103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB0241 Introduced 1/31/2023, by Sen. Laura Ellman SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3215 ILCS 5/356z.3a215 ILCS 124/10 Amends the Illinois Insurance Code. Makes a change in provisions concerning disclosure of nonparticipating provider limited benefits. Adds reproductive health care to the definition of "ancillary services". Amends the Network Adequacy and Transparency Act. Provides that an insurer providing a network plan shall file a description with the Director of Insurance of written policies and procedures on how the network plan will provide 24-hour, 7-day per week access to reproductive health care. Provides that the Department of Insurance shall consider establishing ratios for reproductive health care physicians or other providers. Effective July 1, 2024, except that certain changes take effect January 1, 2025. LRB103 27273 BMS 53644 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB0241 Introduced 1/31/2023, by Sen. Laura Ellman SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3215 ILCS 5/356z.3a215 ILCS 124/10 215 ILCS 5/356z.3 215 ILCS 5/356z.3a 215 ILCS 124/10 Amends the Illinois Insurance Code. Makes a change in provisions concerning disclosure of nonparticipating provider limited benefits. Adds reproductive health care to the definition of "ancillary services". Amends the Network Adequacy and Transparency Act. Provides that an insurer providing a network plan shall file a description with the Director of Insurance of written policies and procedures on how the network plan will provide 24-hour, 7-day per week access to reproductive health care. Provides that the Department of Insurance shall consider establishing ratios for reproductive health care physicians or other providers. Effective July 1, 2024, except that certain changes take effect January 1, 2025. LRB103 27273 BMS 53644 b LRB103 27273 BMS 53644 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB0241 Introduced 1/31/2023, by Sen. Laura Ellman SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.3215 ILCS 5/356z.3a215 ILCS 124/10 215 ILCS 5/356z.3 215 ILCS 5/356z.3a 215 ILCS 124/10
215 ILCS 5/356z.3
215 ILCS 5/356z.3a
215 ILCS 124/10
Amends the Illinois Insurance Code. Makes a change in provisions concerning disclosure of nonparticipating provider limited benefits. Adds reproductive health care to the definition of "ancillary services". Amends the Network Adequacy and Transparency Act. Provides that an insurer providing a network plan shall file a description with the Director of Insurance of written policies and procedures on how the network plan will provide 24-hour, 7-day per week access to reproductive health care. Provides that the Department of Insurance shall consider establishing ratios for reproductive health care physicians or other providers. Effective July 1, 2024, except that certain changes take effect January 1, 2025.
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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 Insurance Code is amended by
5 changing Sections 356z.3 and 356z.3a as follows:
6 (215 ILCS 5/356z.3)
7 Sec. 356z.3. Disclosure of limited benefit. An insurer
8 that issues, delivers, amends, or renews an individual or
9 group policy of accident and health insurance in this State
10 after the effective date of this amendatory Act of the 92nd
11 General Assembly and arranges, contracts with, or administers
12 contracts with a provider whereby beneficiaries are provided
13 an incentive to use the services of such provider must include
14 the following disclosure on its contracts and evidences of
15 coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
16 NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that
17 when you elect to utilize the services of a non-participating
18 provider for a covered service in non-emergency situations,
19 benefit payments to such non-participating provider are not
20 based upon the amount billed. The basis of your benefit
21 payment will be determined according to your policy's fee
22 schedule, usual and customary charge (which is determined by
23 comparing charges for similar services adjusted to the
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB0241 Introduced 1/31/2023, by Sen. Laura Ellman SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.3215 ILCS 5/356z.3a215 ILCS 124/10 215 ILCS 5/356z.3 215 ILCS 5/356z.3a 215 ILCS 124/10
215 ILCS 5/356z.3
215 ILCS 5/356z.3a
215 ILCS 124/10
Amends the Illinois Insurance Code. Makes a change in provisions concerning disclosure of nonparticipating provider limited benefits. Adds reproductive health care to the definition of "ancillary services". Amends the Network Adequacy and Transparency Act. Provides that an insurer providing a network plan shall file a description with the Director of Insurance of written policies and procedures on how the network plan will provide 24-hour, 7-day per week access to reproductive health care. Provides that the Department of Insurance shall consider establishing ratios for reproductive health care physicians or other providers. Effective July 1, 2024, except that certain changes take effect January 1, 2025.
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A BILL FOR
215 ILCS 5/356z.3
215 ILCS 5/356z.3a
215 ILCS 124/10
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1 geographical area where the services are performed), or other
2 method as defined by the policy. YOU CAN EXPECT TO PAY MORE
3 THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE
4 PLAN HAS PAID ITS REQUIRED PORTION. Non-participating
5 providers may bill members for any amount up to the billed
6 charge after the plan has paid its portion of the bill, except
7 as provided in Section 356z.3a of the Illinois Insurance Code
8 for covered services received at a participating health care
9 facility from a nonparticipating provider that are: (a)
10 ancillary services, (b) items or services furnished as a
11 result of unforeseen, urgent medical needs that arise at the
12 time the item or service is furnished, or (c) items or services
13 received when the facility or the non-participating provider
14 fails to satisfy the notice and consent criteria specified
15 under Section 356z.3a, or (d) reproductive health care, as
16 defined in Section 1-10 of the Reproductive Health Act.
17 Participating providers have agreed to accept discounted
18 payments for services with no additional billing to the member
19 other than co-insurance and deductible amounts. You may obtain
20 further information about the participating status of
21 professional providers and information on out-of-pocket
22 expenses by calling the toll free telephone number on your
23 identification card.".
24 (Source: P.A. 102-901, eff. 1-1-23.)
25 (215 ILCS 5/356z.3a)
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1 Sec. 356z.3a. Billing; emergency services;
2 nonparticipating providers.
3 (a) As used in this Section:
4 "Ancillary services" means:
5 (1) items and services related to emergency medicine,
6 anesthesiology, pathology, radiology, and neonatology that
7 are provided by any health care provider;
8 (2) items and services provided by assistant surgeons,
9 hospitalists, and intensivists;
10 (3) diagnostic services, including radiology and
11 laboratory services, except for advanced diagnostic
12 laboratory tests identified on the most current list
13 published by the United States Secretary of Health and
14 Human Services under 42 U.S.C. 300gg-132(b)(3);
15 (4) items and services provided by other specialty
16 practitioners as the United States Secretary of Health and
17 Human Services specifies through rulemaking under 42
18 U.S.C. 300gg-132(b)(3);
19 (5) items and services provided by a nonparticipating
20 provider if there is no participating provider who can
21 furnish the item or service at the facility; and
22 (6) items and services provided by a nonparticipating
23 provider if there is no participating provider who will
24 furnish the item or service because a participating
25 provider has asserted the participating provider's rights
26 under the Health Care Right of Conscience Act; and .
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1 (7) reproductive health care, as defined in Section
2 1-10 of the Reproductive Health Act.
3 "Cost sharing" means the amount an insured, beneficiary,
4 or enrollee is responsible for paying for a covered item or
5 service under the terms of the policy or certificate. "Cost
6 sharing" includes copayments, coinsurance, and amounts paid
7 toward deductibles, but does not include amounts paid towards
8 premiums, balance billing by out-of-network providers, or the
9 cost of items or services that are not covered under the policy
10 or certificate.
11 "Emergency department of a hospital" means any hospital
12 department that provides emergency services, including a
13 hospital outpatient department.
14 "Emergency medical condition" has the meaning ascribed to
15 that term in Section 10 of the Managed Care Reform and Patient
16 Rights Act.
17 "Emergency medical screening examination" has the meaning
18 ascribed to that term in Section 10 of the Managed Care Reform
19 and Patient Rights Act.
20 "Emergency services" means, with respect to an emergency
21 medical condition:
22 (1) in general, an emergency medical screening
23 examination, including ancillary services routinely
24 available to the emergency department to evaluate such
25 emergency medical condition, and such further medical
26 examination and treatment as would be required to
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1 stabilize the patient regardless of the department of the
2 hospital or other facility in which such further
3 examination or treatment is furnished; or
4 (2) additional items and services for which benefits
5 are provided or covered under the coverage and that are
6 furnished by a nonparticipating provider or
7 nonparticipating emergency facility regardless of the
8 department of the hospital or other facility in which such
9 items are furnished after the insured, beneficiary, or
10 enrollee is stabilized and as part of outpatient
11 observation or an inpatient or outpatient stay with
12 respect to the visit in which the services described in
13 paragraph (1) are furnished. Services after stabilization
14 cease to be emergency services only when all the
15 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
16 regulations thereunder are met.
17 "Freestanding Emergency Center" means a facility licensed
18 under Section 32.5 of the Emergency Medical Services (EMS)
19 Systems Act.
20 "Health care facility" means, in the context of
21 non-emergency services, any of the following:
22 (1) a hospital as defined in 42 U.S.C. 1395x(e);
23 (2) a hospital outpatient department;
24 (3) a critical access hospital certified under 42
25 U.S.C. 1395i-4(e);
26 (4) an ambulatory surgical treatment center as defined
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1 in the Ambulatory Surgical Treatment Center Act; or
2 (5) any recipient of a license under the Hospital
3 Licensing Act that is not otherwise described in this
4 definition.
5 "Health care provider" means a provider as defined in
6 subsection (d) of Section 370g. "Health care provider" does
7 not include a provider of air ambulance or ground ambulance
8 services.
9 "Health care services" has the meaning ascribed to that
10 term in subsection (a) of Section 370g.
11 "Health insurance issuer" has the meaning ascribed to that
12 term in Section 5 of the Illinois Health Insurance Portability
13 and Accountability Act.
14 "Nonparticipating emergency facility" means, with respect
15 to the furnishing of an item or service under a policy of group
16 or individual health insurance coverage, any of the following
17 facilities that does not have a contractual relationship
18 directly or indirectly with a health insurance issuer in
19 relation to the coverage:
20 (1) an emergency department of a hospital;
21 (2) a Freestanding Emergency Center;
22 (3) an ambulatory surgical treatment center as defined
23 in the Ambulatory Surgical Treatment Center Act; or
24 (4) with respect to emergency services described in
25 paragraph (2) of the definition of "emergency services", a
26 hospital.
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1 "Nonparticipating provider" means, with respect to the
2 furnishing of an item or service under a policy of group or
3 individual health insurance coverage, any health care provider
4 who does not have a contractual relationship directly or
5 indirectly with a health insurance issuer in relation to the
6 coverage.
7 "Participating emergency facility" means any of the
8 following facilities that has a contractual relationship
9 directly or indirectly with a health insurance issuer offering
10 group or individual health insurance coverage setting forth
11 the terms and conditions on which a relevant health care
12 service is provided to an insured, beneficiary, or enrollee
13 under the coverage:
14 (1) an emergency department of a hospital;
15 (2) a Freestanding Emergency Center;
16 (3) an ambulatory surgical treatment center as defined
17 in the Ambulatory Surgical Treatment Center Act; or
18 (4) with respect to emergency services described in
19 paragraph (2) of the definition of "emergency services", a
20 hospital.
21 For purposes of this definition, a single case agreement
22 between an emergency facility and an issuer that is used to
23 address unique situations in which an insured, beneficiary, or
24 enrollee requires services that typically occur out-of-network
25 constitutes a contractual relationship and is limited to the
26 parties to the agreement.
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1 "Participating health care facility" means any health care
2 facility that has a contractual relationship directly or
3 indirectly with a health insurance issuer offering group or
4 individual health insurance coverage setting forth the terms
5 and conditions on which a relevant health care service is
6 provided to an insured, beneficiary, or enrollee under the
7 coverage. A single case agreement between an emergency
8 facility and an issuer that is used to address unique
9 situations in which an insured, beneficiary, or enrollee
10 requires services that typically occur out-of-network
11 constitutes a contractual relationship for purposes of this
12 definition and is limited to the parties to the agreement.
13 "Participating provider" means any health care provider
14 that has a contractual relationship directly or indirectly
15 with a health insurance issuer offering group or individual
16 health insurance coverage setting forth the terms and
17 conditions on which a relevant health care service is provided
18 to an insured, beneficiary, or enrollee under the coverage.
19 "Qualifying payment amount" has the meaning given to that
20 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
21 promulgated thereunder.
22 "Recognized amount" means the lesser of the amount
23 initially billed by the provider or the qualifying payment
24 amount.
25 "Stabilize" means "stabilization" as defined in Section 10
26 of the Managed Care Reform and Patient Rights Act.
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1 "Treating provider" means a health care provider who has
2 evaluated the individual.
3 "Visit" means, with respect to health care services
4 furnished to an individual at a health care facility, health
5 care services furnished by a provider at the facility, as well
6 as equipment, devices, telehealth services, imaging services,
7 laboratory services, and preoperative and postoperative
8 services regardless of whether the provider furnishing such
9 services is at the facility.
10 (b) Emergency services. When a beneficiary, insured, or
11 enrollee receives emergency services from a nonparticipating
12 provider or a nonparticipating emergency facility, the health
13 insurance issuer shall ensure that the beneficiary, insured,
14 or enrollee shall incur no greater out-of-pocket costs than
15 the beneficiary, insured, or enrollee would have incurred with
16 a participating provider or a participating emergency
17 facility. Any cost-sharing requirements shall be applied as
18 though the emergency services had been received from a
19 participating provider or a participating facility. Cost
20 sharing shall be calculated based on the recognized amount for
21 the emergency services. If the cost sharing for the same item
22 or service furnished by a participating provider would have
23 been a flat-dollar copayment, that amount shall be the
24 cost-sharing amount unless the provider has billed a lesser
25 total amount. In no event shall the beneficiary, insured,
26 enrollee, or any group policyholder or plan sponsor be liable
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1 to or billed by the health insurance issuer, the
2 nonparticipating provider, or the nonparticipating emergency
3 facility for any amount beyond the cost sharing calculated in
4 accordance with this subsection with respect to the emergency
5 services delivered. Administrative requirements or limitations
6 shall be no greater than those applicable to emergency
7 services received from a participating provider or a
8 participating emergency facility.
9 (b-5) Non-emergency services at participating health care
10 facilities.
11 (1) When a beneficiary, insured, or enrollee utilizes
12 a participating health care facility and, due to any
13 reason, covered ancillary services are provided by a
14 nonparticipating provider during or resulting from the
15 visit, the health insurance issuer shall ensure that the
16 beneficiary, insured, or enrollee shall incur no greater
17 out-of-pocket costs than the beneficiary, insured, or
18 enrollee would have incurred with a participating provider
19 for the ancillary services. Any cost-sharing requirements
20 shall be applied as though the ancillary services had been
21 received from a participating provider. Cost sharing shall
22 be calculated based on the recognized amount for the
23 ancillary services. If the cost sharing for the same item
24 or service furnished by a participating provider would
25 have been a flat-dollar copayment, that amount shall be
26 the cost-sharing amount unless the provider has billed a
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1 lesser total amount. In no event shall the beneficiary,
2 insured, enrollee, or any group policyholder or plan
3 sponsor be liable to or billed by the health insurance
4 issuer, the nonparticipating provider, or the
5 participating health care facility for any amount beyond
6 the cost sharing calculated in accordance with this
7 subsection with respect to the ancillary services
8 delivered. In addition to ancillary services, the
9 requirements of this paragraph shall also apply with
10 respect to covered items or services furnished as a result
11 of unforeseen, urgent medical needs that arise at the time
12 an item or service is furnished, regardless of whether the
13 nonparticipating provider satisfied the notice and consent
14 criteria under paragraph (2) of this subsection.
15 (2) When a beneficiary, insured, or enrollee utilizes
16 a participating health care facility and receives
17 non-emergency covered health care services other than
18 those described in paragraph (1) of this subsection from a
19 nonparticipating provider during or resulting from the
20 visit, the health insurance issuer shall ensure that the
21 beneficiary, insured, or enrollee incurs no greater
22 out-of-pocket costs than the beneficiary, insured, or
23 enrollee would have incurred with a participating provider
24 unless the nonparticipating provider or the participating
25 health care facility on behalf of the nonparticipating
26 provider satisfies the notice and consent criteria
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1 provided in 42 U.S.C. 300gg-132 and regulations
2 promulgated thereunder. If the notice and consent criteria
3 are not satisfied, then:
4 (A) any cost-sharing requirements shall be applied
5 as though the health care services had been received
6 from a participating provider;
7 (B) cost sharing shall be calculated based on the
8 recognized amount for the health care services; and
9 (C) in no event shall the beneficiary, insured,
10 enrollee, or any group policyholder or plan sponsor be
11 liable to or billed by the health insurance issuer,
12 the nonparticipating provider, or the participating
13 health care facility for any amount beyond the cost
14 sharing calculated in accordance with this subsection
15 with respect to the health care services delivered.
16 (c) Notwithstanding any other provision of this Code,
17 except when the notice and consent criteria are satisfied for
18 the situation in paragraph (2) of subsection (b-5), any
19 benefits a beneficiary, insured, or enrollee receives for
20 services under the situations in subsection (b) or (b-5) are
21 assigned to the nonparticipating providers or the facility
22 acting on their behalf. Upon receipt of the provider's bill or
23 facility's bill, the health insurance issuer shall provide the
24 nonparticipating provider or the facility with a written
25 explanation of benefits that specifies the proposed
26 reimbursement and the applicable deductible, copayment, or
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1 coinsurance amounts owed by the insured, beneficiary, or
2 enrollee. The health insurance issuer shall pay any
3 reimbursement subject to this Section directly to the
4 nonparticipating provider or the facility.
5 (d) For bills assigned under subsection (c), the
6 nonparticipating provider or the facility may bill the health
7 insurance issuer for the services rendered, and the health
8 insurance issuer may pay the billed amount or attempt to
9 negotiate reimbursement with the nonparticipating provider or
10 the facility. Within 30 calendar days after the provider or
11 facility transmits the bill to the health insurance issuer,
12 the issuer shall send an initial payment or notice of denial of
13 payment with the written explanation of benefits to the
14 provider or facility. If attempts to negotiate reimbursement
15 for services provided by a nonparticipating provider do not
16 result in a resolution of the payment dispute within 30 days
17 after receipt of written explanation of benefits by the health
18 insurance issuer, then the health insurance issuer or
19 nonparticipating provider or the facility may initiate binding
20 arbitration to determine payment for services provided on a
21 per-bill basis. The party requesting arbitration shall notify
22 the other party arbitration has been initiated and state its
23 final offer before arbitration. In response to this notice,
24 the nonrequesting party shall inform the requesting party of
25 its final offer before the arbitration occurs. Arbitration
26 shall be initiated by filing a request with the Department of
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1 Insurance.
2 (e) The Department of Insurance shall publish a list of
3 approved arbitrators or entities that shall provide binding
4 arbitration. These arbitrators shall be American Arbitration
5 Association or American Health Lawyers Association trained
6 arbitrators. Both parties must agree on an arbitrator from the
7 Department of Insurance's or its approved entity's list of
8 arbitrators. If no agreement can be reached, then a list of 5
9 arbitrators shall be provided by the Department of Insurance
10 or the approved entity. From the list of 5 arbitrators, the
11 health insurance issuer can veto 2 arbitrators and the
12 provider or facility can veto 2 arbitrators. The remaining
13 arbitrator shall be the chosen arbitrator. This arbitration
14 shall consist of a review of the written submissions by both
15 parties. The arbitrator shall not establish a rebuttable
16 presumption that the qualifying payment amount should be the
17 total amount owed to the provider or facility by the
18 combination of the issuer and the insured, beneficiary, or
19 enrollee. Binding arbitration shall provide for a written
20 decision within 45 days after the request is filed with the
21 Department of Insurance. Both parties shall be bound by the
22 arbitrator's decision. The arbitrator's expenses and fees,
23 together with other expenses, not including attorney's fees,
24 incurred in the conduct of the arbitration, shall be paid as
25 provided in the decision.
26 (f) (Blank).
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1 (g) Section 368a of this Act shall not apply during the
2 pendency of a decision under subsection (d). Upon the issuance
3 of the arbitrator's decision, Section 368a applies with
4 respect to the amount, if any, by which the arbitrator's
5 determination exceeds the issuer's initial payment under
6 subsection (c), or the entire amount of the arbitrator's
7 determination if initial payment was denied. Any interest
8 required to be paid to a provider under Section 368a shall not
9 accrue until after 30 days of an arbitrator's decision as
10 provided in subsection (d), but in no circumstances longer
11 than 150 days from the date the nonparticipating
12 facility-based provider billed for services rendered.
13 (h) Nothing in this Section shall be interpreted to change
14 the prudent layperson provisions with respect to emergency
15 services under the Managed Care Reform and Patient Rights Act.
16 (i) Nothing in this Section shall preclude a health care
17 provider from billing a beneficiary, insured, or enrollee for
18 reasonable administrative fees, such as service fees for
19 checks returned for nonsufficient funds and missed
20 appointments.
21 (j) Nothing in this Section shall preclude a beneficiary,
22 insured, or enrollee from assigning benefits to a
23 nonparticipating provider when the notice and consent criteria
24 are satisfied under paragraph (2) of subsection (b-5) or in
25 any other situation not described in subsection (b) or (b-5).
26 (k) Except when the notice and consent criteria are
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1 satisfied under paragraph (2) of subsection (b-5), if an
2 individual receives health care services under the situations
3 described in subsection (b) or (b-5), no referral requirement
4 or any other provision contained in the policy or certificate
5 of coverage shall deny coverage, reduce benefits, or otherwise
6 defeat the requirements of this Section for services that
7 would have been covered with a participating provider.
8 However, this subsection shall not be construed to preclude a
9 provider contract with a health insurance issuer, or with an
10 administrator or similar entity acting on the issuer's behalf,
11 from imposing requirements on the participating provider,
12 participating emergency facility, or participating health care
13 facility relating to the referral of covered individuals to
14 nonparticipating providers.
15 (l) Except if the notice and consent criteria are
16 satisfied under paragraph (2) of subsection (b-5),
17 cost-sharing amounts calculated in conformity with this
18 Section shall count toward any deductible or out-of-pocket
19 maximum applicable to in-network coverage.
20 (m) The Department has the authority to enforce the
21 requirements of this Section in the situations described in
22 subsections (b) and (b-5), and in any other situation for
23 which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
24 regulations promulgated thereunder would prohibit an
25 individual from being billed or liable for emergency services
26 furnished by a nonparticipating provider or nonparticipating
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1 emergency facility or for non-emergency health care services
2 furnished by a nonparticipating provider at a participating
3 health care facility.
4 (n) This Section does not apply with respect to air
5 ambulance or ground ambulance services. This Section does not
6 apply to any policy of excepted benefits or to short-term,
7 limited-duration health insurance coverage.
8 (Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
9 Section 10. The Network Adequacy and Transparency Act is
10 amended by changing Section 10 as follows:
11 (215 ILCS 124/10)
12 Sec. 10. Network adequacy.
13 (a) An insurer providing a network plan shall file a
14 description of all of the following with the Director:
15 (1) The written policies and procedures for adding
16 providers to meet patient needs based on increases in the
17 number of beneficiaries, changes in the
18 patient-to-provider ratio, changes in medical and health
19 care capabilities, and increased demand for services.
20 (2) The written policies and procedures for making
21 referrals within and outside the network.
22 (3) The written policies and procedures on how the
23 network plan will provide 24-hour, 7-day per week access
24 to network-affiliated primary care, emergency services,
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1 reproductive health care, and women's principal health
2 care providers.
3 An insurer shall not prohibit a preferred provider from
4 discussing any specific or all treatment options with
5 beneficiaries irrespective of the insurer's position on those
6 treatment options or from advocating on behalf of
7 beneficiaries within the utilization review, grievance, or
8 appeals processes established by the insurer in accordance
9 with any rights or remedies available under applicable State
10 or federal law.
11 (b) Insurers must file for review a description of the
12 services to be offered through a network plan. The description
13 shall include all of the following:
14 (1) A geographic map of the area proposed to be served
15 by the plan by county service area and zip code, including
16 marked locations for preferred providers.
17 (2) As deemed necessary by the Department, the names,
18 addresses, phone numbers, and specialties of the providers
19 who have entered into preferred provider agreements under
20 the network plan.
21 (3) The number of beneficiaries anticipated to be
22 covered by the network plan.
23 (4) An Internet website and toll-free telephone number
24 for beneficiaries and prospective beneficiaries to access
25 current and accurate lists of preferred providers,
26 additional information about the plan, as well as any
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1 other information required by Department rule.
2 (5) A description of how health care services to be
3 rendered under the network plan are reasonably accessible
4 and available to beneficiaries. The description shall
5 address all of the following:
6 (A) the type of health care services to be
7 provided by the network plan;
8 (B) the ratio of physicians and other providers to
9 beneficiaries, by specialty and including primary care
10 physicians and facility-based physicians when
11 applicable under the contract, necessary to meet the
12 health care needs and service demands of the currently
13 enrolled population;
14 (C) the travel and distance standards for plan
15 beneficiaries in county service areas; and
16 (D) a description of how the use of telemedicine,
17 telehealth, or mobile care services may be used to
18 partially meet the network adequacy standards, if
19 applicable.
20 (6) A provision ensuring that whenever a beneficiary
21 has made a good faith effort, as evidenced by accessing
22 the provider directory, calling the network plan, and
23 calling the provider, to utilize preferred providers for a
24 covered service and it is determined the insurer does not
25 have the appropriate preferred providers due to
26 insufficient number, type, unreasonable travel distance or
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1 delay, or preferred providers refusing to provide a
2 covered service because it is contrary to the conscience
3 of the preferred providers, as protected by the Health
4 Care Right of Conscience Act, the insurer shall ensure,
5 directly or indirectly, by terms contained in the payer
6 contract, that the beneficiary will be provided the
7 covered service at no greater cost to the beneficiary than
8 if the service had been provided by a preferred provider.
9 This paragraph (6) does not apply to: (A) a beneficiary
10 who willfully chooses to access a non-preferred provider
11 for health care services available through the panel of
12 preferred providers, or (B) a beneficiary enrolled in a
13 health maintenance organization. In these circumstances,
14 the contractual requirements for non-preferred provider
15 reimbursements shall apply unless Section 356z.3a of the
16 Illinois Insurance Code requires otherwise. In no event
17 shall a beneficiary who receives care at a participating
18 health care facility be required to search for
19 participating providers under the circumstances described
20 in subsection (b) or (b-5) of Section 356z.3a of the
21 Illinois Insurance Code except under the circumstances
22 described in paragraph (2) of subsection (b-5).
23 (7) A provision that the beneficiary shall receive
24 emergency care coverage such that payment for this
25 coverage is not dependent upon whether the emergency
26 services are performed by a preferred or non-preferred
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1 provider and the coverage shall be at the same benefit
2 level as if the service or treatment had been rendered by a
3 preferred provider. For purposes of this paragraph (7),
4 "the same benefit level" means that the beneficiary is
5 provided the covered service at no greater cost to the
6 beneficiary than if the service had been provided by a
7 preferred provider. This provision shall be consistent
8 with Section 356z.3a of the Illinois Insurance Code.
9 (8) A limitation that, if the plan provides that the
10 beneficiary will incur a penalty for failing to
11 pre-certify inpatient hospital treatment, the penalty may
12 not exceed $1,000 per occurrence in addition to the plan
13 cost sharing provisions.
14 (c) The network plan shall demonstrate to the Director a
15 minimum ratio of providers to plan beneficiaries as required
16 by the Department.
17 (1) The ratio of physicians or other providers to plan
18 beneficiaries shall be established annually by the
19 Department in consultation with the Department of Public
20 Health based upon the guidance from the federal Centers
21 for Medicare and Medicaid Services. The Department shall
22 not establish ratios for vision or dental providers who
23 provide services under dental-specific or vision-specific
24 benefits. The Department shall consider establishing
25 ratios for the following physicians or other providers:
26 (A) Primary Care;
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1 (B) Pediatrics;
2 (C) Cardiology;
3 (D) Gastroenterology;
4 (E) General Surgery;
5 (F) Neurology;
6 (G) OB/GYN;
7 (H) Oncology/Radiation;
8 (I) Ophthalmology;
9 (J) Urology;
10 (K) Behavioral Health;
11 (L) Allergy/Immunology;
12 (M) Chiropractic;
13 (N) Dermatology;
14 (O) Endocrinology;
15 (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
16 (Q) Infectious Disease;
17 (R) Nephrology;
18 (S) Neurosurgery;
19 (T) Orthopedic Surgery;
20 (U) Physiatry/Rehabilitative;
21 (V) Plastic Surgery;
22 (W) Pulmonary;
23 (X) Rheumatology;
24 (Y) Anesthesiology;
25 (Z) Pain Medicine;
26 (AA) Pediatric Specialty Services;
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1 (BB) Outpatient Dialysis; and
2 (CC) HIV; and .
3 (DD) Reproductive Health Care.
4 (2) The Director shall establish a process for the
5 review of the adequacy of these standards, along with an
6 assessment of additional specialties to be included in the
7 list under this subsection (c).
8 (d) The network plan shall demonstrate to the Director
9 maximum travel and distance standards for plan beneficiaries,
10 which shall be established annually by the Department in
11 consultation with the Department of Public Health based upon
12 the guidance from the federal Centers for Medicare and
13 Medicaid Services. These standards shall consist of the
14 maximum minutes or miles to be traveled by a plan beneficiary
15 for each county type, such as large counties, metro counties,
16 or rural counties as defined by Department rule.
17 The maximum travel time and distance standards must
18 include standards for each physician and other provider
19 category listed for which ratios have been established.
20 The Director shall establish a process for the review of
21 the adequacy of these standards along with an assessment of
22 additional specialties to be included in the list under this
23 subsection (d).
24 (d-5)(1) Every insurer shall ensure that beneficiaries
25 have timely and proximate access to treatment for mental,
26 emotional, nervous, or substance use disorders or conditions
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1 in accordance with the provisions of paragraph (4) of
2 subsection (a) of Section 370c of the Illinois Insurance Code.
3 Insurers shall use a comparable process, strategy, evidentiary
4 standard, and other factors in the development and application
5 of the network adequacy standards for timely and proximate
6 access to treatment for mental, emotional, nervous, or
7 substance use disorders or conditions and those for the access
8 to treatment for medical and surgical conditions. As such, the
9 network adequacy standards for timely and proximate access
10 shall equally be applied to treatment facilities and providers
11 for mental, emotional, nervous, or substance use disorders or
12 conditions and specialists providing medical or surgical
13 benefits pursuant to the parity requirements of Section 370c.1
14 of the Illinois Insurance Code and the federal Paul Wellstone
15 and Pete Domenici Mental Health Parity and Addiction Equity
16 Act of 2008. Notwithstanding the foregoing, the network
17 adequacy standards for timely and proximate access to
18 treatment for mental, emotional, nervous, or substance use
19 disorders or conditions shall, at a minimum, satisfy the
20 following requirements:
21 (A) For beneficiaries residing in the metropolitan
22 counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
23 network adequacy standards for timely and proximate access
24 to treatment for mental, emotional, nervous, or substance
25 use disorders or conditions means a beneficiary shall not
26 have to travel longer than 30 minutes or 30 miles from the
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1 beneficiary's residence to receive outpatient treatment
2 for mental, emotional, nervous, or substance use disorders
3 or conditions. Beneficiaries shall not be required to wait
4 longer than 10 business days between requesting an initial
5 appointment and being seen by the facility or provider of
6 mental, emotional, nervous, or substance use disorders or
7 conditions for outpatient treatment or to wait longer than
8 20 business days between requesting a repeat or follow-up
9 appointment and being seen by the facility or provider of
10 mental, emotional, nervous, or substance use disorders or
11 conditions for outpatient treatment; however, subject to
12 the protections of paragraph (3) of this subsection, a
13 network plan shall not be held responsible if the
14 beneficiary or provider voluntarily chooses to schedule an
15 appointment outside of these required time frames.
16 (B) For beneficiaries residing in Illinois counties
17 other than those counties listed in subparagraph (A) of
18 this paragraph, network adequacy standards for timely and
19 proximate access to treatment for mental, emotional,
20 nervous, or substance use disorders or conditions means a
21 beneficiary shall not have to travel longer than 60
22 minutes or 60 miles from the beneficiary's residence to
23 receive outpatient treatment for mental, emotional,
24 nervous, or substance use disorders or conditions.
25 Beneficiaries shall not be required to wait longer than 10
26 business days between requesting an initial appointment
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1 and being seen by the facility or provider of mental,
2 emotional, nervous, or substance use disorders or
3 conditions for outpatient treatment or to wait longer than
4 20 business days between requesting a repeat or follow-up
5 appointment and being seen by the facility or provider of
6 mental, emotional, nervous, or substance use disorders or
7 conditions for outpatient treatment; however, subject to
8 the protections of paragraph (3) of this subsection, a
9 network plan shall not be held responsible if the
10 beneficiary or provider voluntarily chooses to schedule an
11 appointment outside of these required time frames.
12 (2) For beneficiaries residing in all Illinois counties,
13 network adequacy standards for timely and proximate access to
14 treatment for mental, emotional, nervous, or substance use
15 disorders or conditions means a beneficiary shall not have to
16 travel longer than 60 minutes or 60 miles from the
17 beneficiary's residence to receive inpatient or residential
18 treatment for mental, emotional, nervous, or substance use
19 disorders or conditions.
20 (3) If there is no in-network facility or provider
21 available for a beneficiary to receive timely and proximate
22 access to treatment for mental, emotional, nervous, or
23 substance use disorders or conditions in accordance with the
24 network adequacy standards outlined in this subsection, the
25 insurer shall provide necessary exceptions to its network to
26 ensure admission and treatment with a provider or at a
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1 treatment facility in accordance with the network adequacy
2 standards in this subsection.
3 (e) Except for network plans solely offered as a group
4 health plan, these ratio and time and distance standards apply
5 to the lowest cost-sharing tier of any tiered network.
6 (f) The network plan may consider use of other health care
7 service delivery options, such as telemedicine or telehealth,
8 mobile clinics, and centers of excellence, or other ways of
9 delivering care to partially meet the requirements set under
10 this Section.
11 (g) Except for the requirements set forth in subsection
12 (d-5), insurers who are not able to comply with the provider
13 ratios and time and distance standards established by the
14 Department may request an exception to these requirements from
15 the Department. The Department may grant an exception in the
16 following circumstances:
17 (1) if no providers or facilities meet the specific
18 time and distance standard in a specific service area and
19 the insurer (i) discloses information on the distance and
20 travel time points that beneficiaries would have to travel
21 beyond the required criterion to reach the next closest
22 contracted provider outside of the service area and (ii)
23 provides contact information, including names, addresses,
24 and phone numbers for the next closest contracted provider
25 or facility;
26 (2) if patterns of care in the service area do not
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1 support the need for the requested number of provider or
2 facility type and the insurer provides data on local
3 patterns of care, such as claims data, referral patterns,
4 or local provider interviews, indicating where the
5 beneficiaries currently seek this type of care or where
6 the physicians currently refer beneficiaries, or both; or
7 (3) other circumstances deemed appropriate by the
8 Department consistent with the requirements of this Act.
9 (h) Insurers are required to report to the Director any
10 material change to an approved network plan within 15 days
11 after the change occurs and any change that would result in
12 failure to meet the requirements of this Act. Upon notice from
13 the insurer, the Director shall reevaluate the network plan's
14 compliance with the network adequacy and transparency
15 standards of this Act.
16 (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
17 102-1117, eff. 1-13-23.)
18 Section 99. Effective date. This Act takes effect July 1,
19 2024, except that the changes to Section 356z.3 of the
20 Illinois Insurance Code take effect January 1, 2025.
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