HB5313 EngrossedLRB103 38443 RPS 68579 b HB5313 Engrossed LRB103 38443 RPS 68579 b
HB5313 Engrossed LRB103 38443 RPS 68579 b
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 Network Adequacy and Transparency Act is
5 amended by changing Section 25 and by adding Section 35 as
6 follows:
7 (215 ILCS 124/25)
8 Sec. 25. Network transparency.
9 (a) A network plan shall post electronically an
10 up-to-date, accurate, and complete provider directory for each
11 of its network plans, with the information and search
12 functions, as described in this Section.
13 (1) In making the directory available electronically,
14 the network plans shall ensure that the general public is
15 able to view all of the current providers for a plan
16 through a clearly identifiable link or tab and without
17 creating or accessing an account or entering a policy or
18 contract number.
19 (2) The network plan shall update the online provider
20 directory at least monthly. Providers shall notify the
21 network plan electronically or in writing of any changes
22 to their information as listed in the provider directory,
23 including the information required in subparagraph (K) of
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1 paragraph (1) of subsection (b). The network plan shall
2 update its online provider directory in a manner
3 consistent with the information provided by the provider
4 within 10 business days after being notified of the change
5 by the provider. Nothing in this paragraph (2) shall void
6 any contractual relationship between the provider and the
7 plan.
8 (3) The network plan shall, at least annually, audit
9 periodically at least 25% of its provider directories for
10 accuracy, make any corrections necessary, and retain
11 documentation of the audit. The network plan shall submit
12 the audit to the Department, and the Department shall make
13 the audit publicly available Director upon request. As
14 part of these audits, the network plan shall contact any
15 provider in its network that has not submitted a claim to
16 the plan or otherwise communicated his or her intent to
17 continue participation in the plan's network.
18 (4) A network plan shall provide a printed print copy
19 of a current provider directory or a printed print copy of
20 the requested directory information upon request of a
21 beneficiary or a prospective beneficiary. Printed Print
22 copies must be updated quarterly and an errata that
23 reflects changes in the provider network must be updated
24 quarterly.
25 (5) For each network plan, a network plan shall
26 include, in plain language in both the electronic and
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1 print directory, the following general information:
2 (A) in plain language, a description of the
3 criteria the plan has used to build its provider
4 network;
5 (B) if applicable, in plain language, a
6 description of the criteria the insurer or network
7 plan has used to create tiered networks;
8 (C) if applicable, in plain language, how the
9 network plan designates the different provider tiers
10 or levels in the network and identifies for each
11 specific provider, hospital, or other type of facility
12 in the network which tier each is placed, for example,
13 by name, symbols, or grouping, in order for a
14 beneficiary-covered person or a prospective
15 beneficiary-covered person to be able to identify the
16 provider tier; and
17 (D) if applicable, a notation that authorization
18 or referral may be required to access some providers; .
19 (E) a telephone number and email address for a
20 customer service representative to whom directory
21 inaccuracies may be reported; and
22 (F) a
detailed description of the process to
23 dispute charges for out-of-network providers or
24 facilities that were incorrectly listed as in-network
25 prior to the provision of care and a telephone number
26 and email address to dispute such charges.
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1 (6) A network plan shall make it clear for both its
2 electronic and print directories what provider directory
3 applies to which network plan, such as including the
4 specific name of the network plan as marketed and issued
5 in this State. The network plan shall include in both its
6 electronic and print directories a customer service email
7 address and telephone number or electronic link that
8 beneficiaries or the general public may use to notify the
9 network plan of inaccurate provider directory information
10 and contact information for the Department's Office of
11 Consumer Health Insurance.
12 (7) A provider directory, whether in electronic or
13 print format, shall accommodate the communication needs of
14 individuals with disabilities, and include a link to or
15 information regarding available assistance for persons
16 with limited English proficiency.
17 (b) For each network plan, a network plan shall make
18 available through an electronic provider directory the
19 following information in a searchable format:
20 (1) for health care professionals:
21 (A) name;
22 (B) gender;
23 (C) participating office locations;
24 (D) patient population served (such as pediatric,
25 adult, elderly, or women) and specialty or
26 subspecialty, if applicable;
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1 (E) medical group affiliations, if applicable;
2 (F) facility affiliations, if applicable;
3 (G) participating facility affiliations, if
4 applicable;
5 (H) languages spoken other than English, if
6 applicable;
7 (I) whether accepting new patients;
8 (J) board certifications, if applicable; and
9 (K) use of telehealth or telemedicine, including,
10 but not limited to:
11 (i) whether the provider offers the use of
12 telehealth or telemedicine to deliver services to
13 patients for whom it would be clinically
14 appropriate;
15 (ii) what modalities are used and what types
16 of services may be provided via telehealth or
17 telemedicine; and
18 (iii) whether the provider has the ability and
19 willingness to include in a telehealth or
20 telemedicine encounter a family caregiver who is
21 in a separate location than the patient if the
22 patient wishes and provides his or her consent;
23 and
24 (L) the anticipated date the provider will leave
25 the network, if applicable, which shall be included
26 not more than 10 days after the network provides
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1 notice in accordance with Section 15 of this Act; and
2 (2) for hospitals:
3 (A) hospital name;
4 (B) hospital type (such as acute, rehabilitation,
5 children's, or cancer);
6 (C) participating hospital location; and
7 (D) hospital accreditation status; and
8 (3) for facilities, other than hospitals, by type:
9 (A) facility name;
10 (B) facility type;
11 (C) types of services performed; and
12 (D) participating facility location or locations;
13 and .
14 (E) the anticipated date the facility will leave
15 the network, if applicable, which shall be included
16 not more than 10 days after the network confirms the
17 facility is scheduled to leave the network.
18 (c) For the electronic provider directories, for each
19 network plan, a network plan shall make available all of the
20 following information in addition to the searchable
21 information required in this Section:
22 (1) for health care professionals:
23 (A) contact information; and
24 (B) languages spoken other than English by
25 clinical staff, if applicable;
26 (2) for hospitals, telephone number; and
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1 (3) for facilities other than hospitals, telephone
2 number.
3 (d) The insurer or network plan shall make available in
4 print, upon request, the following provider directory
5 information for the applicable network plan:
6 (1) for health care professionals:
7 (A) name;
8 (B) contact information;
9 (C) participating office location or locations;
10 (D) patient population (such as pediatric, adult,
11 elderly, or women) and specialty or subspecialty, if
12 applicable;
13 (E) languages spoken other than English, if
14 applicable;
15 (F) whether accepting new patients; and
16 (G) use of telehealth or telemedicine, including,
17 but not limited to:
18 (i) whether the provider offers the use of
19 telehealth or telemedicine to deliver services to
20 patients for whom it would be clinically
21 appropriate;
22 (ii) what modalities are used and what types
23 of services may be provided via telehealth or
24 telemedicine; and
25 (iii) whether the provider has the ability and
26 willingness to include in a telehealth or
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1 telemedicine encounter a family caregiver who is
2 in a separate location than the patient if the
3 patient wishes and provides his or her consent;
4 (2) for hospitals:
5 (A) hospital name;
6 (B) hospital type (such as acute, rehabilitation,
7 children's, or cancer); and
8 (C) participating hospital location and telephone
9 number; and
10 (3) for facilities, other than hospitals, by type:
11 (A) facility name;
12 (B) facility type;
13 (C) types of services performed; and
14 (D) participating facility location or locations
15 and telephone numbers.
16 (e) The network plan shall include a disclosure in the
17 print format provider directory that the information included
18 in the directory is accurate as of the date of printing and
19 that beneficiaries or prospective beneficiaries should consult
20 the insurer's electronic provider directory on its website and
21 contact the provider. The network plan shall also include a
22 telephone number and email address in the print format
23 provider directory for a customer service representative where
24 the beneficiary can obtain current provider directory
25 information or report directory inaccuracies. The network plan
26 shall include in the print format provider directory a
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1 detailed description of the process to dispute charges for
2 out-of-network providers or facilities that were incorrectly
3 listed as in-network prior to the provision of care and a
4 telephone number and email address to dispute those charges.
5 (f) The Director may conduct periodic audits of the
6 accuracy of provider directories and shall conduct random
7 audits of at least 10% of plans each year. A network plan shall
8 not be subject to any fines or penalties for information
9 required in this Section that a provider submits that is
10 inaccurate or incomplete.
11 (Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
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