve compliance
16 with State and federal statutes, rules, and orders, an
17 insurance compliance self-evaluative privilege is recognized
18 to protect the confidentiality of communications relating to
19 voluntary internal compliance audits. The General Assembly
20 hereby finds and declares that protection of insurance
21 consumers is enhanced by companies' voluntary compliance with
22 this State's insurance and other laws and that the public will
23 benefit from incentives to identify and remedy insurance and
24 other compliance issues. It is further declared that limited
25 expansion of the protection against disclosure will encourage
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1 voluntary compliance and improve insurance market conduct
2 quality and that the voluntary provisions of this Section will
3 not inhibit the exercise of the regulatory authority by those
4 entrusted with protecting insurance consumers.
5 (b)(1) An insurance compliance self-evaluative audit
6 document is privileged information and is not admissible as
7 evidence in any legal action in any civil, criminal, or
8 administrative proceeding, except as provided in subsections
9 (c) and (d) of this Section. Documents, communications, data,
10 reports, or other information created as a result of a claim
11 involving personal injury or workers' compensation made
12 against an insurance policy are not insurance compliance
13 self-evaluative audit documents and are admissible as evidence
14 in civil proceedings as otherwise provided by applicable rules
15 of evidence or civil procedure, subject to any applicable
16 statutory or common law privilege, including but not limited
17 to the work product doctrine, the attorney-client privilege,
18 or the subsequent remedial measures exclusion.
19 (2) If any company, person, or entity performs or directs
20 the performance of an insurance compliance audit, an officer
21 or employee involved with the insurance compliance audit, or
22 any consultant who is hired for the purpose of performing the
23 insurance compliance audit, may not be examined in any civil,
24 criminal, or administrative proceeding as to the insurance
25 compliance audit or any insurance compliance self-evaluative
26 audit document, as defined in this Section. This subsection
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1 (b)(2) does not apply if the privilege set forth in subsection
2 (b)(1) of this Section is determined under subsection (c) or
3 (d) not to apply.
4 (3) A company may voluntarily submit, in connection with
5 examinations conducted under this Article, an insurance
6 compliance self-evaluative audit document to the Director, or
7 his or her designee, as a confidential document under
8 subsection (i) of Section 132 or subsection (f) of Section
9 132.5 of this Code, as applicable, without waiving the
10 privilege set forth in this Section to which the company would
11 otherwise be entitled; provided, however, that the provisions
12 in Sections 132 and subsection (f) of Section 132.5 permitting
13 the Director to make confidential documents public pursuant to
14 subsection (e) of Section 132.5 and grant access to the
15 National Association of Insurance Commissioners shall not
16 apply to the insurance compliance self-evaluative audit
17 document so voluntarily submitted. Nothing contained in this
18 subsection shall give the Director any authority to compel a
19 company to disclose involuntarily or otherwise provide an
20 insurance compliance self-evaluative audit document.
21 (c)(1) The privilege set forth in subsection (b) of this
22 Section does not apply to the extent that it is expressly
23 waived by the company that prepared or caused to be prepared
24 the insurance compliance self-evaluative audit document.
25 (2) In a civil or administrative proceeding, a court of
26 record may, after an in camera review, require disclosure of
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1 material for which the privilege set forth in subsection (b)
2 of this Section is asserted, if the court determines one of the
3 following:
4 (A) the privilege is asserted for a fraudulent
5 purpose;
6 (B) the material is not subject to the privilege; or
7 (C) even if subject to the privilege, the material
8 shows evidence of noncompliance with State and federal
9 statutes, rules and orders and the company failed to
10 undertake reasonable corrective action or eliminate the
11 noncompliance within a reasonable time.
12 (3) In a criminal proceeding, a court of record may, after
13 an in camera review, require disclosure of material for which
14 the privilege described in subsection (b) of this Section is
15 asserted, if the court determines one of the following:
16 (A) the privilege is asserted for a fraudulent
17 purpose;
18 (B) the material is not subject to the privilege;
19 (C) even if subject to the privilege, the material
20 shows evidence of noncompliance with State and federal
21 statutes, rules and orders and the company failed to
22 undertake reasonable corrective action or eliminate such
23 noncompliance within a reasonable time; or
24 (D) the material contains evidence relevant to
25 commission of a criminal offense under this Code, and all
26 of the following factors are present:
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1 (i) the Director, State's Attorney, or Attorney
2 General has a compelling need for the information;
3 (ii) the information is not otherwise available;
4 and
5 (iii) the Director, State's Attorney, or Attorney
6 General is unable to obtain the substantial equivalent
7 of the information by any means without incurring
8 unreasonable cost and delay.
9 (d)(1) Within 30 days after the Director, State's
10 Attorney, or Attorney General makes a written request by
11 certified mail for disclosure of an insurance compliance
12 self-evaluative audit document under this subsection, the
13 company that prepared or caused the document to be prepared
14 may file with the appropriate court a petition requesting an
15 in camera hearing on whether the insurance compliance
16 self-evaluative audit document or portions of the document are
17 privileged under this Section or subject to disclosure. The
18 court has jurisdiction over a petition filed by a company
19 under this subsection requesting an in camera hearing on
20 whether the insurance compliance self-evaluative audit
21 document or portions of the document are privileged or subject
22 to disclosure. Failure by the company to file a petition
23 waives the privilege.
24 (2) A company asserting the insurance compliance
25 self-evaluative privilege in response to a request for
26 disclosure under this subsection shall include in its request
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1 for an in camera hearing all of the information set forth in
2 subsection (d)(5) of this Section.
3 (3) Upon the filing of a petition under this subsection,
4 the court shall issue an order scheduling, within 45 days
5 after the filing of the petition, an in camera hearing to
6 determine whether the insurance compliance self-evaluative
7 audit document or portions of the document are privileged
8 under this Section or subject to disclosure.
9 (4) The court, after an in camera review, may require
10 disclosure of material for which the privilege in subsection
11 (b) of this Section is asserted if the court determines, based
12 upon its in camera review, that any one of the conditions set
13 forth in subsection (c)(2)(A) through (C) is applicable as to
14 a civil or administrative proceeding or that any one of the
15 conditions set forth in subsection (c)(3)(A) through (D) is
16 applicable as to a criminal proceeding. Upon making such a
17 determination, the court may only compel the disclosure of
18 those portions of an insurance compliance self-evaluative
19 audit document relevant to issues in dispute in the underlying
20 proceeding. Any compelled disclosure will not be considered to
21 be a public document or be deemed to be a waiver of the
22 privilege for any other civil, criminal, or administrative
23 proceeding. A party unsuccessfully opposing disclosure may
24 apply to the court for an appropriate order protecting the
25 document from further disclosure.
26 (5) A company asserting the insurance compliance
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1 self-evaluative privilege in response to a request for
2 disclosure under this subsection (d) shall provide to the
3 Director, State's Attorney, or Attorney General, as the case
4 may be, at the time of filing any objection to the disclosure,
5 all of the following information:
6 (A) The date of the insurance compliance
7 self-evaluative audit document.
8 (B) The identity of the entity conducting the audit.
9 (C) The general nature of the activities covered by
10 the insurance compliance audit.
11 (D) An identification of the portions of the insurance
12 compliance self-evaluative audit document for which the
13 privilege is being asserted.
14 (e) (1) A company asserting the insurance compliance
15 self-evaluative privilege set forth in subsection (b) of this
16 Section has the burden of demonstrating the applicability of
17 the privilege. Once a company has established the
18 applicability of the privilege, a party seeking disclosure
19 under subsections (c)(2)(A) or (C) of this Section has the
20 burden of proving that the privilege is asserted for a
21 fraudulent purpose or that the company failed to undertake
22 reasonable corrective action or eliminate the noncompliance
23 with a reasonable time. The Director, State's Attorney, or
24 Attorney General seeking disclosure under subsection (c)(3) of
25 this Section has the burden of proving the elements set forth
26 in subsection (c)(3) of this Section.
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1 (2) The parties may at any time stipulate in proceedings
2 under subsections (c) or (d) of this Section to entry of an
3 order directing that specific information contained in an
4 insurance compliance self-evaluative audit document is or is
5 not subject to the privilege provided under subsection (b) of
6 this Section.
7 (f) The privilege set forth in subsection (b) of this
8 Section shall not extend to any of the following:
9 (1) documents, communications, data, reports, or other
10 information required to be collected, developed,
11 maintained, reported, or otherwise made available to a
12 regulatory agency pursuant to this Code, or other federal
13 or State law, rule, or order;
14 (2) information obtained by observation or monitoring
15 by any regulatory agency; or
16 (3) information obtained from a source independent of
17 the insurance compliance audit.
18 (g) As used in this Section:
19 (1) "Insurance compliance audit" means a voluntary,
20 internal evaluation, review, assessment, or audit not
21 otherwise expressly required by law of a company or an
22 activity regulated under this Code, or other State or
23 federal law applicable to a company, or of management
24 systems related to the company or activity, that is
25 designed to identify and prevent noncompliance and to
26 improve compliance with those statutes, rules, or orders.
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1 An insurance compliance audit may be conducted by the
2 company, its employees, or by independent contractors.
3 (2) "Insurance compliance self-evaluative audit
4 document" means documents prepared as a result of or in
5 connection with and not prior to an insurance compliance
6 audit. An insurance compliance self-evaluation audit
7 document may include a written response to the findings of
8 an insurance compliance audit. An insurance compliance
9 self-evaluative audit document may include, but is not
10 limited to, as applicable, field notes and records of
11 observations, findings, opinions, suggestions,
12 conclusions, drafts, memoranda, drawings, photographs,
13 computer-generated or electronically recorded
14 information, phone records, maps, charts, graphs, and
15 surveys, provided this supporting information is collected
16 or developed for the primary purpose and in the course of
17 an insurance compliance audit. An insurance compliance
18 self-evaluative audit document may also include any of the
19 following:
20 (A) an insurance compliance audit report prepared
21 by an auditor, who may be an employee of the company or
22 an independent contractor, which may include the scope
23 of the audit, the information gained in the audit, and
24 conclusions and recommendations, with exhibits and
25 appendices;
26 (B) memoranda and documents analyzing portions or
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1 all of the insurance compliance audit report and
2 discussing potential implementation issues;
3 (C) an implementation plan that addresses
4 correcting past noncompliance, improving current
5 compliance, and preventing future noncompliance; or
6 (D) analytic data generated in the course of
7 conducting the insurance compliance audit.
8 (3) "Company" has the same meaning as provided in
9 Section 2 of this Code.
10 (h) Nothing in this Section shall limit, waive, or
11 abrogate the scope or nature of any statutory or common law
12 privilege including, but not limited to, the work product
13 doctrine, the attorney-client privilege, or the subsequent
14 remedial measures exclusion.
15 (Source: P.A. 90-499, eff. 8-19-97; 90-655, eff. 7-30-98.)
16 (215 ILCS 5/402) (from Ch. 73, par. 1014)
17 Sec. 402. Examinations, investigations and hearings. (1)
18 All examinations, investigations and hearings provided for by
19 this Code may be conducted either by the Director personally,
20 or by one or more of the actuaries, technical advisors,
21 deputies, supervisors or examiners employed or retained by the
22 Department and designated by the Director for such purpose.
23 When necessary to supplement its examination procedures, the
24 Department may retain independent actuaries deemed competent
25 by the Director, independent certified public accountants,
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1 attorneys, or qualified examiners of insurance companies
2 deemed competent by the Director, or any combination of the
3 foregoing, the cost of which shall be borne by the company or
4 person being examined. The Director may compensate independent
5 actuaries, certified public accountants and qualified
6 examiners retained for supplementing examination procedures in
7 amounts not to exceed the reasonable and customary charges for
8 such services. The Director may also accept as a part of the
9 Department's examination of any company or person (a) a report
10 by an independent actuary deemed competent by the Director or
11 (b) a report of an audit made by an independent certified
12 public accountant. Neither those persons so designated nor any
13 members of their immediate families shall be officers of,
14 connected with, or financially interested in any company other
15 than as policyholders, nor shall they be financially
16 interested in any other corporation or person affected by the
17 examination, investigation or hearing.
18 (2) All hearings provided for in this Code shall, unless
19 otherwise specially provided, be held at such time and place
20 as shall be designated in a notice which shall be given by the
21 Director in writing to the person or company whose interests
22 are affected, at least 10 days before the date designated
23 therein. The notice shall state the subject of inquiry and the
24 specific charges, if any. The hearings shall be held in the
25 City of Springfield, the City of Chicago, or in the county
26 where the principal business address of the person or company
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1 affected is located.
2 (Source: P.A. 87-757.)
3 (215 ILCS 5/408) (from Ch. 73, par. 1020)
4 Sec. 408. Fees and charges.
5 (1) The Director shall charge, collect and give proper
6 acquittances for the payment of the following fees and
7 charges:
8 (a) For filing all documents submitted for the
9 incorporation or organization or certification of a
10 domestic company, except for a fraternal benefit society,
11 $2,000.
12 (b) For filing all documents submitted for the
13 incorporation or organization of a fraternal benefit
14 society, $500.
15 (c) For filing amendments to articles of incorporation
16 and amendments to declaration of organization, except for
17 a fraternal benefit society, a mutual benefit association,
18 a burial society or a farm mutual, $200.
19 (d) For filing amendments to articles of incorporation
20 of a fraternal benefit society, a mutual benefit
21 association or a burial society, $100.
22 (e) For filing amendments to articles of incorporation
23 of a farm mutual, $50.
24 (f) For filing bylaws or amendments thereto, $50.
25 (g) For filing agreement of merger or consolidation:
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1 (i) for a domestic company, except for a fraternal
2 benefit society, a mutual benefit association, a
3 burial society, or a farm mutual, $2,000.
4 (ii) for a foreign or alien company, except for a
5 fraternal benefit society, $600.
6 (iii) for a fraternal benefit society, a mutual
7 benefit association, a burial society, or a farm
8 mutual, $200.
9 (h) For filing agreements of reinsurance by a domestic
10 company, $200.
11 (i) For filing all documents submitted by a foreign or
12 alien company to be admitted to transact business or
13 accredited as a reinsurer in this State, except for a
14 fraternal benefit society, $5,000.
15 (j) For filing all documents submitted by a foreign or
16 alien fraternal benefit society to be admitted to transact
17 business in this State, $500.
18 (k) For filing declaration of withdrawal of a foreign
19 or alien company, $50.
20 (l) For filing annual statement by a domestic company,
21 except a fraternal benefit society, a mutual benefit
22 association, a burial society, or a farm mutual, $200.
23 (m) For filing annual statement by a domestic
24 fraternal benefit society, $100.
25 (n) For filing annual statement by a farm mutual, a
26 mutual benefit association, or a burial society, $50.
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1 (o) For issuing a certificate of authority or renewal
2 thereof except to a foreign fraternal benefit society,
3 $400.
4 (p) For issuing a certificate of authority or renewal
5 thereof to a foreign fraternal benefit society, $200.
6 (q) For issuing an amended certificate of authority,
7 $50.
8 (r) For each certified copy of certificate of
9 authority, $20.
10 (s) For each certificate of deposit, or valuation, or
11 compliance or surety certificate, $20.
12 (t) For copies of papers or records per page, $1.
13 (u) For each certification to copies of papers or
14 records, $10.
15 (v) For multiple copies of documents or certificates
16 listed in subparagraphs (r), (s), and (u) of paragraph (1)
17 of this Section, $10 for the first copy of a certificate of
18 any type and $5 for each additional copy of the same
19 certificate requested at the same time, unless, pursuant
20 to paragraph (2) of this Section, the Director finds these
21 additional fees excessive.
22 (w) For issuing a permit to sell shares or increase
23 paid-up capital:
24 (i) in connection with a public stock offering,
25 $300;
26 (ii) in any other case, $100.
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1 (x) For issuing any other certificate required or
2 permissible under the law, $50.
3 (y) For filing a plan of exchange of the stock of a
4 domestic stock insurance company, a plan of
5 demutualization of a domestic mutual company, or a plan of
6 reorganization under Article XII, $2,000.
7 (z) For filing a statement of acquisition of a
8 domestic company as defined in Section 131.4 of this Code,
9 $2,000.
10 (aa) For filing an agreement to purchase the business
11 of an organization authorized under the Dental Service
12 Plan Act or the Voluntary Health Services Plans Act or of a
13 health maintenance organization or a limited health
14 service organization, $2,000.
15 (bb) For filing a statement of acquisition of a
16 foreign or alien insurance company as defined in Section
17 131.12a of this Code, $1,000.
18 (cc) For filing a registration statement as required
19 in Sections 131.13 and 131.14, the notification as
20 required by Sections 131.16, 131.20a, or 141.4, or an
21 agreement or transaction required by Sections 124.2(2),
22 141, 141a, or 141.1, $200.
23 (dd) For filing an application for licensing of:
24 (i) a religious or charitable risk pooling trust
25 or a workers' compensation pool, $1,000;
26 (ii) a workers' compensation service company,
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1 $500;
2 (iii) a self-insured automobile fleet, $200; or
3 (iv) a renewal of or amendment of any license
4 issued pursuant to (i), (ii), or (iii) above, $100.
5 (ee) For filing articles of incorporation for a
6 syndicate to engage in the business of insurance through
7 the Illinois Insurance Exchange, $2,000.
8 (ff) For filing amended articles of incorporation for
9 a syndicate engaged in the business of insurance through
10 the Illinois Insurance Exchange, $100.
11 (gg) For filing articles of incorporation for a
12 limited syndicate to join with other subscribers or
13 limited syndicates to do business through the Illinois
14 Insurance Exchange, $1,000.
15 (hh) For filing amended articles of incorporation for
16 a limited syndicate to do business through the Illinois
17 Insurance Exchange, $100.
18 (ii) For a permit to solicit subscriptions to a
19 syndicate or limited syndicate, $100.
20 (jj) For the filing of each form as required in
21 Section 143 of this Code, $50 per form. The fee for
22 advisory and rating organizations shall be $200 per form.
23 (i) For the purposes of the form filing fee,
24 filings made on insert page basis will be considered
25 one form at the time of its original submission.
26 Changes made to a form subsequent to its approval
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1 shall be considered a new filing.
2 (ii) Only one fee shall be charged for a form,
3 regardless of the number of other forms or policies
4 with which it will be used.
5 (iii) Fees charged for a policy filed as it will be
6 issued regardless of the number of forms comprising
7 that policy shall not exceed $1,500. For advisory or
8 rating organizations, fees charged for a policy filed
9 as it will be issued regardless of the number of forms
10 comprising that policy shall not exceed $2,500.
11 (iv) The Director may by rule exempt forms from
12 such fees.
13 (kk) For filing an application for licensing of a
14 reinsurance intermediary, $500.
15 (ll) For filing an application for renewal of a
16 license of a reinsurance intermediary, $200.
17 (mm) For a network adequacy filing required under the
18 Network Adequacy and Transparency Act, $500, except that
19 the fee for a filing required based on a material change is
20 $100.
21 (2) When printed copies or numerous copies of the same
22 paper or records are furnished or certified, the Director may
23 reduce such fees for copies if he finds them excessive. He may,
24 when he considers it in the public interest, furnish without
25 charge to state insurance departments and persons other than
26 companies, copies or certified copies of reports of
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1 examinations and of other papers and records.
2 (3) The expenses incurred in any performance examination
3 authorized by law shall be paid by the company or person being
4 examined. The charge shall be reasonably related to the cost
5 of the examination including but not limited to compensation
6 of examiners, electronic data processing costs, supervision
7 and preparation of an examination report and lodging and
8 travel expenses. All lodging and travel expenses shall be in
9 accord with the applicable travel regulations as published by
10 the Department of Central Management Services and approved by
11 the Governor's Travel Control Board, except that out-of-state
12 lodging and travel expenses related to examinations authorized
13 under Section 132 shall be in accordance with travel rates
14 prescribed under paragraph 301-7.2 of the Federal Travel
15 Regulations, 41 C.F.R. 301-7.2, for reimbursement of
16 subsistence expenses incurred during official travel. All
17 lodging and travel expenses may be reimbursed directly upon
18 authorization of the Director. With the exception of the
19 direct reimbursements authorized by the Director, all
20 performance examination charges collected by the Department
21 shall be paid to the Insurance Producer Administration Fund,
22 however, the electronic data processing costs incurred by the
23 Department in the performance of any examination shall be
24 billed directly to the company being examined for payment to
25 the Technology Management Revolving Fund.
26 (4) At the time of any service of process on the Director
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1 as attorney for such service, the Director shall charge and
2 collect the sum of $20, which may be recovered as taxable costs
3 by the party to the suit or action causing such service to be
4 made if he prevails in such suit or action.
5 (5) (a) The costs incurred by the Department of Insurance
6 in conducting any hearing authorized by law shall be assessed
7 against the parties to the hearing in such proportion as the
8 Director of Insurance may determine upon consideration of all
9 relevant circumstances including: (1) the nature of the
10 hearing; (2) whether the hearing was instigated by, or for the
11 benefit of a particular party or parties; (3) whether there is
12 a successful party on the merits of the proceeding; and (4) the
13 relative levels of participation by the parties.
14 (b) For purposes of this subsection (5) costs incurred
15 shall mean the hearing officer fees, court reporter fees, and
16 travel expenses of Department of Insurance officers and
17 employees; provided however, that costs incurred shall not
18 include hearing officer fees or court reporter fees unless the
19 Department has retained the services of independent
20 contractors or outside experts to perform such functions.
21 (c) The Director shall make the assessment of costs
22 incurred as part of the final order or decision arising out of
23 the proceeding; provided, however, that such order or decision
24 shall include findings and conclusions in support of the
25 assessment of costs. This subsection (5) shall not be
26 construed as permitting the payment of travel expenses unless
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1 calculated in accordance with the applicable travel
2 regulations of the Department of Central Management Services,
3 as approved by the Governor's Travel Control Board. The
4 Director as part of such order or decision shall require all
5 assessments for hearing officer fees and court reporter fees,
6 if any, to be paid directly to the hearing officer or court
7 reporter by the party(s) assessed for such costs. The
8 assessments for travel expenses of Department officers and
9 employees shall be reimbursable to the Director of Insurance
10 for deposit to the fund out of which those expenses had been
11 paid.
12 (d) The provisions of this subsection (5) shall apply in
13 the case of any hearing conducted by the Director of Insurance
14 not otherwise specifically provided for by law.
15 (6) The Director shall charge and collect an annual
16 financial regulation fee from every domestic company for
17 examination and analysis of its financial condition and to
18 fund the internal costs and expenses of the Interstate
19 Insurance Receivership Commission as may be allocated to the
20 State of Illinois and companies doing an insurance business in
21 this State pursuant to Article X of the Interstate Insurance
22 Receivership Compact. The fee shall be the greater fixed
23 amount based upon the combination of nationwide direct premium
24 income and nationwide reinsurance assumed premium income or
25 upon admitted assets calculated under this subsection as
26 follows:
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1 (a) Combination of nationwide direct premium income
2 and nationwide reinsurance assumed premium.
3 (i) $150, if the premium is less than $500,000 and
4 there is no reinsurance assumed premium;
5 (ii) $750, if the premium is $500,000 or more, but
6 less than $5,000,000 and there is no reinsurance
7 assumed premium; or if the premium is less than
8 $5,000,000 and the reinsurance assumed premium is less
9 than $10,000,000;
10 (iii) $3,750, if the premium is less than
11 $5,000,000 and the reinsurance assumed premium is
12 $10,000,000 or more;
13 (iv) $7,500, if the premium is $5,000,000 or more,
14 but less than $10,000,000;
15 (v) $18,000, if the premium is $10,000,000 or
16 more, but less than $25,000,000;
17 (vi) $22,500, if the premium is $25,000,000 or
18 more, but less than $50,000,000;
19 (vii) $30,000, if the premium is $50,000,000 or
20 more, but less than $100,000,000;
21 (viii) $37,500, if the premium is $100,000,000 or
22 more.
23 (b) Admitted assets.
24 (i) $150, if admitted assets are less than
25 $1,000,000;
26 (ii) $750, if admitted assets are $1,000,000 or
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1 more, but less than $5,000,000;
2 (iii) $3,750, if admitted assets are $5,000,000 or
3 more, but less than $25,000,000;
4 (iv) $7,500, if admitted assets are $25,000,000 or
5 more, but less than $50,000,000;
6 (v) $18,000, if admitted assets are $50,000,000 or
7 more, but less than $100,000,000;
8 (vi) $22,500, if admitted assets are $100,000,000
9 or more, but less than $500,000,000;
10 (vii) $30,000, if admitted assets are $500,000,000
11 or more, but less than $1,000,000,000;
12 (viii) $37,500, if admitted assets are
13 $1,000,000,000 or more.
14 (c) The sum of financial regulation fees charged to
15 the domestic companies of the same affiliated group shall
16 not exceed $250,000 in the aggregate in any single year
17 and shall be billed by the Director to the member company
18 designated by the group.
19 (7) The Director shall charge and collect an annual
20 financial regulation fee from every foreign or alien company,
21 except fraternal benefit societies, for the examination and
22 analysis of its financial condition and to fund the internal
23 costs and expenses of the Interstate Insurance Receivership
24 Commission as may be allocated to the State of Illinois and
25 companies doing an insurance business in this State pursuant
26 to Article X of the Interstate Insurance Receivership Compact.
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1 The fee shall be a fixed amount based upon Illinois direct
2 premium income and nationwide reinsurance assumed premium
3 income in accordance with the following schedule:
4 (a) $150, if the premium is less than $500,000 and
5 there is no reinsurance assumed premium;
6 (b) $750, if the premium is $500,000 or more, but less
7 than $5,000,000 and there is no reinsurance assumed
8 premium; or if the premium is less than $5,000,000 and the
9 reinsurance assumed premium is less than $10,000,000;
10 (c) $3,750, if the premium is less than $5,000,000 and
11 the reinsurance assumed premium is $10,000,000 or more;
12 (d) $7,500, if the premium is $5,000,000 or more, but
13 less than $10,000,000;
14 (e) $18,000, if the premium is $10,000,000 or more,
15 but less than $25,000,000;
16 (f) $22,500, if the premium is $25,000,000 or more,
17 but less than $50,000,000;
18 (g) $30,000, if the premium is $50,000,000 or more,
19 but less than $100,000,000;
20 (h) $37,500, if the premium is $100,000,000 or more.
21 The sum of financial regulation fees under this subsection
22 (7) charged to the foreign or alien companies within the same
23 affiliated group shall not exceed $250,000 in the aggregate in
24 any single year and shall be billed by the Director to the
25 member company designated by the group.
26 (8) Beginning January 1, 1992, the financial regulation
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1 fees imposed under subsections (6) and (7) of this Section
2 shall be paid by each company or domestic affiliated group
3 annually. After January 1, 1994, the fee shall be billed by
4 Department invoice based upon the company's premium income or
5 admitted assets as shown in its annual statement for the
6 preceding calendar year. The invoice is due upon receipt and
7 must be paid no later than June 30 of each calendar year. All
8 financial regulation fees collected by the Department shall be
9 paid to the Insurance Financial Regulation Fund. The
10 Department may not collect financial examiner per diem charges
11 from companies subject to subsections (6) and (7) of this
12 Section undergoing financial examination after June 30, 1992.
13 (9) In addition to the financial regulation fee required
14 by this Section, a company undergoing any financial
15 examination authorized by law shall pay the following costs
16 and expenses incurred by the Department: electronic data
17 processing costs, the expenses authorized under Section 131.21
18 and subsection (d) of Section 132.4 of this Code, and lodging
19 and travel expenses.
20 Electronic data processing costs incurred by the
21 Department in the performance of any examination shall be
22 billed directly to the company undergoing examination for
23 payment to the Technology Management Revolving Fund. Except
24 for direct reimbursements authorized by the Director or direct
25 payments made under Section 131.21 or subsection (d) of
26 Section 132.4 of this Code, all financial regulation fees and
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1 all financial examination charges collected by the Department
2 shall be paid to the Insurance Financial Regulation Fund.
3 All lodging and travel expenses shall be in accordance
4 with applicable travel regulations published by the Department
5 of Central Management Services and approved by the Governor's
6 Travel Control Board, except that out-of-state lodging and
7 travel expenses related to examinations authorized under
8 Sections 132.1 through 132.7 shall be in accordance with
9 travel rates prescribed under paragraph 301-7.2 of the Federal
10 Travel Regulations, 41 C.F.R. 301-7.2, for reimbursement of
11 subsistence expenses incurred during official travel. All
12 lodging and travel expenses may be reimbursed directly upon
13 the authorization of the Director.
14 In the case of an organization or person not subject to the
15 financial regulation fee, the expenses incurred in any
16 financial examination authorized by law shall be paid by the
17 organization or person being examined. The charge shall be
18 reasonably related to the cost of the examination including,
19 but not limited to, compensation of examiners and other costs
20 described in this subsection.
21 (10) Any company, person, or entity failing to make any
22 payment of $150 or more as required under this Section shall be
23 subject to the penalty and interest provisions provided for in
24 subsections (4) and (7) of Section 412.
25 (11) Unless otherwise specified, all of the fees collected
26 under this Section shall be paid into the Insurance Financial
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1 Regulation Fund.
2 (12) For purposes of this Section:
3 (a) "Domestic company" means a company as defined in
4 Section 2 of this Code which is incorporated or organized
5 under the laws of this State, and in addition includes a
6 not-for-profit corporation authorized under the Dental
7 Service Plan Act or the Voluntary Health Services Plans
8 Act, a health maintenance organization, and a limited
9 health service organization.
10 (b) "Foreign company" means a company as defined in
11 Section 2 of this Code which is incorporated or organized
12 under the laws of any state of the United States other than
13 this State and in addition includes a health maintenance
14 organization and a limited health service organization
15 which is incorporated or organized under the laws of any
16 state of the United States other than this State.
17 (c) "Alien company" means a company as defined in
18 Section 2 of this Code which is incorporated or organized
19 under the laws of any country other than the United
20 States.
21 (d) "Fraternal benefit society" means a corporation,
22 society, order, lodge or voluntary association as defined
23 in Section 282.1 of this Code.
24 (e) "Mutual benefit association" means a company,
25 association or corporation authorized by the Director to
26 do business in this State under the provisions of Article
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1 XVIII of this Code.
2 (f) "Burial society" means a person, firm,
3 corporation, society or association of individuals
4 authorized by the Director to do business in this State
5 under the provisions of Article XIX of this Code.
6 (g) "Farm mutual" means a district, county and
7 township mutual insurance company authorized by the
8 Director to do business in this State under the provisions
9 of the Farm Mutual Insurance Company Act of 1986.
10 (Source: P.A. 100-23, eff. 7-6-17.)
11 (215 ILCS 5/511.109) (from Ch. 73, par. 1065.58-109)
12 (Section scheduled to be repealed on January 1, 2027)
13 Sec. 511.109. Examination.
14 (a) The Director or the Director's his designee may
15 examine any applicant for or holder of an administrator's
16 license in accordance with Sections 132 through 132.7 of this
17 Code. If the Director or the examiners find that the
18 administrator has violated this Article or any other
19 insurance-related laws or rules under the Director's
20 jurisdiction because of the manner in which the administrator
21 has conducted business on behalf of an insurer or plan
22 sponsor, then, unless the insurer or plan sponsor is included
23 in the examination and has been afforded the same opportunity
24 to request or participate in a hearing on the examination
25 report, the examination report shall not allege a violation by
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1 the insurer or plan sponsor and the Director's order based on
2 the report shall not impose any requirements, prohibitions, or
3 penalties on the insurer or plan sponsor. Nothing in this
4 Section shall prevent the Director from using any information
5 obtained during the examination of an administrator to
6 examine, investigate, or take other appropriate regulatory or
7 legal action with respect to an insurer or plan sponsor.
8 (b) (Blank). Any administrator being examined shall
9 provide to the Director or his designee convenient and free
10 access, at all reasonable hours at their offices, to all
11 books, records, documents and other papers relating to such
12 administrator's business affairs.
13 (c) (Blank). The Director or his designee may administer
14 oaths and thereafter examine any individual about the business
15 of the administrator.
16 (d) (Blank). The examiners designated by the Director
17 pursuant to this Section may make reports to the Director. Any
18 report alleging substantive violations of this Article, any
19 applicable provisions of the Illinois Insurance Code, or any
20 applicable Part of Title 50 of the Illinois Administrative
21 Code shall be in writing and be based upon facts obtained by
22 the examiners. The report shall be verified by the examiners.
23 (e) (Blank). If a report is made, the Director shall
24 either deliver a duplicate thereof to the administrator being
25 examined or send such duplicate by certified or registered
26 mail to the administrator's address specified in the records
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1 of the Department. The Director shall afford the administrator
2 an opportunity to request a hearing to object to the report.
3 The administrator may request a hearing within 30 days after
4 receipt of the duplicate of the examination report by giving
5 the Director written notice of such request together with
6 written objections to the report. Any hearing shall be
7 conducted in accordance with Sections 402 and 403 of this
8 Code. The right to hearing is waived if the delivery of the
9 report is refused or the report is otherwise undeliverable or
10 the administrator does not timely request a hearing. After the
11 hearing or upon expiration of the time period during which an
12 administrator may request a hearing, if the examination
13 reveals that the administrator is operating in violation of
14 any applicable provision of the Illinois Insurance Code, any
15 applicable Part of Title 50 of the Illinois Administrative
16 Code or prior order, the Director, in the written order, may
17 require the administrator to take any action the Director
18 considers necessary or appropriate in accordance with the
19 report or examination hearing. If the Director issues an
20 order, it shall be issued within 90 days after the report is
21 filed, or if there is a hearing, within 90 days after the
22 conclusion of the hearing. The order is subject to review
23 under the Administrative Review Law.
24 (Source: P.A. 84-887.)
25 (215 ILCS 5/512-3) (from Ch. 73, par. 1065.59-3)
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1 Sec. 512-3. Definitions. For the purposes of this Article,
2 unless the context otherwise requires, the terms defined in
3 this Article have the meanings ascribed to them herein:
4 (a) "Third party prescription program" or "program" means
5 any system of providing for the reimbursement of
6 pharmaceutical services and prescription drug products offered
7 or operated in this State under a contractual arrangement or
8 agreement between a provider of such services and another
9 party who is not the consumer of those services and products.
10 Such programs may include, but need not be limited to,
11 employee benefit plans whereby a consumer receives
12 prescription drugs or other pharmaceutical services and those
13 services are paid for by an agent of the employer or others.
14 (b) "Third party program administrator" or "administrator"
15 means any person, partnership or corporation who issues or
16 causes to be issued any payment or reimbursement to a provider
17 for services rendered pursuant to a third party prescription
18 program, but does not include the Director of Healthcare and
19 Family Services or any agent authorized by the Director to
20 reimburse a provider of services rendered pursuant to a
21 program of which the Department of Healthcare and Family
22 Services is the third party.
23 (c) "Health care payer" means an insurance company, health
24 maintenance organization, limited health service organization,
25 health services plan corporation, or dental service plan
26 corporation authorized to do business in this State.
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1 (Source: P.A. 95-331, eff. 8-21-07.)
2 (215 ILCS 5/512-5) (from Ch. 73, par. 1065.59-5)
3 Sec. 512-5. Fiduciary and Bonding Requirements. A third
4 party prescription program administrator shall (1) establish
5 and maintain a fiduciary account, separate and apart from any
6 and all other accounts, for the receipt and disbursement of
7 funds for reimbursement of providers of services under the
8 program, or (2) post, or cause to be posted, a bond of
9 indemnity in an amount equal to not less than 10% of the total
10 estimated annual reimbursements under the program.
11 The establishment of such fiduciary accounts and bonds
12 shall be consistent with applicable State law. If a bond of
13 indemnity is posted, it shall be held by the Director of
14 Insurance for the benefit and indemnification of the providers
15 of services under the third party prescription program.
16 An administrator who operates more than one third party
17 prescription program may establish and maintain a separate
18 fiduciary account or bond of indemnity for each such program,
19 or may operate and maintain a consolidated fiduciary account
20 or bond of indemnity for all such programs.
21 The requirements of this Section do not apply to any third
22 party prescription program administered by or on behalf of any
23 health care payer insurance company, Health Care Service Plan
24 Corporation or Pharmaceutical Service Plan Corporation
25 authorized to do business in the State of Illinois.
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1 (Source: P.A. 82-1005.)
2 (215 ILCS 5/512-11 new)
3 Sec. 512-11. Examination. The Director or the Director's
4 designee may examine any applicant for or holder of an
5 administrator's registration in accordance with Sections 132
6 through 132.7 of this Code. If the Director or the examiners
7 find that the administrator has violated this Article or any
8 other insurance-related laws or rules under the Director's
9 jurisdiction because of the manner in which the administrator
10 has conducted business on behalf of a separately incorporated
11 health care payer, then, unless the health care payer is
12 included in the examination and has been afforded the same
13 opportunity to request or participate in a hearing on the
14 examination report, the examination report shall not allege a
15 violation by the health care payer and the Director's order
16 based on the report shall not impose any requirements,
17 prohibitions, or penalties on the health care payer. Nothing
18 in this Section shall prevent the Director from using any
19 information obtained during the examination of an
20 administrator to examine, investigate, or take other
21 appropriate regulatory or legal action with respect to a
22 health care payer.
23 (215 ILCS 5/513b3)
24 Sec. 513b3. Examination.
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1 (a) The Director, or the Director's his or her designee,
2 may examine a registered pharmacy benefit manager in
3 accordance with Sections 132 through 132.7 of this Code. If
4 the Director or the examiners find that the pharmacy benefit
5 manager has violated this Article or any other
6 insurance-related laws or rules under the Director's
7 jurisdiction because of the manner in which the pharmacy
8 benefit manager has conducted business on behalf of a health
9 insurer or plan sponsor, then, unless the health insurer or
10 plan sponsor is included in the examination and has been
11 afforded the same opportunity to request or participate in a
12 hearing on the examination report, the examination report
13 shall not allege a violation by the health insurer or plan
14 sponsor and the Director's order based on the report shall not
15 impose any requirements, prohibitions, or penalties on the
16 health insurer or plan sponsor. Nothing in this Section shall
17 prevent the Director from using any information obtained
18 during the examination of an administrator to examine,
19 investigate, or take other appropriate regulatory or legal
20 action with respect to a health insurer or plan sponsor.
21 (b) (Blank). Any pharmacy benefit manager being examined
22 shall provide to the Director, or his or her designee,
23 convenient and free access to all books, records, documents,
24 and other papers relating to such pharmacy benefit manager's
25 business affairs at all reasonable hours at its offices.
26 (c) (Blank). The Director, or his or her designee, may
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1 administer oaths and thereafter examine the pharmacy benefit
2 manager's designee, representative, or any officer or senior
3 manager as listed on the license or registration certificate
4 about the business of the pharmacy benefit manager.
5 (d) (Blank). The examiners designated by the Director
6 under this Section may make reports to the Director. Any
7 report alleging substantive violations of this Article, any
8 applicable provisions of this Code, or any applicable Part of
9 Title 50 of the Illinois Administrative Code shall be in
10 writing and be based upon facts obtained by the examiners. The
11 report shall be verified by the examiners.
12 (e) (Blank). If a report is made, the Director shall
13 either deliver a duplicate report to the pharmacy benefit
14 manager being examined or send such duplicate by certified or
15 registered mail to the pharmacy benefit manager's address
16 specified in the records of the Department. The Director shall
17 afford the pharmacy benefit manager an opportunity to request
18 a hearing to object to the report. The pharmacy benefit
19 manager may request a hearing within 30 days after receipt of
20 the duplicate report by giving the Director written notice of
21 such request together with written objections to the report.
22 Any hearing shall be conducted in accordance with Sections 402
23 and 403 of this Code. The right to a hearing is waived if the
24 delivery of the report is refused or the report is otherwise
25 undeliverable or the pharmacy benefit manager does not timely
26 request a hearing. After the hearing or upon expiration of the
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1 time period during which a pharmacy benefit manager may
2 request a hearing, if the examination reveals that the
3 pharmacy benefit manager is operating in violation of any
4 applicable provision of this Code, any applicable Part of
5 Title 50 of the Illinois Administrative Code, a provision of
6 this Article, or prior order, the Director, in the written
7 order, may require the pharmacy benefit manager to take any
8 action the Director considers necessary or appropriate in
9 accordance with the report or examination hearing. If the
10 Director issues an order, it shall be issued within 90 days
11 after the report is filed, or if there is a hearing, within 90
12 days after the conclusion of the hearing. The order is subject
13 to review under the Administrative Review Law.
14 (Source: P.A. 101-452, eff. 1-1-20.)
15 Section 15. The Network Adequacy and Transparency Act is
16 amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and
17 by adding Sections 35 and 40 as follows:
18 (215 ILCS 124/3)
19 Sec. 3. Applicability of Act. This Act applies to an
20 individual or group policy of accident and health insurance
21 coverage with a network plan amended, delivered, issued, or
22 renewed in this State on or after January 1, 2019. This Act
23 does not apply to an individual or group policy for excepted
24 benefits or short-term, limited-duration health insurance
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1 coverage dental or vision insurance or a limited health
2 service organization with a network plan amended, delivered,
3 issued, or renewed in this State on or after January 1, 2019,
4 except to the extent that federal law establishes network
5 adequacy and transparency standards for stand-alone dental
6 plans, which the Department shall enforce.
7 (Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
8 (215 ILCS 124/5)
9 Sec. 5. Definitions. In this Act:
10 "Authorized representative" means a person to whom a
11 beneficiary has given express written consent to represent the
12 beneficiary; a person authorized by law to provide substituted
13 consent for a beneficiary; or the beneficiary's treating
14 provider only when the beneficiary or his or her family member
15 is unable to provide consent.
16 "Beneficiary" means an individual, an enrollee, an
17 insured, a participant, or any other person entitled to
18 reimbursement for covered expenses of or the discounting of
19 provider fees for health care services under a program in
20 which the beneficiary has an incentive to utilize the services
21 of a provider that has entered into an agreement or
22 arrangement with an issuer insurer.
23 "Department" means the Department of Insurance.
24 "Essential community provider" has the meaning ascribed to
25 that term in 45 CFR 156.235.
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1 "Excepted benefits" has the meaning ascribed to that term
2 in 42 U.S.C. 300gg-91(c).
3 "Director" means the Director of Insurance.
4 "Family caregiver" means a relative, partner, friend, or
5 neighbor who has a significant relationship with the patient
6 and administers or assists the patient with activities of
7 daily living, instrumental activities of daily living, or
8 other medical or nursing tasks for the quality and welfare of
9 that patient.
10 "Group health plan" has the meaning ascribed to that term
11 in Section 5 of the Illinois Health Insurance Portability and
12 Accountability Act.
13 "Health insurance coverage" has the meaning ascribed to
14 that term in Section 5 of the Illinois Health Insurance
15 Portability and Accountability Act. "Health insurance
16 coverage" does not include any coverage or benefits under
17 Medicare or under the medical assistance program established
18 under Article V of the Illinois Public Aid Code.
19 "Issuer" means a "health insurance issuer" as defined in
20 Section 5 of the Illinois Health Insurance Portability and
21 Accountability Act.
22 "Insurer" means any entity that offers individual or group
23 accident and health insurance, including, but not limited to,
24 health maintenance organizations, preferred provider
25 organizations, exclusive provider organizations, and other
26 plan structures requiring network participation, excluding the
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1 medical assistance program under the Illinois Public Aid Code,
2 the State employees group health insurance program, workers
3 compensation insurance, and pharmacy benefit managers.
4 "Material change" means a significant reduction in the
5 number of providers available in a network plan, including,
6 but not limited to, a reduction of 10% or more in a specific
7 type of providers within any county, the removal of a major
8 health system that causes a network to be significantly
9 different within any county from the network when the
10 beneficiary purchased the network plan, or any change that
11 would cause the network to no longer satisfy the requirements
12 of this Act or the Department's rules for network adequacy and
13 transparency.
14 "Network" means the group or groups of preferred providers
15 providing services to a network plan.
16 "Network plan" means an individual or group policy of
17 accident and health insurance coverage that either requires a
18 covered person to use or creates incentives, including
19 financial incentives, for a covered person to use providers
20 managed, owned, under contract with, or employed by the issuer
21 or by a third party contracted to arrange, contract for, or
22 administer such provider-related incentives for the issuer
23 insurer.
24 "Ongoing course of treatment" means (1) treatment for a
25 life-threatening condition, which is a disease or condition
26 for which likelihood of death is probable unless the course of
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1 the disease or condition is interrupted; (2) treatment for a
2 serious acute condition, defined as a disease or condition
3 requiring complex ongoing care that the covered person is
4 currently receiving, such as chemotherapy, radiation therapy,
5 or post-operative visits, or a serious and complex condition
6 as defined under 42 U.S.C. 300gg-113(b)(2); (3) a course of
7 treatment for a health condition that a treating provider
8 attests that discontinuing care by that provider would worsen
9 the condition or interfere with anticipated outcomes; or (4)
10 the third trimester of pregnancy through the post-partum
11 period ; (5) undergoing a course of institutional or inpatient
12 care from the provider within the meaning of 42 U.S.C.
13 300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective
14 surgery from the provider, including receipt of postoperative
15 care from such provider with respect to such a surgery; or (7)
16 being determined to be terminally ill, as determined under 42
17 U.S.C. 1395x(dd)(3)(A), and receiving treatment for such
18 illness from such provider.
19 "Preferred provider" means any provider who has entered,
20 either directly or indirectly, into an agreement with an
21 employer or risk-bearing entity relating to health care
22 services that may be rendered to beneficiaries under a network
23 plan.
24 "Providers" means physicians licensed to practice medicine
25 in all its branches, other health care professionals,
26 hospitals, or other health care institutions or facilities
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1 that provide health care services.
2 "Short-term, limited-duration health insurance coverage"
3 has the meaning ascribed to that term in Section 5 of the
4 Short-Term, Limited-Duration Health Insurance Coverage Act.
5 "Stand-alone dental plan" has the meaning ascribed to that
6 term in 45 CFR 156.400.
7 "Telehealth" has the meaning given to that term in Section
8 356z.22 of the Illinois Insurance Code.
9 "Telemedicine" has the meaning given to that term in
10 Section 49.5 of the Medical Practice Act of 1987.
11 "Tiered network" means a network that identifies and
12 groups some or all types of provider and facilities into
13 specific groups to which different provider reimbursement,
14 covered person cost-sharing or provider access requirements,
15 or any combination thereof, apply for the same services.
16 "Woman's principal health care provider" means a physician
17 licensed to practice medicine in all of its branches
18 specializing in obstetrics, gynecology, or family practice.
19 (Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)
20 (215 ILCS 124/10)
21 Sec. 10. Network adequacy.
22 (a) Before issuing, delivering, or renewing a network
23 plan, an issuer An insurer providing a network plan shall file
24 a description of all of the following with the Director:
25 (1) The written policies and procedures for adding
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1 providers to meet patient needs based on increases in the
2 number of beneficiaries, changes in the
3 patient-to-provider ratio, changes in medical and health
4 care capabilities, and increased demand for services.
5 (2) The written policies and procedures for making
6 referrals within and outside the network.
7 (3) The written policies and procedures on how the
8 network plan will provide 24-hour, 7-day per week access
9 to network-affiliated primary care, emergency services,
10 and women's principal health care providers.
11 An issuer insurer shall not prohibit a preferred provider
12 from discussing any specific or all treatment options with
13 beneficiaries irrespective of the insurer's position on those
14 treatment options or from advocating on behalf of
15 beneficiaries within the utilization review, grievance, or
16 appeals processes established by the issuer insurer in
17 accordance with any rights or remedies available under
18 applicable State or federal law.
19 (b) Before issuing, delivering, or renewing a network
20 plan, an issuer Insurers must file for review a description of
21 the services to be offered through a network plan. The
22 description shall include all of the following:
23 (1) A geographic map of the area proposed to be served
24 by the plan by county service area and zip code, including
25 marked locations for preferred providers.
26 (2) As deemed necessary by the Department, the names,
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1 addresses, phone numbers, and specialties of the providers
2 who have entered into preferred provider agreements under
3 the network plan.
4 (3) The number of beneficiaries anticipated to be
5 covered by the network plan.
6 (4) An Internet website and toll-free telephone number
7 for beneficiaries and prospective beneficiaries to access
8 current and accurate lists of preferred providers,
9 additional information about the plan, as well as any
10 other information required by Department rule.
11 (5) A description of how health care services to be
12 rendered under the network plan are reasonably accessible
13 and available to beneficiaries. The description shall
14 address all of the following:
15 (A) the type of health care services to be
16 provided by the network plan;
17 (B) the ratio of physicians and other providers to
18 beneficiaries, by specialty and including primary care
19 physicians and facility-based physicians when
20 applicable under the contract, necessary to meet the
21 health care needs and service demands of the currently
22 enrolled population;
23 (C) the travel and distance standards for plan
24 beneficiaries in county service areas; and
25 (D) a description of how the use of telemedicine,
26 telehealth, or mobile care services may be used to
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1 partially meet the network adequacy standards, if
2 applicable.
3 (6) A provision ensuring that whenever a beneficiary
4 has made a good faith effort, as evidenced by accessing
5 the provider directory, calling the network plan, and
6 calling the provider, to utilize preferred providers for a
7 covered service and it is determined the insurer does not
8 have the appropriate preferred providers due to
9 insufficient number, type, unreasonable travel distance or
10 delay, or preferred providers refusing to provide a
11 covered service because it is contrary to the conscience
12 of the preferred providers, as protected by the Health
13 Care Right of Conscience Act, the issuer insurer shall
14 ensure, directly or indirectly, by terms contained in the
15 payer contract, that the beneficiary will be provided the
16 covered service at no greater cost to the beneficiary than
17 if the service had been provided by a preferred provider.
18 This paragraph (6) does not apply to: (A) a beneficiary
19 who willfully chooses to access a non-preferred provider
20 for health care services available through the panel of
21 preferred providers, or (B) a beneficiary enrolled in a
22 health maintenance organization. In these circumstances,
23 the contractual requirements for non-preferred provider
24 reimbursements shall apply unless Section 356z.3a of the
25 Illinois Insurance Code requires otherwise. In no event
26 shall a beneficiary who receives care at a participating
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1 health care facility be required to search for
2 participating providers under the circumstances described
3 in subsection (b) or (b-5) of Section 356z.3a of the
4 Illinois Insurance Code except under the circumstances
5 described in paragraph (2) of subsection (b-5).
6 (7) A provision that the beneficiary shall receive
7 emergency care coverage such that payment for this
8 coverage is not dependent upon whether the emergency
9 services are performed by a preferred or non-preferred
10 provider and the coverage shall be at the same benefit
11 level as if the service or treatment had been rendered by a
12 preferred provider. For purposes of this paragraph (7),
13 "the same benefit level" means that the beneficiary is
14 provided the covered service at no greater cost to the
15 beneficiary than if the service had been provided by a
16 preferred provider. This provision shall be consistent
17 with Section 356z.3a of the Illinois Insurance Code.
18 (8) A limitation that, if the plan provides that the
19 beneficiary will incur a penalty for failing to
20 pre-certify inpatient hospital treatment, the penalty may
21 not exceed $1,000 per occurrence in addition to the plan
22 cost sharing provisions.
23 (9) For a network plan in the individual or small group
24 market other than a grandfathered health plan, evidence that
25 the network plan:
26 (A) contracts with at least 35% of the essential
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1 community providers in the service area of the network
2 plan that are available to participate in the provider
3 network of the network plan, as calculated using the
4 methodology contained in the most recent Letter to Issuers
5 in the Federally-facilitated Marketplaces issued by the
6 federal Centers for Medicare and Medicaid Services. The
7 Director may specify a different percentage by rule.
8 (B) offers contracts in good faith to all available
9 Indian health care providers in the service area of the
10 network plan, including, without limitation, the Indian
11 Health Service, Indian tribes, tribal organizations, and
12 urban Indian organizations, as defined in 25 U.S.C. 1603,
13 which apply the special terms and conditions necessitated
14 by federal statutes and regulations as referenced in the
15 Model Qualified Health Plan Addendum for Indian Health
16 Care Providers issued by the federal Centers for Medicare
17 and Medicaid Services.
18 (C) offers contracts in good faith to at least one
19 essential community provider in each category of essential
20 community provider, as contained in the most recent Letter
21 to Issuers in the Federally-facilitated Marketplaces, in
22 each county in the service area of the network plan, where
23 an essential community provider in that category is
24 available and provides medical or dental services that are
25 covered by the network plan. To offer a contract in good
26 faith, a network plan must offer contract terms comparable
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1 to the terms that an issuer would offer to a similarly
2 situated provider that is not an essential community
3 provider, except for terms that would not be applicable to
4 an essential community provider, including, without
5 limitation, because of the type of services that an
6 essential community provider provides. A network plan must
7 be able to provide verification of such offers if the
8 Centers for Medicare and Medicaid Services of the United
9 States Department of Health and Human Services requests to
10 verify compliance with this policy.
11 (c) The issuer network plan shall demonstrate to the
12 Director a minimum ratio of providers to plan beneficiaries as
13 required by the Department for each network plan.
14 (1) The minimum ratio of physicians or other providers
15 to plan beneficiaries shall be established annually by the
16 Department in consultation with the Department of Public
17 Health based upon the guidance from the federal Centers
18 for Medicare and Medicaid Services. The Department shall
19 not establish ratios for vision or dental providers who
20 provide services under dental-specific or vision-specific
21 benefits, except to the extent provided under federal law
22 for stand-alone dental plans. The Department shall
23 consider establishing ratios for the following physicians
24 or other providers:
25 (A) Primary Care;
26 (B) Pediatrics;
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1 (C) Cardiology;
2 (D) Gastroenterology;
3 (E) General Surgery;
4 (F) Neurology;
5 (G) OB/GYN;
6 (H) Oncology/Radiation;
7 (I) Ophthalmology;
8 (J) Urology;
9 (K) Behavioral Health;
10 (L) Allergy/Immunology;
11 (M) Chiropractic;
12 (N) Dermatology;
13 (O) Endocrinology;
14 (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
15 (Q) Infectious Disease;
16 (R) Nephrology;
17 (S) Neurosurgery;
18 (T) Orthopedic Surgery;
19 (U) Physiatry/Rehabilitative;
20 (V) Plastic Surgery;
21 (W) Pulmonary;
22 (X) Rheumatology;
23 (Y) Anesthesiology;
24 (Z) Pain Medicine;
25 (AA) Pediatric Specialty Services;
26 (BB) Outpatient Dialysis; and
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1 (CC) HIV.
2 (2) The Director shall establish a process for the
3 review of the adequacy of these standards, along with an
4 assessment of additional specialties to be included in the
5 list under this subsection (c).
6 (3) Notwithstanding any other law or rule, the minimum
7 ratio for each provider type shall be no less than any such
8 ratio established for qualified health plans in
9 Federally-Facilitated Exchanges by federal law or by the
10 federal Centers for Medicare and Medicaid Services, even
11 if the network plan is issued in the large group market or
12 is otherwise not issued through an exchange. Federal
13 standards for stand-alone dental plans shall only apply to
14 such network plans. In the absence of an applicable
15 Department rule, the federal standards shall apply for the
16 time period specified in the federal law, regulation, or
17 guidance. If the Centers for Medicare and Medicaid
18 Services establish standards that are more stringent than
19 the standards in effect under any Department rule, the
20 Department may amend its rules to conform to the more
21 stringent federal standards.
22 (4) Prior to the enactment of an applicable Department
23 rule or the promulgation of federal standards for
24 qualified health plans or stand-alone dental plans, the
25 minimum ratios for any network plan issued, delivered,
26 amended, or renewed during 2024 shall be the following,
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1 expressed in terms of providers to beneficiaries for
2 health care professionals and in terms of providers per
3 county for facilities:
4 (A) primary care physician, general practice,
5 family practice, internal medicine, pediatrician,
6 primary care physician assistant, or primary care
7 nurse practitioner - 1:500;
8 (B) allergy/immunology - 1:15,000;
9 (C) cardiology - 1:10,000;
10 (D) chiropractic - 1:10,000;
11 (E) dermatology - 1:10,000;
12 (F) endocrinology - 1:10,000;
13 (G) ENT/otolaryngology - 1:15,000;
14 (H) gastroenterology - 1:10,000;
15 (I) general surgery - 1:5,000;
16 (J) gynecology or OB/GYN - 1:2,500;
17 (K) infectious diseases - 1:15,000;
18 (L) nephrology - 1:10,000;
19 (M) neurology - 1:20,000;
20 (N) oncology/radiation - 1:15,000;
21 (O) ophthalmology - 1:10,000;
22 (P) orthopedic surgery - 1:10,000;
23 (Q) physiatry/rehabilitative medicine - 1:15,000;
24 (R) plastic surgery - 1:20,000;
25 (S) behavioral health - 1:5,000;
26 (T) pulmonology - 1:10,000;
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1 (U) rheumatology - 1:10,000;
2 (V) urology - 1:10,000;
3 (W) acute inpatient hospital with emergency
4 services available 24 hours a day, 7 days a week - one
5 per county; and
6 (X) inpatient or residential behavioral health
7 facility - one per county.
8 (d) The network plan shall demonstrate to the Director
9 maximum travel and distance standards and appointment wait
10 time standards for plan beneficiaries, which shall be
11 established annually by the Department in consultation with
12 the Department of Public Health based upon the guidance from
13 the federal Centers for Medicare and Medicaid Services. These
14 standards shall consist of the maximum minutes or miles to be
15 traveled by a plan beneficiary for each county type, such as
16 large counties, metro counties, or rural counties as defined
17 by Department rule.
18 The maximum travel time and distance standards must
19 include standards for each physician and other provider
20 category listed for which ratios have been established.
21 The Director shall establish a process for the review of
22 the adequacy of these standards along with an assessment of
23 additional specialties to be included in the list under this
24 subsection (d).
25 Notwithstanding any other law or Department rule, the
26 maximum travel and distance standards and appointment wait
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1 time standards shall be no greater than any such standards
2 established for qualified health plans in
3 Federally-Facilitated Exchanges by federal law or by the
4 federal Centers for Medicare and Medicaid Services, even if
5 the network plan is issued in the large group market or is
6 otherwise not issued through an exchange. Federal standards
7 for stand-alone dental plans shall only apply to such network
8 plans. In the absence of an applicable Department rule, the
9 federal standards shall apply for the time period specified in
10 the federal law, regulation, or guidance. If the Centers for
11 Medicare and Medicaid Services establish standards that are
12 more stringent than the standards in effect under any
13 Department rule, the Department may amend its rules to conform
14 to the more stringent federal standards.
15 If the federal area designations for the maximum time or
16 distance or appointment wait time standards required are
17 changed by the most recent Letter to Issuers in the
18 Federally-facilitated Marketplaces, the Department shall post
19 on its website notice of such changes and may amend its rules
20 to conform to those designations if the Director deems
21 appropriate.
22 (d-5)(1) Every issuer insurer shall ensure that
23 beneficiaries have timely and proximate access to treatment
24 for mental, emotional, nervous, or substance use disorders or
25 conditions in accordance with the provisions of paragraph (4)
26 of subsection (a) of Section 370c of the Illinois Insurance
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1 Code. Issuers Insurers shall use a comparable process,
2 strategy, evidentiary standard, and other factors in the
3 development and application of the network adequacy standards
4 for timely and proximate access to treatment for mental,
5 emotional, nervous, or substance use disorders or conditions
6 and those for the access to treatment for medical and surgical
7 conditions. As such, the network adequacy standards for timely
8 and proximate access shall equally be applied to treatment
9 facilities and providers for mental, emotional, nervous, or
10 substance use disorders or conditions and specialists
11 providing medical or surgical benefits pursuant to the parity
12 requirements of Section 370c.1 of the Illinois Insurance Code
13 and the federal Paul Wellstone and Pete Domenici Mental Health
14 Parity and Addiction Equity Act of 2008. Notwithstanding the
15 foregoing, the network adequacy standards for timely and
16 proximate access to treatment for mental, emotional, nervous,
17 or substance use disorders or conditions shall, at a minimum,
18 satisfy the following requirements:
19 (A) For beneficiaries residing in the metropolitan
20 counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
21 network adequacy standards for timely and proximate access
22 to treatment for mental, emotional, nervous, or substance
23 use disorders or conditions means a beneficiary shall not
24 have to travel longer than 30 minutes or 30 miles from the
25 beneficiary's residence to receive outpatient treatment
26 for mental, emotional, nervous, or substance use disorders
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1 or conditions. Beneficiaries shall not be required to wait
2 longer than 10 business days between requesting an initial
3 appointment and being seen by the facility or provider of
4 mental, emotional, nervous, or substance use disorders or
5 conditions for outpatient treatment or to wait longer than
6 20 business days between requesting a repeat or follow-up
7 appointment and being seen by the facility or provider of
8 mental, emotional, nervous, or substance use disorders or
9 conditions for outpatient treatment; however, subject to
10 the protections of paragraph (3) of this subsection, a
11 network plan shall not be held responsible if the
12 beneficiary or provider voluntarily chooses to schedule an
13 appointment outside of these required time frames.
14 (B) For beneficiaries residing in Illinois counties
15 other than those counties listed in subparagraph (A) of
16 this paragraph, network adequacy standards for timely and
17 proximate access to treatment for mental, emotional,
18 nervous, or substance use disorders or conditions means a
19 beneficiary shall not have to travel longer than 60
20 minutes or 60 miles from the beneficiary's residence to
21 receive outpatient treatment for mental, emotional,
22 nervous, or substance use disorders or conditions.
23 Beneficiaries shall not be required to wait longer than 10
24 business days between requesting an initial appointment
25 and being seen by the facility or provider of mental,
26 emotional, nervous, or substance use disorders or
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1 conditions for outpatient treatment or to wait longer than
2 20 business days between requesting a repeat or follow-up
3 appointment and being seen by the facility or provider of
4 mental, emotional, nervous, or substance use disorders or
5 conditions for outpatient treatment; however, subject to
6 the protections of paragraph (3) of this subsection, a
7 network plan shall not be held responsible if the
8 beneficiary or provider voluntarily chooses to schedule an
9 appointment outside of these required time frames.
10 (2) For beneficiaries residing in all Illinois counties,
11 network adequacy standards for timely and proximate access to
12 treatment for mental, emotional, nervous, or substance use
13 disorders or conditions means a beneficiary shall not have to
14 travel longer than 60 minutes or 60 miles from the
15 beneficiary's residence to receive inpatient or residential
16 treatment for mental, emotional, nervous, or substance use
17 disorders or conditions.
18 (3) If there is no in-network facility or provider
19 available for a beneficiary to receive timely and proximate
20 access to treatment for mental, emotional, nervous, or
21 substance use disorders or conditions in accordance with the
22 network adequacy standards outlined in this subsection, the
23 issuer insurer shall provide necessary exceptions to its
24 network to ensure admission and treatment with a provider or
25 at a treatment facility in accordance with the network
26 adequacy standards in this subsection.
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1 (4) If the federal Centers for Medicare and Medicaid
2 Services establish or law requires more stringent standards
3 for qualified health plans in the Federally-Facilitated
4 Exchanges, the federal standards shall control for the time
5 period specified in the federal law, regulation, or guidance,
6 even if the network plan is issued in the large group market or
7 is otherwise not issued through an exchange.
8 (e) Except for network plans solely offered as a group
9 health plan, these ratio and time and distance standards apply
10 to the lowest cost-sharing tier of any tiered network.
11 (f) The network plan may consider use of other health care
12 service delivery options, such as telemedicine or telehealth,
13 mobile clinics, and centers of excellence, or other ways of
14 delivering care to partially meet the requirements set under
15 this Section.
16 (g) Except for the requirements set forth in subsection
17 (d-5), issuers insurers who are not able to comply with the
18 provider ratios and time and distance or appointment wait time
19 standards established under this Act by the Department may
20 request an exception to these requirements from the
21 Department. The Department may grant an exception in the
22 following circumstances:
23 (1) if no providers or facilities meet the specific
24 time and distance standard in a specific service area and
25 the issuer insurer (i) discloses information on the
26 distance and travel time points that beneficiaries would
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1 have to travel beyond the required criterion to reach the
2 next closest contracted provider outside of the service
3 area and (ii) provides contact information, including
4 names, addresses, and phone numbers for the next closest
5 contracted provider or facility;
6 (2) if patterns of care in the service area do not
7 support the need for the requested number of provider or
8 facility type and the issuer insurer provides data on
9 local patterns of care, such as claims data, referral
10 patterns, or local provider interviews, indicating where
11 the beneficiaries currently seek this type of care or
12 where the physicians currently refer beneficiaries, or
13 both; or
14 (3) other circumstances deemed appropriate by the
15 Department consistent with the requirements of this Act.
16 (h) Issuers Insurers are required to report to the
17 Director any material change to an approved network plan
18 within 15 days after the change occurs and any change that
19 would result in failure to meet the requirements of this Act.
20 The issuer shall submit a revised version of the complete
21 network adequacy filing based on the material change, and the
22 issuer shall attach versions with the changes indicated for
23 each document that was revised from the previous version of
24 the filing. Upon notice from the issuer insurer, the Director
25 shall reevaluate the network plan's compliance with the
26 network adequacy and transparency standards of this Act. For
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1 every day past 15 days that the issuer fails to submit a
2 revised network adequacy filing to the Director, the Director
3 shall order a fine of $1,000 per day.
4 (i) If a network plan is inadequate under this Act with
5 respect to a provider type in a county, and if the network plan
6 does not have an approved exception for that provider type in
7 that county pursuant to subsection (g), an issuer shall
8 process out-of-network claims for covered health care services
9 received from that provider type within that county at the
10 in-network benefit level and shall retroactively adjudicate
11 and reimburse beneficiaries to achieve that objective if their
12 claims were processed at the out-of-network level contrary to
13 this subsection.
14 (j) If the Director determines that a network is
15 inadequate in any county and no exception has been granted
16 under subsection (g) and the issuer does not have a process in
17 place to comply with subsection (d-5), the Director may
18 prohibit the network plan from being issued or renewed within
19 that county until the Director determines that the network is
20 adequate apart from processes and exceptions described in
21 subsections (d-5) and (g). Nothing in this subsection shall be
22 construed to terminate any beneficiary's health insurance
23 coverage under a network plan before the expiration of the
24 beneficiary's policy period if the Director makes a
25 determination under this subsection after the issuance or
26 renewal of the beneficiary's policy or certificate because of
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1 a material change. Policies or certificates issued or renewed
2 in violation of this subsection shall subject the issuer to a
3 civil penalty of $1,000 per policy.
4 (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
5 102-1117, eff. 1-13-23.)
6 (215 ILCS 124/15)
7 Sec. 15. Notice of nonrenewal or termination.
8 (a) A network plan must give at least 60 days' notice of
9 nonrenewal or termination of a provider to the provider and to
10 the beneficiaries served by the provider. The notice shall
11 include a name and address to which a beneficiary or provider
12 may direct comments and concerns regarding the nonrenewal or
13 termination and the telephone number maintained by the
14 Department for consumer complaints. Immediate written notice
15 may be provided without 60 days' notice when a provider's
16 license has been disciplined by a State licensing board or
17 when the network plan reasonably believes direct imminent
18 physical harm to patients under the provider's providers care
19 may occur. The notice to the beneficiary shall provide the
20 individual with an opportunity to notify the issuer of the
21 individual's need for transitional care.
22 (b) Primary care providers must notify active affected
23 patients of nonrenewal or termination of the provider from the
24 network plan, except in the case of incapacitation.
25 (Source: P.A. 100-502, eff. 9-15-17.)
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1 (215 ILCS 124/20)
2 Sec. 20. Transition of services.
3 (a) A network plan shall provide for continuity of care
4 for its beneficiaries as follows:
5 (1) If a beneficiary's physician or hospital provider
6 leaves the network plan's network of providers for reasons
7 other than termination of a contract in situations
8 involving imminent harm to a patient or a final
9 disciplinary action by a State licensing board and the
10 provider remains within the network plan's service area,
11 if benefits provided under such network plan with respect
12 to such provider or facility are terminated because of a
13 change in the terms of the participation of such provider
14 or facility in such plan, or if a contract between a group
15 health plan and a health insurance issuer offering a
16 network plan in connection with the group health plan is
17 terminated and results in a loss of benefits provided
18 under such plan with respect to such provider, then the
19 network plan shall permit the beneficiary to continue an
20 ongoing course of treatment with that provider during a
21 transitional period for the following duration:
22 (A) 90 days from the date of the notice to the
23 beneficiary of the provider's disaffiliation from the
24 network plan if the beneficiary has an ongoing course
25 of treatment; or
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1 (B) if the beneficiary has entered the third
2 trimester of pregnancy at the time of the provider's
3 disaffiliation, a period that includes the provision
4 of post-partum care directly related to the delivery.
5 (2) Notwithstanding the provisions of paragraph (1) of
6 this subsection (a), such care shall be authorized by the
7 network plan during the transitional period in accordance
8 with the following:
9 (A) the provider receives continued reimbursement
10 from the network plan at the rates and terms and
11 conditions applicable under the terminated contract
12 prior to the start of the transitional period;
13 (B) the provider adheres to the network plan's
14 quality assurance requirements, including provision to
15 the network plan of necessary medical information
16 related to such care; and
17 (C) the provider otherwise adheres to the network
18 plan's policies and procedures, including, but not
19 limited to, procedures regarding referrals and
20 obtaining preauthorizations for treatment.
21 (3) The provisions of this Section governing health
22 care provided during the transition period do not apply if
23 the beneficiary has successfully transitioned to another
24 provider participating in the network plan, if the
25 beneficiary has already met or exceeded the benefit
26 limitations of the plan, or if the care provided is not
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1 medically necessary.
2 (b) A network plan shall provide for continuity of care
3 for new beneficiaries as follows:
4 (1) If a new beneficiary whose provider is not a
5 member of the network plan's provider network, but is
6 within the network plan's service area, enrolls in the
7 network plan, the network plan shall permit the
8 beneficiary to continue an ongoing course of treatment
9 with the beneficiary's current physician during a
10 transitional period:
11 (A) of 90 days from the effective date of
12 enrollment if the beneficiary has an ongoing course of
13 treatment; or
14 (B) if the beneficiary has entered the third
15 trimester of pregnancy at the effective date of
16 enrollment, that includes the provision of post-partum
17 care directly related to the delivery.
18 (2) If a beneficiary, or a beneficiary's authorized
19 representative, elects in writing to continue to receive
20 care from such provider pursuant to paragraph (1) of this
21 subsection (b), such care shall be authorized by the
22 network plan for the transitional period in accordance
23 with the following:
24 (A) the provider receives reimbursement from the
25 network plan at rates established by the network plan;
26 (B) the provider adheres to the network plan's
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1 quality assurance requirements, including provision to
2 the network plan of necessary medical information
3 related to such care; and
4 (C) the provider otherwise adheres to the network
5 plan's policies and procedures, including, but not
6 limited to, procedures regarding referrals and
7 obtaining preauthorization for treatment.
8 (3) The provisions of this Section governing health
9 care provided during the transition period do not apply if
10 the beneficiary has successfully transitioned to another
11 provider participating in the network plan, if the
12 beneficiary has already met or exceeded the benefit
13 limitations of the plan, or if the care provided is not
14 medically necessary.
15 (c) In no event shall this Section be construed to require
16 a network plan to provide coverage for benefits not otherwise
17 covered or to diminish or impair preexisting condition
18 limitations contained in the beneficiary's contract.
19 (d) A provider shall comply with the requirements of 42
20 U.S.C. 300gg-138.
21 (Source: P.A. 100-502, eff. 9-15-17.)
22 (215 ILCS 124/25)
23 Sec. 25. Network transparency.
24 (a) A network plan shall post electronically an
25 up-to-date, accurate, and complete provider directory for each
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1 of its network plans, with the information and search
2 functions, as described in this Section.
3 (1) In making the directory available electronically,
4 the network plans shall ensure that the general public is
5 able to view all of the current providers for a plan
6 through a clearly identifiable link or tab and without
7 creating or accessing an account or entering a policy or
8 contract number.
9 (2) The network plan shall update the online provider
10 directory at least monthly. An issuer's failure to update
11 a network plan's directory shall subject the issuer to a
12 civil penalty of $5,000 per month. Providers shall notify
13 the network plan electronically or in writing of any
14 changes to their information as listed in the provider
15 directory, including the information required in
16 subparagraph (K) of paragraph (1) of subsection (b). If a
17 provider is no longer accepting new patients, the provider
18 must give notice to the issuer within 5 business days
19 after deciding to cease accepting new patients, or within
20 5 business days after the effective date of this
21 amendatory Act of the 103rd General Assembly, whichever is
22 later. The network plan shall update its online provider
23 directory in a manner consistent with the information
24 provided by the provider within 2 10 business days after
25 being notified of the change by the provider. Nothing in
26 this paragraph (2) shall void any contractual relationship
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1 between the provider and the plan.
2 (3) At least once every 90 days, the The network plan
3 shall audit each periodically at least 25% of its print
4 and online provider directories for accuracy, make any
5 corrections necessary, and retain documentation of the
6 audit. The network plan shall submit the audit to the
7 Director upon request. As part of these audits, the
8 network plan shall contact any provider in its network
9 that has not submitted a claim to the plan or otherwise
10 communicated his or her intent to continue participation
11 in the plan's network. The audits shall comply with 42
12 U.S.C. 300gg-115(a)(2), except that "provider directory
13 information" shall include all information required to be
14 included in a provider directory pursuant to this Act.
15 (4) A network plan shall provide a print copy of a
16 current provider directory or a print copy of the
17 requested directory information upon request of a
18 beneficiary or a prospective beneficiary. Print copies
19 must be updated quarterly and an errata that reflects
20 changes in the provider network must be updated quarterly.
21 (5) For each network plan, a network plan shall
22 include, in plain language in both the electronic and
23 print directory, the following general information:
24 (A) in plain language, a description of the
25 criteria the plan has used to build its provider
26 network;
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1 (B) if applicable, in plain language, a
2 description of the criteria the issuer insurer or
3 network plan has used to create tiered networks;
4 (C) if applicable, in plain language, how the
5 network plan designates the different provider tiers
6 or levels in the network and identifies for each
7 specific provider, hospital, or other type of facility
8 in the network which tier each is placed, for example,
9 by name, symbols, or grouping, in order for a
10 beneficiary-covered person or a prospective
11 beneficiary-covered person to be able to identify the
12 provider tier; and
13 (D) if applicable, a notation that authorization
14 or referral may be required to access some providers.
15 (6) A network plan shall make it clear for both its
16 electronic and print directories what provider directory
17 applies to which network plan, such as including the
18 specific name of the network plan as marketed and issued
19 in this State. The network plan shall include in both its
20 electronic and print directories a customer service email
21 address and telephone number or electronic link that
22 beneficiaries or the general public may use to notify the
23 network plan of inaccurate provider directory information
24 and contact information for the Department's Office of
25 Consumer Health Insurance.
26 (7) A provider directory, whether in electronic or
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1 print format, shall accommodate the communication needs of
2 individuals with disabilities, and include a link to or
3 information regarding available assistance for persons
4 with limited English proficiency.
5 (b) For each network plan, a network plan shall make
6 available through an electronic provider directory the
7 following information in a searchable format:
8 (1) for health care professionals:
9 (A) name;
10 (B) gender;
11 (C) participating office locations;
12 (D) specialty, if applicable;
13 (E) medical group affiliations, if applicable;
14 (F) facility affiliations, if applicable;
15 (G) participating facility affiliations, if
16 applicable;
17 (H) languages spoken other than English, if
18 applicable;
19 (I) whether accepting new patients;
20 (J) board certifications, if applicable; and
21 (K) use of telehealth or telemedicine, including,
22 but not limited to:
23 (i) whether the provider offers the use of
24 telehealth or telemedicine to deliver services to
25 patients for whom it would be clinically
26 appropriate;
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1 (ii) what modalities are used and what types
2 of services may be provided via telehealth or
3 telemedicine; and
4 (iii) whether the provider has the ability and
5 willingness to include in a telehealth or
6 telemedicine encounter a family caregiver who is
7 in a separate location than the patient if the
8 patient wishes and provides his or her consent;
9 (2) for hospitals:
10 (A) hospital name;
11 (B) hospital type (such as acute, rehabilitation,
12 children's, or cancer);
13 (C) participating hospital location; and
14 (D) hospital accreditation status; and
15 (3) for facilities, other than hospitals, by type:
16 (A) facility name;
17 (B) facility type;
18 (C) types of services performed; and
19 (D) participating facility location or locations,
20 including for each location where the health care
21 professional is at the location at least 3 days per
22 week.
23 (c) For the electronic provider directories, for each
24 network plan, a network plan shall make available all of the
25 following information in addition to the searchable
26 information required in this Section:
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1 (1) for health care professionals:
2 (A) contact information, including both a
3 telephone number and digital contact information if
4 the provider has supplied digital contact information;
5 and
6 (B) languages spoken other than English by
7 clinical staff, if applicable;
8 (2) for hospitals, telephone number and digital
9 contact information; and
10 (3) for facilities other than hospitals, telephone
11 number.
12 (d) The issuer insurer or network plan shall make
13 available in print, upon request, the following provider
14 directory information for the applicable network plan:
15 (1) for health care professionals:
16 (A) name;
17 (B) contact information, including telephone
18 number and digital contact information if the provider
19 has supplied digital contact information;
20 (C) participating office location or locations,
21 including for each location where the health care
22 professional is at the location at least 3 days per
23 week;
24 (D) specialty, if applicable;
25 (E) languages spoken other than English, if
26 applicable;
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1 (F) whether accepting new patients; and
2 (G) use of telehealth or telemedicine, including,
3 but not limited to:
4 (i) whether the provider offers the use of
5 telehealth or telemedicine to deliver services to
6 patients for whom it would be clinically
7 appropriate;
8 (ii) what modalities are used and what types
9 of services may be provided via telehealth or
10 telemedicine; and
11 (iii) whether the provider has the ability and
12 willingness to include in a telehealth or
13 telemedicine encounter a family caregiver who is
14 in a separate location than the patient if the
15 patient wishes and provides his or her consent;
16 (2) for hospitals:
17 (A) hospital name;
18 (B) hospital type (such as acute, rehabilitation,
19 children's, or cancer); and
20 (C) participating hospital location, and telephone
21 number, and digital contact information; and
22 (3) for facilities, other than hospitals, by type:
23 (A) facility name;
24 (B) facility type;
25 (C) types of services performed; and
26 (D) participating facility location or locations,
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1 and telephone numbers, and digital contact information
2 for each location.
3 (e) The network plan shall include a disclosure in the
4 print format provider directory that the information included
5 in the directory is accurate as of the date of printing and
6 that beneficiaries or prospective beneficiaries should consult
7 the issuer's insurer's electronic provider directory on its
8 website and contact the provider. The network plan shall also
9 include a telephone number in the print format provider
10 directory for a customer service representative where the
11 beneficiary can obtain current provider directory information.
12 (f) The Director may conduct periodic audits of the
13 accuracy of provider directories. A network plan shall not be
14 subject to any fines or penalties for information required in
15 this Section that a provider submits that is inaccurate or
16 incomplete.
17 (g) To the extent not otherwise provided in this Act, an
18 issuer shall comply with the requirements of 42 U.S.C.
19 300gg-115, except that "provider directory information" shall
20 include all information required to be included in a provider
21 directory pursuant to this Section.
22 (Source: P.A. 102-92, eff. 7-9-21.)
23 (215 ILCS 124/30)
24 Sec. 30. Administration and enforcement.
25 (a) Issuers Insurers, as defined in this Act, have a
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1 continuing obligation to comply with the requirements of this
2 Act. Other than the duties specifically created in this Act,
3 nothing in this Act is intended to preclude, prevent, or
4 require the adoption, modification, or termination of any
5 utilization management, quality management, or claims
6 processing methodologies of an issuer insurer.
7 (b) Nothing in this Act precludes, prevents, or requires
8 the adoption, modification, or termination of any network plan
9 term, benefit, coverage or eligibility provision, or payment
10 methodology.
11 (c) The Director shall enforce the provisions of this Act
12 pursuant to the enforcement powers granted to it by law.
13 (d) The Department shall adopt rules to enforce compliance
14 with this Act to the extent necessary.
15 (e) In accordance with Section 5-45.21 of the Illinois
16 Administrative Procedure Act, the Department may adopt
17 emergency rules to implement federal standards for provider
18 ratios, travel time and distance, and appointment wait times
19 if such standards apply to health insurance coverage regulated
20 by the Department and are more stringent than the State
21 standards extant at the time the final federal standards are
22 published.
23 (Source: P.A. 100-502, eff. 9-15-17.)
24 (215 ILCS 124/35 new)
25 Sec. 35. Provider requirements. Providers shall comply
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1 with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations
2 promulgated thereunder, as well as Section 20 and paragraph
3 (2) of subsection (a) of Section 25 of this Act, except that
4 "provider directory information" includes all information
5 required to be included in a provider directory pursuant to
6 Section 25 of this Act. To the extent a provider is licensed by
7 the Department of Financial and Professional Regulation or by
8 the Department of Public Health, that agency shall have the
9 authority to investigate, examine, process complaints, issue
10 subpoenas, examine witnesses under oath, issue a fine, or take
11 disciplinary action against the provider's license for
12 violations of these requirements in accordance with the
13 provider's applicable licensing statute.
14 (215 ILCS 124/40 new)
15 Sec. 40. Confidentiality.
16 (a) All records in the custody or possession of the
17 Department are presumed to be open to public inspection or
18 copying unless exempt from disclosure by Section 7 or 7.5 of
19 the Freedom of Information Act. Except as otherwise provided
20 in this Section or other applicable law, the filings required
21 under this Act shall be open to public inspection or copying.
22 (b) The following information shall not be deemed
23 confidential:
24 (1) actual or projected ratios of providers to
25 beneficiaries;
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1 (2) actual or projected time and distance between
2 network providers and beneficiaries or actual or projected
3 waiting times for a beneficiary to see a network provider;
4 (3) geographic maps of network providers;
5 (4) requests for exceptions under subsection (g) of
6 Section 10, except with respect to any discussion of
7 ongoing or planned contractual negotiations with providers
8 that the issuer requests to be treated as confidential;
9 and
10 (5) provider directories.
11 (c) An issuer's work papers and reports on the results of a
12 self-audit of its provider directories shall remain
13 confidential unless expressly waived by the insurer or unless
14 deemed public information under federal law.
15 (d) The filings required under Section 10 of this Act
16 shall be confidential while they remain under the Department's
17 review but shall become open to public inspection and copying
18 upon completion of the review, except as provided in this
19 Section or under other applicable law.
20 (e) Nothing in this Section shall supersede the statutory
21 requirement that work papers obtained during a market conduct
22 examination be deemed confidential.
23 Section 20. The Managed Care Reform and Patient Rights Act
24 is amended by changing Sections 20 and 25 as follows:
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1 (215 ILCS 134/20)
2 Sec. 20. Notice of nonrenewal or termination. A health
3 care plan must give at least 60 days notice of nonrenewal or
4 termination of a health care provider to the health care
5 provider and to the enrollees served by the health care
6 provider. The notice shall include a name and address to which
7 an enrollee or health care provider may direct comments and
8 concerns regarding the nonrenewal or termination. Immediate
9 written notice may be provided without 60 days notice when a
10 health care provider's license has been disciplined by a State
11 licensing board. The notice to the enrollee shall provide the
12 individual with an opportunity to notify the health care plan
13 of the individual's need for transitional care.
14 (Source: P.A. 91-617, eff. 1-1-00.)
15 (215 ILCS 134/25)
16 Sec. 25. Transition of services.
17 (a) A health care plan shall provide for continuity of
18 care for its enrollees as follows:
19 (1) If an enrollee's health care provider physician
20 leaves the health care plan's network of health care
21 providers for reasons other than termination of a contract
22 in situations involving imminent harm to a patient or a
23 final disciplinary action by a State licensing board and
24 the provider physician remains within the health care
25 plan's service area, or if benefits provided under such
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1 health care plan with respect to such provider are
2 terminated because of a change in the terms of the
3 participation of such provider in such plan, or if a
4 contract between a group health plan, as defined in
5 Section 5 of the Illinois Health Insurance Portability and
6 Accountability Act, and a health care plan offered
7 connection with the group health plan is terminated and
8 results in a loss of benefits provided under such plan
9 with respect to such provider, the health care plan shall
10 permit the enrollee to continue an ongoing course of
11 treatment with that provider physician during a
12 transitional period:
13 (A) of 90 days from the date of the notice of
14 provider's physician's termination from the health
15 care plan to the enrollee of the provider's
16 physician's disaffiliation from the health care plan
17 if the enrollee has an ongoing course of treatment; or
18 (B) if the enrollee has entered the third
19 trimester of pregnancy at the time of the provider's
20 physician's disaffiliation, that includes the
21 provision of post-partum care directly related to the
22 delivery.
23 (2) Notwithstanding the provisions in item (1) of this
24 subsection, such care shall be authorized by the health
25 care plan during the transitional period only if the
26 provider physician agrees:
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1 (A) to continue to accept reimbursement from the
2 health care plan at the rates applicable prior to the
3 start of the transitional period;
4 (B) to adhere to the health care plan's quality
5 assurance requirements and to provide to the health
6 care plan necessary medical information related to
7 such care; and
8 (C) to otherwise adhere to the health care plan's
9 policies and procedures, including but not limited to
10 procedures regarding referrals and obtaining
11 preauthorizations for treatment.
12 (3) During an enrollee's plan year, a health care plan
13 shall not remove a drug from its formulary or negatively
14 change its preferred or cost-tier sharing unless, at least
15 60 days before making the formulary change, the health
16 care plan:
17 (A) provides general notification of the change in
18 its formulary to current and prospective enrollees;
19 (B) directly notifies enrollees currently
20 receiving coverage for the drug, including information
21 on the specific drugs involved and the steps they may
22 take to request coverage determinations and
23 exceptions, including a statement that a certification
24 of medical necessity by the enrollee's prescribing
25 provider will result in continuation of coverage at
26 the existing level; and
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1 (C) directly notifies by first class mail and
2 through an electronic transmission, if available, the
3 prescribing provider of all health care plan enrollees
4 currently prescribed the drug affected by the proposed
5 change; the notice shall include a one-page form by
6 which the prescribing provider can notify the health
7 care plan by first class mail that coverage of the drug
8 for the enrollee is medically necessary.
9 The notification in paragraph (C) may direct the
10 prescribing provider to an electronic portal through which
11 the prescribing provider may electronically file a
12 certification to the health care plan that coverage of the
13 drug for the enrollee is medically necessary. The
14 prescribing provider may make a secure electronic
15 signature beside the words "certification of medical
16 necessity", and this certification shall authorize
17 continuation of coverage for the drug.
18 If the prescribing provider certifies to the health
19 care plan either in writing or electronically that the
20 drug is medically necessary for the enrollee as provided
21 in paragraph (C), a health care plan shall authorize
22 coverage for the drug prescribed based solely on the
23 prescribing provider's assertion that coverage is
24 medically necessary, and the health care plan is
25 prohibited from making modifications to the coverage
26 related to the covered drug, including, but not limited
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1 to:
2 (i) increasing the out-of-pocket costs for the
3 covered drug;
4 (ii) moving the covered drug to a more restrictive
5 tier; or
6 (iii) denying an enrollee coverage of the drug for
7 which the enrollee has been previously approved for
8 coverage by the health care plan.
9 Nothing in this item (3) prevents a health care plan
10 from removing a drug from its formulary or denying an
11 enrollee coverage if the United States Food and Drug
12 Administration has issued a statement about the drug that
13 calls into question the clinical safety of the drug, the
14 drug manufacturer has notified the United States Food and
15 Drug Administration of a manufacturing discontinuance or
16 potential discontinuance of the drug as required by
17 Section 506C of the Federal Food, Drug, and Cosmetic Act,
18 as codified in 21 U.S.C. 356c, or the drug manufacturer
19 has removed the drug from the market.
20 Nothing in this item (3) prohibits a health care plan,
21 by contract, written policy or procedure, or any other
22 agreement or course of conduct, from requiring a
23 pharmacist to effect substitutions of prescription drugs
24 consistent with Section 19.5 of the Pharmacy Practice Act,
25 under which a pharmacist may substitute an interchangeable
26 biologic for a prescribed biologic product, and Section 25
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1 of the Pharmacy Practice Act, under which a pharmacist may
2 select a generic drug determined to be therapeutically
3 equivalent by the United States Food and Drug
4 Administration and in accordance with the Illinois Food,
5 Drug and Cosmetic Act.
6 This item (3) applies to a policy or contract that is
7 amended, delivered, issued, or renewed on or after January
8 1, 2019. This item (3) does not apply to a health plan as
9 defined in the State Employees Group Insurance Act of 1971
10 or medical assistance under Article V of the Illinois
11 Public Aid Code.
12 (b) A health care plan shall provide for continuity of
13 care for new enrollees as follows:
14 (1) If a new enrollee whose physician is not a member
15 of the health care plan's provider network, but is within
16 the health care plan's service area, enrolls in the health
17 care plan, the health care plan shall permit the enrollee
18 to continue an ongoing course of treatment with the
19 enrollee's current physician during a transitional period:
20 (A) of 90 days from the effective date of
21 enrollment if the enrollee has an ongoing course of
22 treatment; or
23 (B) if the enrollee has entered the third
24 trimester of pregnancy at the effective date of
25 enrollment, that includes the provision of post-partum
26 care directly related to the delivery.
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1 (2) If an enrollee elects to continue to receive care
2 from such physician pursuant to item (1) of this
3 subsection, such care shall be authorized by the health
4 care plan for the transitional period only if the
5 physician agrees:
6 (A) to accept reimbursement from the health care
7 plan at rates established by the health care plan;
8 such rates shall be the level of reimbursement
9 applicable to similar physicians within the health
10 care plan for such services;
11 (B) to adhere to the health care plan's quality
12 assurance requirements and to provide to the health
13 care plan necessary medical information related to
14 such care; and
15 (C) to otherwise adhere to the health care plan's
16 policies and procedures including, but not limited to
17 procedures regarding referrals and obtaining
18 preauthorization for treatment.
19 (c) In no event shall this Section be construed to require
20 a health care plan to provide coverage for benefits not
21 otherwise covered or to diminish or impair preexisting
22 condition limitations contained in the enrollee's contract. In
23 no event shall this Section be construed to prohibit the
24 addition of prescription drugs to a health care plan's list of
25 covered drugs during the coverage year.
26 (d) In this Section, "ongoing course of treatment" has the
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1 meaning ascribed to that term in Section 5 of the Network
2 Adequacy and Transparency Act.
3 (Source: P.A. 100-1052, eff. 8-24-18.)
4 Section 99. Effective date. This Act takes effect upon
5 becoming law.
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
HB4126- 104 -LRB103 33572 RJT 63384 b HB4126 - 104 - LRB103 33572 RJT 63384 b
HB4126 - 104 - LRB103 33572 RJT 63384 b
1 INDEX
2 Statutes amended in order of appearance
HB4126 - 103 - LRB103 33572 RJT 63384 b
HB4126- 104 -LRB103 33572 RJT 63384 b HB4126 - 104 - LRB103 33572 RJT 63384 b
HB4126 - 104 - LRB103 33572 RJT 63384 b
1 INDEX
2 Statutes amended in order of appearance
HB4126 - 104 - LRB103 33572 RJT 63384 b