Illinois 2023-2024 Regular Session

Illinois House Bill HB5313 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	HB5313 EngrossedLRB103 38443 RPS 68579 b HB5313 Engrossed LRB103 38443 RPS 68579 b
2		-	HB5313 Engrossed LRB103 38443 RPS 68579 b
	1	+	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5313 Introduced , by Rep. Margaret Croke SYNOPSIS AS INTRODUCED: 215 ILCS 124/25215 ILCS 124/35 new Amends the Network Adequacy and Transparency Act. Provides that a network plan shall, at least annually, audit (instead of audit periodically) at least 25% of its provider directories for accuracy, make any corrections necessary, and retain documentation of the audit. Provides that the network plan shall submit the audit to the Department of Insurance (instead of to the Director of Insurance upon request). Provides that the Department shall make the audit publicly available. Provides that a network plan shall include in the print format provider directory (i) a detailed description of the process to dispute charges for out-of-network providers or facilities that were incorrectly listed as in-network prior to the provision of care and (ii) a telephone number and email address to dispute those charges. Makes changes to the information that must be provided in a network plan's electronic and print directory. Requires the Director to conduct random audits of the accuracy of provider directories for at least 10% of plans each year. Provides that a consumer who incurs a cost for inappropriate out-of-network charges for a provider, facility, or hospital that was listed as in-network prior to the provision of services may file a verified complaint with the Department, and the Department shall conduct an investigation of the verified complaint and determine whether the complaint is sufficient. Provides that, upon a finding of sufficiency, the Director shall have the authority to levy a fine for not less than the cost incurred by the consumer for inappropriate out-of-network charges for a provider, facility, or hospital that was listed in-network. Provides that the fines collected by the Director shall be remitted to the consumer. LRB103 38443 RPS 68579 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5313 Introduced , by Rep. Margaret Croke SYNOPSIS AS INTRODUCED: 215 ILCS 124/25215 ILCS 124/35 new 215 ILCS 124/25 215 ILCS 124/35 new Amends the Network Adequacy and Transparency Act. Provides that a network plan shall, at least annually, audit (instead of audit periodically) at least 25% of its provider directories for accuracy, make any corrections necessary, and retain documentation of the audit. Provides that the network plan shall submit the audit to the Department of Insurance (instead of to the Director of Insurance upon request). Provides that the Department shall make the audit publicly available. Provides that a network plan shall include in the print format provider directory (i) a detailed description of the process to dispute charges for out-of-network providers or facilities that were incorrectly listed as in-network prior to the provision of care and (ii) a telephone number and email address to dispute those charges. Makes changes to the information that must be provided in a network plan's electronic and print directory. Requires the Director to conduct random audits of the accuracy of provider directories for at least 10% of plans each year. Provides that a consumer who incurs a cost for inappropriate out-of-network charges for a provider, facility, or hospital that was listed as in-network prior to the provision of services may file a verified complaint with the Department, and the Department shall conduct an investigation of the verified complaint and determine whether the complaint is sufficient. Provides that, upon a finding of sufficiency, the Director shall have the authority to levy a fine for not less than the cost incurred by the consumer for inappropriate out-of-network charges for a provider, facility, or hospital that was listed in-network. Provides that the fines collected by the Director shall be remitted to the consumer. LRB103 38443 RPS 68579 b LRB103 38443 RPS 68579 b A BILL FOR
	2	+	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5313 Introduced , by Rep. Margaret Croke SYNOPSIS AS INTRODUCED:
	3	+	215 ILCS 124/25215 ILCS 124/35 new 215 ILCS 124/25 215 ILCS 124/35 new
	4	+	215 ILCS 124/25
	5	+	215 ILCS 124/35 new
	6	+	Amends the Network Adequacy and Transparency Act. Provides that a network plan shall, at least annually, audit (instead of audit periodically) at least 25% of its provider directories for accuracy, make any corrections necessary, and retain documentation of the audit. Provides that the network plan shall submit the audit to the Department of Insurance (instead of to the Director of Insurance upon request). Provides that the Department shall make the audit publicly available. Provides that a network plan shall include in the print format provider directory (i) a detailed description of the process to dispute charges for out-of-network providers or facilities that were incorrectly listed as in-network prior to the provision of care and (ii) a telephone number and email address to dispute those charges. Makes changes to the information that must be provided in a network plan's electronic and print directory. Requires the Director to conduct random audits of the accuracy of provider directories for at least 10% of plans each year. Provides that a consumer who incurs a cost for inappropriate out-of-network charges for a provider, facility, or hospital that was listed as in-network prior to the provision of services may file a verified complaint with the Department, and the Department shall conduct an investigation of the verified complaint and determine whether the complaint is sufficient. Provides that, upon a finding of sufficiency, the Director shall have the authority to levy a fine for not less than the cost incurred by the consumer for inappropriate out-of-network charges for a provider, facility, or hospital that was listed in-network. Provides that the fines collected by the Director shall be remitted to the consumer.
	7	+	LRB103 38443 RPS 68579 b LRB103 38443 RPS 68579 b
	8	+	LRB103 38443 RPS 68579 b
	9	+	A BILL FOR
	10	+	HB5313LRB103 38443 RPS 68579 b HB5313 LRB103 38443 RPS 68579 b
	11	+	HB5313 LRB103 38443 RPS 68579 b
3	12		1 AN ACT concerning regulation.
4	13		2 Be it enacted by the People of the State of Illinois,
5	14		3 represented in the General Assembly:
6	15		4 Section 5. The Network Adequacy and Transparency Act is
7	16		5 amended by changing Section 25 and by adding Section 35 as
8	17		6 follows:
9	18		7 (215 ILCS 124/25)
10	19		8 Sec. 25. Network transparency.
11	20		9 (a) A network plan shall post electronically an
12	21		10 up-to-date, accurate, and complete provider directory for each
13	22		11 of its network plans, with the information and search
14	23		12 functions, as described in this Section.
15	24		13 (1) In making the directory available electronically,
16	25		14 the network plans shall ensure that the general public is
17	26		15 able to view all of the current providers for a plan
18	27		16 through a clearly identifiable link or tab and without
19	28		17 creating or accessing an account or entering a policy or
20	29		18 contract number.
21	30		19 (2) The network plan shall update the online provider
22	31		20 directory at least monthly. Providers shall notify the
23	32		21 network plan electronically or in writing of any changes
24	33		22 to their information as listed in the provider directory,
25	34		23 including the information required in subparagraph (K) of
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29		-	HB5313 Engrossed LRB103 38443 RPS 68579 b
	38	+	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5313 Introduced , by Rep. Margaret Croke SYNOPSIS AS INTRODUCED:
	39	+	215 ILCS 124/25215 ILCS 124/35 new 215 ILCS 124/25 215 ILCS 124/35 new
	40	+	215 ILCS 124/25
	41	+	215 ILCS 124/35 new
	42	+	Amends the Network Adequacy and Transparency Act. Provides that a network plan shall, at least annually, audit (instead of audit periodically) at least 25% of its provider directories for accuracy, make any corrections necessary, and retain documentation of the audit. Provides that the network plan shall submit the audit to the Department of Insurance (instead of to the Director of Insurance upon request). Provides that the Department shall make the audit publicly available. Provides that a network plan shall include in the print format provider directory (i) a detailed description of the process to dispute charges for out-of-network providers or facilities that were incorrectly listed as in-network prior to the provision of care and (ii) a telephone number and email address to dispute those charges. Makes changes to the information that must be provided in a network plan's electronic and print directory. Requires the Director to conduct random audits of the accuracy of provider directories for at least 10% of plans each year. Provides that a consumer who incurs a cost for inappropriate out-of-network charges for a provider, facility, or hospital that was listed as in-network prior to the provision of services may file a verified complaint with the Department, and the Department shall conduct an investigation of the verified complaint and determine whether the complaint is sufficient. Provides that, upon a finding of sufficiency, the Director shall have the authority to levy a fine for not less than the cost incurred by the consumer for inappropriate out-of-network charges for a provider, facility, or hospital that was listed in-network. Provides that the fines collected by the Director shall be remitted to the consumer.
	43	+	LRB103 38443 RPS 68579 b LRB103 38443 RPS 68579 b
	44	+	LRB103 38443 RPS 68579 b
	45	+	A BILL FOR
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	51	+	215 ILCS 124/25
	52	+	215 ILCS 124/35 new
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34	71		1 paragraph (1) of subsection (b). The network plan shall
35	72		2 update its online provider directory in a manner
36	73		3 consistent with the information provided by the provider
37	74		4 within 10 business days after being notified of the change
38	75		5 by the provider. Nothing in this paragraph (2) shall void
39	76		6 any contractual relationship between the provider and the
40	77		7 plan.
41	78		8 (3) The network plan shall, at least annually, audit
42	79		9 periodically at least 25% of its provider directories for
43	80		10 accuracy, make any corrections necessary, and retain
44	81		11 documentation of the audit. The network plan shall submit
45	82		12 the audit to the Department, and the Department shall make
46	83		13 the audit publicly available Director upon request. As
47	84		14 part of these audits, the network plan shall contact any
48	85		15 provider in its network that has not submitted a claim to
49	86		16 the plan or otherwise communicated his or her intent to
50	87		17 continue participation in the plan's network.
51	88		18 (4) A network plan shall provide a printed print copy
52	89		19 of a current provider directory or a printed print copy of
53	90		20 the requested directory information upon request of a
54	91		21 beneficiary or a prospective beneficiary. Printed Print
55	92		22 copies must be updated quarterly and an errata that
56	93		23 reflects changes in the provider network must be updated
57	94		24 quarterly.
58	95		25 (5) For each network plan, a network plan shall
59	96		26 include, in plain language in both the electronic and
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70	107		1 print directory, the following general information:
71	108		2 (A) in plain language, a description of the
72	109		3 criteria the plan has used to build its provider
73	110		4 network;
74	111		5 (B) if applicable, in plain language, a
75	112		6 description of the criteria the insurer or network
76	113		7 plan has used to create tiered networks;
77	114		8 (C) if applicable, in plain language, how the
78	115		9 network plan designates the different provider tiers
79	116		10 or levels in the network and identifies for each
80	117		11 specific provider, hospital, or other type of facility
81	118		12 in the network which tier each is placed, for example,
82	119		13 by name, symbols, or grouping, in order for a
83	120		14 beneficiary-covered person or a prospective
84	121		15 beneficiary-covered person to be able to identify the
85	122		16 provider tier; and
86	123		17 (D) if applicable, a notation that authorization
87	124		18 or referral may be required to access some providers; .
88	125		19 (E) a telephone number and email address for a
89	126		20 customer service representative to whom directory
90	127		21 inaccuracies may be reported; and
91	128		22 (F) a
92	129		detailed description of the process to
93	130		23 dispute charges for out-of-network providers or
94	131		24 facilities that were incorrectly listed as in-network
95	132		25 prior to the provision of care and a telephone number
96	133		26 and email address to dispute such charges.
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107	144		1 (6) A network plan shall make it clear for both its
108	145		2 electronic and print directories what provider directory
109	146		3 applies to which network plan, such as including the
110	147		4 specific name of the network plan as marketed and issued
111	148		5 in this State. The network plan shall include in both its
112	149		6 electronic and print directories a customer service email
113	150		7 address and telephone number or electronic link that
114	151		8 beneficiaries or the general public may use to notify the
115	152		9 network plan of inaccurate provider directory information
116	153		10 and contact information for the Department's Office of
117	154		11 Consumer Health Insurance.
118	155		12 (7) A provider directory, whether in electronic or
119	156		13 print format, shall accommodate the communication needs of
120	157		14 individuals with disabilities, and include a link to or
121	158		15 information regarding available assistance for persons
122	159		16 with limited English proficiency.
123	160		17 (b) For each network plan, a network plan shall make
124	161		18 available through an electronic provider directory the
125	162		19 following information in a searchable format:
126	163		20 (1) for health care professionals:
127	164		21 (A) name;
128	165		22 (B) gender;
129	166		23 (C) participating office locations;
130	167		24 (D) patient population served (such as pediatric,
131	168		25 adult, elderly, or women) and specialty or
132	169		26 subspecialty, if applicable;
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143	180		1 (E) medical group affiliations, if applicable;
144	181		2 (F) facility affiliations, if applicable;
145	182		3 (G) participating facility affiliations, if
146	183		4 applicable;
147	184		5 (H) languages spoken other than English, if
148	185		6 applicable;
149	186		7 (I) whether accepting new patients;
150	187		8 (J) board certifications, if applicable; and
151	188		9 (K) use of telehealth or telemedicine, including,
152	189		10 but not limited to:
153	190		11 (i) whether the provider offers the use of
154	191		12 telehealth or telemedicine to deliver services to
155	192		13 patients for whom it would be clinically
156	193		14 appropriate;
157	194		15 (ii) what modalities are used and what types
158	195		16 of services may be provided via telehealth or
159	196		17 telemedicine; and
160	197		18 (iii) whether the provider has the ability and
161	198		19 willingness to include in a telehealth or
162	199		20 telemedicine encounter a family caregiver who is
163	200		21 in a separate location than the patient if the
164	201		22 patient wishes and provides his or her consent;
165	202		23 and
166	203		24 (L) the anticipated date the provider will leave
167	204		25 the network, if applicable, which shall be included
168	205		26 not more than 10 days after the network provides
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179	216		1 notice in accordance with Section 15 of this Act; and
180	217		2 (2) for hospitals:
181	218		3 (A) hospital name;
182	219		4 (B) hospital type (such as acute, rehabilitation,
183	220		5 children's, or cancer);
184	221		6 (C) participating hospital location; and
185	222		7 (D) hospital accreditation status; and
186	223		8 (3) for facilities, other than hospitals, by type:
187	224		9 (A) facility name;
188	225		10 (B) facility type;
189	226		11 (C) types of services performed; and
190	227		12 (D) participating facility location or locations;
191	228		13 and .
192	229		14 (E) the anticipated date the facility will leave
193	230		15 the network, if applicable, which shall be included
194	231		16 not more than 10 days after the network confirms the
195	232		17 facility is scheduled to leave the network.
196	233		18 (c) For the electronic provider directories, for each
197	234		19 network plan, a network plan shall make available all of the
198	235		20 following information in addition to the searchable
199	236		21 information required in this Section:
200	237		22 (1) for health care professionals:
201	238		23 (A) contact information; and
202	239		24 (B) languages spoken other than English by
203	240		25 clinical staff, if applicable;
204	241		26 (2) for hospitals, telephone number; and
205	242
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215	252		1 (3) for facilities other than hospitals, telephone
216	253		2 number.
217	254		3 (d) The insurer or network plan shall make available in
218	255		4 print, upon request, the following provider directory
219	256		5 information for the applicable network plan:
220	257		6 (1) for health care professionals:
221	258		7 (A) name;
222	259		8 (B) contact information;
223	260		9 (C) participating office location or locations;
224	261		10 (D) patient population (such as pediatric, adult,
225	262		11 elderly, or women) and specialty or subspecialty, if
226	263		12 applicable;
227	264		13 (E) languages spoken other than English, if
228	265		14 applicable;
229	266		15 (F) whether accepting new patients; and
230	267		16 (G) use of telehealth or telemedicine, including,
231	268		17 but not limited to:
232	269		18 (i) whether the provider offers the use of
233	270		19 telehealth or telemedicine to deliver services to
234	271		20 patients for whom it would be clinically
235	272		21 appropriate;
236	273		22 (ii) what modalities are used and what types
237	274		23 of services may be provided via telehealth or
238	275		24 telemedicine; and
239	276		25 (iii) whether the provider has the ability and
240	277		26 willingness to include in a telehealth or
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251	288		1 telemedicine encounter a family caregiver who is
252	289		2 in a separate location than the patient if the
253	290		3 patient wishes and provides his or her consent;
254	291		4 (2) for hospitals:
255	292		5 (A) hospital name;
256	293		6 (B) hospital type (such as acute, rehabilitation,
257	294		7 children's, or cancer); and
258	295		8 (C) participating hospital location and telephone
259	296		9 number; and
260	297		10 (3) for facilities, other than hospitals, by type:
261	298		11 (A) facility name;
262	299		12 (B) facility type;
263	300		13 (C) types of services performed; and
264	301		14 (D) participating facility location or locations
265	302		15 and telephone numbers.
266	303		16 (e) The network plan shall include a disclosure in the
267	304		17 print format provider directory that the information included
268	305		18 in the directory is accurate as of the date of printing and
269	306		19 that beneficiaries or prospective beneficiaries should consult
270	307		20 the insurer's electronic provider directory on its website and
271	308		21 contact the provider. The network plan shall also include a
272	309		22 telephone number and email address in the print format
273	310		23 provider directory for a customer service representative where
274	311		24 the beneficiary can obtain current provider directory
275	312		25 information or report directory inaccuracies. The network plan
276	313		26 shall include in the print format provider directory a
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287	324		1 detailed description of the process to dispute charges for
288	325		2 out-of-network providers or facilities that were incorrectly
289	326		3 listed as in-network prior to the provision of care and a
290	327		4 telephone number and email address to dispute those charges.
291	328		5 (f) The Director may conduct periodic audits of the
292	329		6 accuracy of provider directories and shall conduct random
293	330		7 audits of at least 10% of plans each year. A network plan shall
294	331		8 not be subject to any fines or penalties for information
295	332		9 required in this Section that a provider submits that is
296	333		10 inaccurate or incomplete.
297	334		11 (Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
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