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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 Network Adequacy and Transparency Act is
5 amended by changing Section 10 as follows:
6 (215 ILCS 124/10)
7 Sec. 10. Network adequacy.
8 (a) An insurer providing a network plan shall file a
9 description of all of the following with the Director:
10 (1) The written policies and procedures for adding
11 providers to meet patient needs based on increases in the
12 number of beneficiaries, changes in the
13 patient-to-provider ratio, changes in medical and health
14 care capabilities, and increased demand for services.
15 (2) The written policies and procedures for making
16 referrals within and outside the network.
17 (3) The written policies and procedures on how the
18 network plan will provide 24-hour, 7-day per week access
19 to network-affiliated primary care, emergency services,
20 and women's principal health care providers.
21 An insurer shall not prohibit a preferred provider from
22 discussing any specific or all treatment options with
23 beneficiaries irrespective of the insurer's position on those
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1 treatment options or from advocating on behalf of
2 beneficiaries within the utilization review, grievance, or
3 appeals processes established by the insurer in accordance
4 with any rights or remedies available under applicable State
5 or federal law.
6 (b) Insurers must file for review a description of the
7 services to be offered through a network plan. The description
8 shall include all of the following:
9 (1) A geographic map of the area proposed to be served
10 by the plan by county service area and zip code, including
11 marked locations for preferred providers.
12 (2) As deemed necessary by the Department, the names,
13 addresses, phone numbers, and specialties of the providers
14 who have entered into preferred provider agreements under
15 the network plan.
16 (3) The number of beneficiaries anticipated to be
17 covered by the network plan.
18 (4) An Internet website and toll-free telephone number
19 for beneficiaries and prospective beneficiaries to access
20 current and accurate lists of preferred providers,
21 additional information about the plan, as well as any
22 other information required by Department rule.
23 (5) A description of how health care services to be
24 rendered under the network plan are reasonably accessible
25 and available to beneficiaries. The description shall
26 address all of the following:
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1 (A) the type of health care services to be
2 provided by the network plan;
3 (B) the ratio of physicians and other providers to
4 beneficiaries, by specialty and including primary care
5 physicians and facility-based physicians when
6 applicable under the contract, necessary to meet the
7 health care needs and service demands of the currently
8 enrolled population;
9 (C) the travel and distance standards for plan
10 beneficiaries in county service areas; and
11 (D) a description of how the use of telemedicine,
12 telehealth, or mobile care services may be used to
13 partially meet the network adequacy standards, if
14 applicable.
15 (6) A provision ensuring that whenever a beneficiary
16 has made a good faith effort, as evidenced by accessing
17 the provider directory, calling the network plan, and
18 calling the provider, to utilize preferred providers for a
19 covered service and it is determined the insurer does not
20 have the appropriate preferred providers due to
21 insufficient number, type, unreasonable travel distance or
22 delay, or preferred providers refusing to provide a
23 covered service because it is contrary to the conscience
24 of the preferred providers, as protected by the Health
25 Care Right of Conscience Act, the insurer shall ensure,
26 directly or indirectly, by terms contained in the payer
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1 contract, that the beneficiary will be provided the
2 covered service at no greater cost to the beneficiary than
3 if the service had been provided by a preferred provider.
4 This paragraph (6) does not apply to: (A) a beneficiary
5 who willfully chooses to access a non-preferred provider
6 for health care services available through the panel of
7 preferred providers, or (B) a beneficiary enrolled in a
8 health maintenance organization. In these circumstances,
9 the contractual requirements for non-preferred provider
10 reimbursements shall apply unless Section 356z.3a of the
11 Illinois Insurance Code requires otherwise. In no event
12 shall a beneficiary who receives care at a participating
13 health care facility be required to search for
14 participating providers under the circumstances described
15 in subsection (b) or (b-5) of Section 356z.3a of the
16 Illinois Insurance Code except under the circumstances
17 described in paragraph (2) of subsection (b-5).
18 (7) A provision that the beneficiary shall receive
19 emergency care coverage such that payment for this
20 coverage is not dependent upon whether the emergency
21 services are performed by a preferred or non-preferred
22 provider and the coverage shall be at the same benefit
23 level as if the service or treatment had been rendered by a
24 preferred provider. For purposes of this paragraph (7),
25 "the same benefit level" means that the beneficiary is
26 provided the covered service at no greater cost to the
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1 beneficiary than if the service had been provided by a
2 preferred provider. This provision shall be consistent
3 with Section 356z.3a of the Illinois Insurance Code.
4 (8) A limitation that, if the plan provides that the
5 beneficiary will incur a penalty for failing to
6 pre-certify inpatient hospital treatment, the penalty may
7 not exceed $1,000 per occurrence in addition to the plan
8 cost sharing provisions.
9 (c) The network plan shall demonstrate to the Director a
10 minimum ratio of providers to plan beneficiaries as required
11 by the Department.
12 (1) The ratio of physicians or other providers to plan
13 beneficiaries shall be established annually by the
14 Department in consultation with the Department of Public
15 Health based upon the guidance from the federal Centers
16 for Medicare and Medicaid Services. The Department shall
17 not establish ratios for vision or dental providers who
18 provide services under dental-specific or vision-specific
19 benefits. The Department shall consider establishing
20 ratios for the following physicians or other providers:
21 (A) Primary Care;
22 (B) Pediatrics;
23 (C) Cardiology;
24 (D) Gastroenterology;
25 (E) General Surgery;
26 (F) Neurology;
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1 (G) OB/GYN;
2 (H) Oncology/Radiation;
3 (I) Ophthalmology;
4 (J) Urology;
5 (K) Behavioral Health;
6 (L) Allergy/Immunology;
7 (M) Chiropractic;
8 (N) Dermatology;
9 (O) Endocrinology;
10 (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
11 (Q) Infectious Disease;
12 (R) Nephrology;
13 (S) Neurosurgery;
14 (T) Orthopedic Surgery;
15 (U) Physiatry/Rehabilitative;
16 (V) Plastic Surgery;
17 (W) Pulmonary;
18 (X) Rheumatology;
19 (Y) Anesthesiology;
20 (Z) Pain Medicine;
21 (AA) Pediatric Specialty Services;
22 (BB) Outpatient Dialysis; and
23 (CC) HIV.
24 (1.5) Beginning January 1, 2026, every insurer shall
25 demonstrate to the Director that each in-network hospital
26 has at least one radiologist, pathologist,
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1 anesthesiologist, and emergency room physician as a
2 preferred provider in a network plan. The Department may,
3 by rule, require additional types of hospital-based
4 medical specialists to be included as preferred providers
5 in each in-network hospital in a network plan.
6 (2) The Director shall establish a process for the
7 review of the adequacy of these standards, along with an
8 assessment of additional specialties to be included in the
9 list under this subsection (c).
10 (d) The network plan shall demonstrate to the Director
11 maximum travel and distance standards for plan beneficiaries,
12 which shall be established annually by the Department in
13 consultation with the Department of Public Health based upon
14 the guidance from the federal Centers for Medicare and
15 Medicaid Services. These standards shall consist of the
16 maximum minutes or miles to be traveled by a plan beneficiary
17 for each county type, such as large counties, metro counties,
18 or rural counties as defined by Department rule.
19 The maximum travel time and distance standards must
20 include standards for each physician and other provider
21 category listed for which ratios have been established.
22 The Director shall establish a process for the review of
23 the adequacy of these standards along with an assessment of
24 additional specialties to be included in the list under this
25 subsection (d).
26 (d-5)(1) Every insurer shall ensure that beneficiaries
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1 have timely and proximate access to treatment for mental,
2 emotional, nervous, or substance use disorders or conditions
3 in accordance with the provisions of paragraph (4) of
4 subsection (a) of Section 370c of the Illinois Insurance Code.
5 Insurers shall use a comparable process, strategy, evidentiary
6 standard, and other factors in the development and application
7 of the network adequacy standards for timely and proximate
8 access to treatment for mental, emotional, nervous, or
9 substance use disorders or conditions and those for the access
10 to treatment for medical and surgical conditions. As such, the
11 network adequacy standards for timely and proximate access
12 shall equally be applied to treatment facilities and providers
13 for mental, emotional, nervous, or substance use disorders or
14 conditions and specialists providing medical or surgical
15 benefits pursuant to the parity requirements of Section 370c.1
16 of the Illinois Insurance Code and the federal Paul Wellstone
17 and Pete Domenici Mental Health Parity and Addiction Equity
18 Act of 2008. Notwithstanding the foregoing, the network
19 adequacy standards for timely and proximate access to
20 treatment for mental, emotional, nervous, or substance use
21 disorders or conditions shall, at a minimum, satisfy the
22 following requirements:
23 (A) For beneficiaries residing in the metropolitan
24 counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
25 network adequacy standards for timely and proximate access
26 to treatment for mental, emotional, nervous, or substance
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1 use disorders or conditions means a beneficiary shall not
2 have to travel longer than 30 minutes or 30 miles from the
3 beneficiary's residence to receive outpatient treatment
4 for mental, emotional, nervous, or substance use disorders
5 or conditions. Beneficiaries shall not be required to wait
6 longer than 10 business days between requesting an initial
7 appointment and being seen by the facility or provider of
8 mental, emotional, nervous, or substance use disorders or
9 conditions for outpatient treatment or to wait longer than
10 20 business days between requesting a repeat or follow-up
11 appointment and being seen by the facility or provider of
12 mental, emotional, nervous, or substance use disorders or
13 conditions for outpatient treatment; however, subject to
14 the protections of paragraph (3) of this subsection, a
15 network plan shall not be held responsible if the
16 beneficiary or provider voluntarily chooses to schedule an
17 appointment outside of these required time frames.
18 (B) For beneficiaries residing in Illinois counties
19 other than those counties listed in subparagraph (A) of
20 this paragraph, network adequacy standards for timely and
21 proximate access to treatment for mental, emotional,
22 nervous, or substance use disorders or conditions means a
23 beneficiary shall not have to travel longer than 60
24 minutes or 60 miles from the beneficiary's residence to
25 receive outpatient treatment for mental, emotional,
26 nervous, or substance use disorders or conditions.
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1 Beneficiaries shall not be required to wait longer than 10
2 business days between requesting an initial appointment
3 and being seen by the facility or provider of mental,
4 emotional, nervous, or substance use disorders or
5 conditions for outpatient treatment or to wait longer than
6 20 business days between requesting a repeat or follow-up
7 appointment and being seen by the facility or provider of
8 mental, emotional, nervous, or substance use disorders or
9 conditions for outpatient treatment; however, subject to
10 the protections of paragraph (3) of this subsection, a
11 network plan shall not be held responsible if the
12 beneficiary or provider voluntarily chooses to schedule an
13 appointment outside of these required time frames.
14 (2) For beneficiaries residing in all Illinois counties,
15 network adequacy standards for timely and proximate access to
16 treatment for mental, emotional, nervous, or substance use
17 disorders or conditions means a beneficiary shall not have to
18 travel longer than 60 minutes or 60 miles from the
19 beneficiary's residence to receive inpatient or residential
20 treatment for mental, emotional, nervous, or substance use
21 disorders or conditions.
22 (3) If there is no in-network facility or provider
23 available for a beneficiary to receive timely and proximate
24 access to treatment for mental, emotional, nervous, or
25 substance use disorders or conditions in accordance with the
26 network adequacy standards outlined in this subsection, the
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1 insurer shall provide necessary exceptions to its network to
2 ensure admission and treatment with a provider or at a
3 treatment facility in accordance with the network adequacy
4 standards in this subsection.
5 (e) Except for network plans solely offered as a group
6 health plan, these ratio and time and distance standards apply
7 to the lowest cost-sharing tier of any tiered network.
8 (f) The network plan may consider use of other health care
9 service delivery options, such as telemedicine or telehealth,
10 mobile clinics, and centers of excellence, or other ways of
11 delivering care to partially meet the requirements set under
12 this Section.
13 (g) Except for the requirements set forth in subsection
14 (d-5), insurers who are not able to comply with the provider
15 ratios and time and distance standards established by the
16 Department may request an exception to these requirements from
17 the Department. The Department may grant an exception in the
18 following circumstances:
19 (1) if no providers or facilities meet the specific
20 time and distance standard in a specific service area and
21 the insurer (i) discloses information on the distance and
22 travel time points that beneficiaries would have to travel
23 beyond the required criterion to reach the next closest
24 contracted provider outside of the service area and (ii)
25 provides contact information, including names, addresses,
26 and phone numbers for the next closest contracted provider
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