Illinois 2023-2024 Regular Session

Illinois House Bill HB5801 Compare Versions

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

Old	New	Differences
1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5801 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED: 215 ILCS 124/10 Amends the Network Adequacy and Transparency Act. Provides that the Department of Insurance shall consider establishing ratios for providers of genetic medicine and genetic counseling. LRB103 39930 RPS 70997 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5801 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED: 215 ILCS 124/10 215 ILCS 124/10 Amends the Network Adequacy and Transparency Act. Provides that the Department of Insurance shall consider establishing ratios for providers of genetic medicine and genetic counseling. LRB103 39930 RPS 70997 b LRB103 39930 RPS 70997 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5801 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED:
3	3	215 ILCS 124/10 215 ILCS 124/10
4	4	215 ILCS 124/10
5	5	Amends the Network Adequacy and Transparency Act. Provides that the Department of Insurance shall consider establishing ratios for providers of genetic medicine and genetic counseling.
6	6	LRB103 39930 RPS 70997 b LRB103 39930 RPS 70997 b
7	7	LRB103 39930 RPS 70997 b
8	8	A BILL FOR
9	9	HB5801LRB103 39930 RPS 70997 b HB5801 LRB103 39930 RPS 70997 b
10	10	HB5801 LRB103 39930 RPS 70997 b
11	11	1 AN ACT concerning regulation.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Network Adequacy and Transparency Act is
15	15	5 amended by changing Section 10 as follows:
16	16	6 (215 ILCS 124/10)
17	17	7 Sec. 10. Network adequacy.
18	18	8 (a) An insurer providing a network plan shall file a
19	19	9 description of all of the following with the Director:
20	20	10 (1) The written policies and procedures for adding
21	21	11 providers to meet patient needs based on increases in the
22	22	12 number of beneficiaries, changes in the
23	23	13 patient-to-provider ratio, changes in medical and health
24	24	14 care capabilities, and increased demand for services.
25	25	15 (2) The written policies and procedures for making
26	26	16 referrals within and outside the network.
27	27	17 (3) The written policies and procedures on how the
28	28	18 network plan will provide 24-hour, 7-day per week access
29	29	19 to network-affiliated primary care, emergency services,
30	30	20 and women's principal health care providers.
31	31	21 An insurer shall not prohibit a preferred provider from
32	32	22 discussing any specific or all treatment options with
33	33	23 beneficiaries irrespective of the insurer's position on those
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5801 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED:
38	38	215 ILCS 124/10 215 ILCS 124/10
39	39	215 ILCS 124/10
40	40	Amends the Network Adequacy and Transparency Act. Provides that the Department of Insurance shall consider establishing ratios for providers of genetic medicine and genetic counseling.
41	41	LRB103 39930 RPS 70997 b LRB103 39930 RPS 70997 b
42	42	LRB103 39930 RPS 70997 b
43	43	A BILL FOR
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68	68	1 treatment options or from advocating on behalf of
69	69	2 beneficiaries within the utilization review, grievance, or
70	70	3 appeals processes established by the insurer in accordance
71	71	4 with any rights or remedies available under applicable State
72	72	5 or federal law.
73	73	6 (b) Insurers must file for review a description of the
74	74	7 services to be offered through a network plan. The description
75	75	8 shall include all of the following:
76	76	9 (1) A geographic map of the area proposed to be served
77	77	10 by the plan by county service area and zip code, including
78	78	11 marked locations for preferred providers.
79	79	12 (2) As deemed necessary by the Department, the names,
80	80	13 addresses, phone numbers, and specialties of the providers
81	81	14 who have entered into preferred provider agreements under
82	82	15 the network plan.
83	83	16 (3) The number of beneficiaries anticipated to be
84	84	17 covered by the network plan.
85	85	18 (4) An Internet website and toll-free telephone number
86	86	19 for beneficiaries and prospective beneficiaries to access
87	87	20 current and accurate lists of preferred providers,
88	88	21 additional information about the plan, as well as any
89	89	22 other information required by Department rule.
90	90	23 (5) A description of how health care services to be
91	91	24 rendered under the network plan are reasonably accessible
92	92	25 and available to beneficiaries. The description shall
93	93	26 address all of the following:
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104	104	1 (A) the type of health care services to be
105	105	2 provided by the network plan;
106	106	3 (B) the ratio of physicians and other providers to
107	107	4 beneficiaries, by specialty and including primary care
108	108	5 physicians and facility-based physicians when
109	109	6 applicable under the contract, necessary to meet the
110	110	7 health care needs and service demands of the currently
111	111	8 enrolled population;
112	112	9 (C) the travel and distance standards for plan
113	113	10 beneficiaries in county service areas; and
114	114	11 (D) a description of how the use of telemedicine,
115	115	12 telehealth, or mobile care services may be used to
116	116	13 partially meet the network adequacy standards, if
117	117	14 applicable.
118	118	15 (6) A provision ensuring that whenever a beneficiary
119	119	16 has made a good faith effort, as evidenced by accessing
120	120	17 the provider directory, calling the network plan, and
121	121	18 calling the provider, to utilize preferred providers for a
122	122	19 covered service and it is determined the insurer does not
123	123	20 have the appropriate preferred providers due to
124	124	21 insufficient number, type, unreasonable travel distance or
125	125	22 delay, or preferred providers refusing to provide a
126	126	23 covered service because it is contrary to the conscience
127	127	24 of the preferred providers, as protected by the Health
128	128	25 Care Right of Conscience Act, the insurer shall ensure,
129	129	26 directly or indirectly, by terms contained in the payer
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140	140	1 contract, that the beneficiary will be provided the
141	141	2 covered service at no greater cost to the beneficiary than
142	142	3 if the service had been provided by a preferred provider.
143	143	4 This paragraph (6) does not apply to: (A) a beneficiary
144	144	5 who willfully chooses to access a non-preferred provider
145	145	6 for health care services available through the panel of
146	146	7 preferred providers, or (B) a beneficiary enrolled in a
147	147	8 health maintenance organization. In these circumstances,
148	148	9 the contractual requirements for non-preferred provider
149	149	10 reimbursements shall apply unless Section 356z.3a of the
150	150	11 Illinois Insurance Code requires otherwise. In no event
151	151	12 shall a beneficiary who receives care at a participating
152	152	13 health care facility be required to search for
153	153	14 participating providers under the circumstances described
154	154	15 in subsection (b) or (b-5) of Section 356z.3a of the
155	155	16 Illinois Insurance Code except under the circumstances
156	156	17 described in paragraph (2) of subsection (b-5).
157	157	18 (7) A provision that the beneficiary shall receive
158	158	19 emergency care coverage such that payment for this
159	159	20 coverage is not dependent upon whether the emergency
160	160	21 services are performed by a preferred or non-preferred
161	161	22 provider and the coverage shall be at the same benefit
162	162	23 level as if the service or treatment had been rendered by a
163	163	24 preferred provider. For purposes of this paragraph (7),
164	164	25 "the same benefit level" means that the beneficiary is
165	165	26 provided the covered service at no greater cost to the
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176	176	1 beneficiary than if the service had been provided by a
177	177	2 preferred provider. This provision shall be consistent
178	178	3 with Section 356z.3a of the Illinois Insurance Code.
179	179	4 (8) A limitation that, if the plan provides that the
180	180	5 beneficiary will incur a penalty for failing to
181	181	6 pre-certify inpatient hospital treatment, the penalty may
182	182	7 not exceed $1,000 per occurrence in addition to the plan
183	183	8 cost sharing provisions.
184	184	9 (c) The network plan shall demonstrate to the Director a
185	185	10 minimum ratio of providers to plan beneficiaries as required
186	186	11 by the Department.
187	187	12 (1) The ratio of physicians or other providers to plan
188	188	13 beneficiaries shall be established annually by the
189	189	14 Department in consultation with the Department of Public
190	190	15 Health based upon the guidance from the federal Centers
191	191	16 for Medicare and Medicaid Services. The Department shall
192	192	17 not establish ratios for vision or dental providers who
193	193	18 provide services under dental-specific or vision-specific
194	194	19 benefits. The Department shall consider establishing
195	195	20 ratios for the following physicians or other providers:
196	196	21 (A) Primary Care;
197	197	22 (B) Pediatrics;
198	198	23 (C) Cardiology;
199	199	24 (D) Gastroenterology;
200	200	25 (E) General Surgery;
201	201	26 (F) Neurology;
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212	212	1 (G) OB/GYN;
213	213	2 (H) Oncology/Radiation;
214	214	3 (I) Ophthalmology;
215	215	4 (J) Urology;
216	216	5 (K) Behavioral Health;
217	217	6 (L) Allergy/Immunology;
218	218	7 (M) Chiropractic;
219	219	8 (N) Dermatology;
220	220	9 (O) Endocrinology;
221	221	10 (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
222	222	11 (Q) Infectious Disease;
223	223	12 (R) Nephrology;
224	224	13 (S) Neurosurgery;
225	225	14 (T) Orthopedic Surgery;
226	226	15 (U) Physiatry/Rehabilitative;
227	227	16 (V) Plastic Surgery;
228	228	17 (W) Pulmonary;
229	229	18 (X) Rheumatology;
230	230	19 (Y) Anesthesiology;
231	231	20 (Z) Pain Medicine;
232	232	21 (AA) Pediatric Specialty Services;
233	233	22 (BB) Outpatient Dialysis; and
234	234	23 (CC) HIV; and .
235	235	24 (DD) Genetic Medicine and Genetic Counseling.
236	236	25 (2) The Director shall establish a process for the
237	237	26 review of the adequacy of these standards, along with an
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248	248	1 assessment of additional specialties to be included in the
249	249	2 list under this subsection (c).
250	250	3 (d) The network plan shall demonstrate to the Director
251	251	4 maximum travel and distance standards for plan beneficiaries,
252	252	5 which shall be established annually by the Department in
253	253	6 consultation with the Department of Public Health based upon
254	254	7 the guidance from the federal Centers for Medicare and
255	255	8 Medicaid Services. These standards shall consist of the
256	256	9 maximum minutes or miles to be traveled by a plan beneficiary
257	257	10 for each county type, such as large counties, metro counties,
258	258	11 or rural counties as defined by Department rule.
259	259	12 The maximum travel time and distance standards must
260	260	13 include standards for each physician and other provider
261	261	14 category listed for which ratios have been established.
262	262	15 The Director shall establish a process for the review of
263	263	16 the adequacy of these standards along with an assessment of
264	264	17 additional specialties to be included in the list under this
265	265	18 subsection (d).
266	266	19 (d-5)(1) Every insurer shall ensure that beneficiaries
267	267	20 have timely and proximate access to treatment for mental,
268	268	21 emotional, nervous, or substance use disorders or conditions
269	269	22 in accordance with the provisions of paragraph (4) of
270	270	23 subsection (a) of Section 370c of the Illinois Insurance Code.
271	271	24 Insurers shall use a comparable process, strategy, evidentiary
272	272	25 standard, and other factors in the development and application
273	273	26 of the network adequacy standards for timely and proximate
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284	284	1 access to treatment for mental, emotional, nervous, or
285	285	2 substance use disorders or conditions and those for the access
286	286	3 to treatment for medical and surgical conditions. As such, the
287	287	4 network adequacy standards for timely and proximate access
288	288	5 shall equally be applied to treatment facilities and providers
289	289	6 for mental, emotional, nervous, or substance use disorders or
290	290	7 conditions and specialists providing medical or surgical
291	291	8 benefits pursuant to the parity requirements of Section 370c.1
292	292	9 of the Illinois Insurance Code and the federal Paul Wellstone
293	293	10 and Pete Domenici Mental Health Parity and Addiction Equity
294	294	11 Act of 2008. Notwithstanding the foregoing, the network
295	295	12 adequacy standards for timely and proximate access to
296	296	13 treatment for mental, emotional, nervous, or substance use
297	297	14 disorders or conditions shall, at a minimum, satisfy the
298	298	15 following requirements:
299	299	16 (A) For beneficiaries residing in the metropolitan
300	300	17 counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
301	301	18 network adequacy standards for timely and proximate access
302	302	19 to treatment for mental, emotional, nervous, or substance
303	303	20 use disorders or conditions means a beneficiary shall not
304	304	21 have to travel longer than 30 minutes or 30 miles from the
305	305	22 beneficiary's residence to receive outpatient treatment
306	306	23 for mental, emotional, nervous, or substance use disorders
307	307	24 or conditions. Beneficiaries shall not be required to wait
308	308	25 longer than 10 business days between requesting an initial
309	309	26 appointment and being seen by the facility or provider of
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320	320	1 mental, emotional, nervous, or substance use disorders or
321	321	2 conditions for outpatient treatment or to wait longer than
322	322	3 20 business days between requesting a repeat or follow-up
323	323	4 appointment and being seen by the facility or provider of
324	324	5 mental, emotional, nervous, or substance use disorders or
325	325	6 conditions for outpatient treatment; however, subject to
326	326	7 the protections of paragraph (3) of this subsection, a
327	327	8 network plan shall not be held responsible if the
328	328	9 beneficiary or provider voluntarily chooses to schedule an
329	329	10 appointment outside of these required time frames.
330	330	11 (B) For beneficiaries residing in Illinois counties
331	331	12 other than those counties listed in subparagraph (A) of
332	332	13 this paragraph, network adequacy standards for timely and
333	333	14 proximate access to treatment for mental, emotional,
334	334	15 nervous, or substance use disorders or conditions means a
335	335	16 beneficiary shall not have to travel longer than 60
336	336	17 minutes or 60 miles from the beneficiary's residence to
337	337	18 receive outpatient treatment for mental, emotional,
338	338	19 nervous, or substance use disorders or conditions.
339	339	20 Beneficiaries shall not be required to wait longer than 10
340	340	21 business days between requesting an initial appointment
341	341	22 and being seen by the facility or provider of mental,
342	342	23 emotional, nervous, or substance use disorders or
343	343	24 conditions for outpatient treatment or to wait longer than
344	344	25 20 business days between requesting a repeat or follow-up
345	345	26 appointment and being seen by the facility or provider of
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356	356	1 mental, emotional, nervous, or substance use disorders or
357	357	2 conditions for outpatient treatment; however, subject to
358	358	3 the protections of paragraph (3) of this subsection, a
359	359	4 network plan shall not be held responsible if the
360	360	5 beneficiary or provider voluntarily chooses to schedule an
361	361	6 appointment outside of these required time frames.
362	362	7 (2) For beneficiaries residing in all Illinois counties,
363	363	8 network adequacy standards for timely and proximate access to
364	364	9 treatment for mental, emotional, nervous, or substance use
365	365	10 disorders or conditions means a beneficiary shall not have to
366	366	11 travel longer than 60 minutes or 60 miles from the
367	367	12 beneficiary's residence to receive inpatient or residential
368	368	13 treatment for mental, emotional, nervous, or substance use
369	369	14 disorders or conditions.
370	370	15 (3) If there is no in-network facility or provider
371	371	16 available for a beneficiary to receive timely and proximate
372	372	17 access to treatment for mental, emotional, nervous, or
373	373	18 substance use disorders or conditions in accordance with the
374	374	19 network adequacy standards outlined in this subsection, the
375	375	20 insurer shall provide necessary exceptions to its network to
376	376	21 ensure admission and treatment with a provider or at a
377	377	22 treatment facility in accordance with the network adequacy
378	378	23 standards in this subsection.
379	379	24 (e) Except for network plans solely offered as a group
380	380	25 health plan, these ratio and time and distance standards apply
381	381	26 to the lowest cost-sharing tier of any tiered network.
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392	392	1 (f) The network plan may consider use of other health care
393	393	2 service delivery options, such as telemedicine or telehealth,
394	394	3 mobile clinics, and centers of excellence, or other ways of
395	395	4 delivering care to partially meet the requirements set under
396	396	5 this Section.
397	397	6 (g) Except for the requirements set forth in subsection
398	398	7 (d-5), insurers who are not able to comply with the provider
399	399	8 ratios and time and distance standards established by the
400	400	9 Department may request an exception to these requirements from
401	401	10 the Department. The Department may grant an exception in the
402	402	11 following circumstances:
403	403	12 (1) if no providers or facilities meet the specific
404	404	13 time and distance standard in a specific service area and
405	405	14 the insurer (i) discloses information on the distance and
406	406	15 travel time points that beneficiaries would have to travel
407	407	16 beyond the required criterion to reach the next closest
408	408	17 contracted provider outside of the service area and (ii)
409	409	18 provides contact information, including names, addresses,
410	410	19 and phone numbers for the next closest contracted provider
411	411	20 or facility;
412	412	21 (2) if patterns of care in the service area do not
413	413	22 support the need for the requested number of provider or
414	414	23 facility type and the insurer provides data on local
415	415	24 patterns of care, such as claims data, referral patterns,
416	416	25 or local provider interviews, indicating where the
417	417	26 beneficiaries currently seek this type of care or where
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