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Illinois Senate Bill SB2641

Illinois 2023-2024 Regular Session

Illinois Senate Bill SB2641 Compare Versions

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1-Public Act 103-0906
21 SB2641 EnrolledLRB103 35049 JAG 64994 b SB2641 Enrolled LRB103 35049 JAG 64994 b
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4-AN ACT concerning regulation.
5-Be it enacted by the People of the State of Illinois,
6-represented in the General Assembly:
7-Section 5. The Network Adequacy and Transparency Act is
8-amended by changing Section 10 as follows:
3+1 AN ACT concerning regulation.
4+2 Be it enacted by the People of the State of Illinois,
5+3 represented in the General Assembly:
6+4 Section 5. The Network Adequacy and Transparency Act is
7+5 amended by changing Section 10 as follows:
8+6 (215 ILCS 124/10)
9+7 Sec. 10. Network adequacy.
10+8 (a) An insurer providing a network plan shall file a
11+9 description of all of the following with the Director:
12+10 (1) The written policies and procedures for adding
13+11 providers to meet patient needs based on increases in the
14+12 number of beneficiaries, changes in the
15+13 patient-to-provider ratio, changes in medical and health
16+14 care capabilities, and increased demand for services.
17+15 (2) The written policies and procedures for making
18+16 referrals within and outside the network.
19+17 (3) The written policies and procedures on how the
20+18 network plan will provide 24-hour, 7-day per week access
21+19 to network-affiliated primary care, emergency services,
22+20 and women's principal health care providers.
23+21 An insurer shall not prohibit a preferred provider from
24+22 discussing any specific or all treatment options with
25+23 beneficiaries irrespective of the insurer's position on those
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34+1 treatment options or from advocating on behalf of
35+2 beneficiaries within the utilization review, grievance, or
36+3 appeals processes established by the insurer in accordance
37+4 with any rights or remedies available under applicable State
38+5 or federal law.
39+6 (b) Insurers must file for review a description of the
40+7 services to be offered through a network plan. The description
41+8 shall include all of the following:
42+9 (1) A geographic map of the area proposed to be served
43+10 by the plan by county service area and zip code, including
44+11 marked locations for preferred providers.
45+12 (2) As deemed necessary by the Department, the names,
46+13 addresses, phone numbers, and specialties of the providers
47+14 who have entered into preferred provider agreements under
48+15 the network plan.
49+16 (3) The number of beneficiaries anticipated to be
50+17 covered by the network plan.
51+18 (4) An Internet website and toll-free telephone number
52+19 for beneficiaries and prospective beneficiaries to access
53+20 current and accurate lists of preferred providers,
54+21 additional information about the plan, as well as any
55+22 other information required by Department rule.
56+23 (5) A description of how health care services to be
57+24 rendered under the network plan are reasonably accessible
58+25 and available to beneficiaries. The description shall
59+26 address all of the following:
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70+1 (A) the type of health care services to be
71+2 provided by the network plan;
72+3 (B) the ratio of physicians and other providers to
73+4 beneficiaries, by specialty and including primary care
74+5 physicians and facility-based physicians when
75+6 applicable under the contract, necessary to meet the
76+7 health care needs and service demands of the currently
77+8 enrolled population;
78+9 (C) the travel and distance standards for plan
79+10 beneficiaries in county service areas; and
80+11 (D) a description of how the use of telemedicine,
81+12 telehealth, or mobile care services may be used to
82+13 partially meet the network adequacy standards, if
83+14 applicable.
84+15 (6) A provision ensuring that whenever a beneficiary
85+16 has made a good faith effort, as evidenced by accessing
86+17 the provider directory, calling the network plan, and
87+18 calling the provider, to utilize preferred providers for a
88+19 covered service and it is determined the insurer does not
89+20 have the appropriate preferred providers due to
90+21 insufficient number, type, unreasonable travel distance or
91+22 delay, or preferred providers refusing to provide a
92+23 covered service because it is contrary to the conscience
93+24 of the preferred providers, as protected by the Health
94+25 Care Right of Conscience Act, the insurer shall ensure,
95+26 directly or indirectly, by terms contained in the payer
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106+1 contract, that the beneficiary will be provided the
107+2 covered service at no greater cost to the beneficiary than
108+3 if the service had been provided by a preferred provider.
109+4 This paragraph (6) does not apply to: (A) a beneficiary
110+5 who willfully chooses to access a non-preferred provider
111+6 for health care services available through the panel of
112+7 preferred providers, or (B) a beneficiary enrolled in a
113+8 health maintenance organization. In these circumstances,
114+9 the contractual requirements for non-preferred provider
115+10 reimbursements shall apply unless Section 356z.3a of the
116+11 Illinois Insurance Code requires otherwise. In no event
117+12 shall a beneficiary who receives care at a participating
118+13 health care facility be required to search for
119+14 participating providers under the circumstances described
120+15 in subsection (b) or (b-5) of Section 356z.3a of the
121+16 Illinois Insurance Code except under the circumstances
122+17 described in paragraph (2) of subsection (b-5).
123+18 (7) A provision that the beneficiary shall receive
124+19 emergency care coverage such that payment for this
125+20 coverage is not dependent upon whether the emergency
126+21 services are performed by a preferred or non-preferred
127+22 provider and the coverage shall be at the same benefit
128+23 level as if the service or treatment had been rendered by a
129+24 preferred provider. For purposes of this paragraph (7),
130+25 "the same benefit level" means that the beneficiary is
131+26 provided the covered service at no greater cost to the
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142+1 beneficiary than if the service had been provided by a
143+2 preferred provider. This provision shall be consistent
144+3 with Section 356z.3a of the Illinois Insurance Code.
145+4 (8) A limitation that, if the plan provides that the
146+5 beneficiary will incur a penalty for failing to
147+6 pre-certify inpatient hospital treatment, the penalty may
148+7 not exceed $1,000 per occurrence in addition to the plan
149+8 cost sharing provisions.
150+9 (c) The network plan shall demonstrate to the Director a
151+10 minimum ratio of providers to plan beneficiaries as required
152+11 by the Department.
153+12 (1) The ratio of physicians or other providers to plan
154+13 beneficiaries shall be established annually by the
155+14 Department in consultation with the Department of Public
156+15 Health based upon the guidance from the federal Centers
157+16 for Medicare and Medicaid Services. The Department shall
158+17 not establish ratios for vision or dental providers who
159+18 provide services under dental-specific or vision-specific
160+19 benefits. The Department shall consider establishing
161+20 ratios for the following physicians or other providers:
162+21 (A) Primary Care;
163+22 (B) Pediatrics;
164+23 (C) Cardiology;
165+24 (D) Gastroenterology;
166+25 (E) General Surgery;
167+26 (F) Neurology;
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178+1 (G) OB/GYN;
179+2 (H) Oncology/Radiation;
180+3 (I) Ophthalmology;
181+4 (J) Urology;
182+5 (K) Behavioral Health;
183+6 (L) Allergy/Immunology;
184+7 (M) Chiropractic;
185+8 (N) Dermatology;
186+9 (O) Endocrinology;
187+10 (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
188+11 (Q) Infectious Disease;
189+12 (R) Nephrology;
190+13 (S) Neurosurgery;
191+14 (T) Orthopedic Surgery;
192+15 (U) Physiatry/Rehabilitative;
193+16 (V) Plastic Surgery;
194+17 (W) Pulmonary;
195+18 (X) Rheumatology;
196+19 (Y) Anesthesiology;
197+20 (Z) Pain Medicine;
198+21 (AA) Pediatric Specialty Services;
199+22 (BB) Outpatient Dialysis; and
200+23 (CC) HIV.
201+24 (1.5) Beginning January 1, 2026, every insurer shall
202+25 demonstrate to the Director that each in-network hospital
203+26 has at least one radiologist, pathologist,
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214+1 anesthesiologist, and emergency room physician as a
215+2 preferred provider in a network plan. The Department may,
216+3 by rule, require additional types of hospital-based
217+4 medical specialists to be included as preferred providers
218+5 in each in-network hospital in a network plan.
219+6 (2) The Director shall establish a process for the
220+7 review of the adequacy of these standards, along with an
221+8 assessment of additional specialties to be included in the
222+9 list under this subsection (c).
223+10 (d) The network plan shall demonstrate to the Director
224+11 maximum travel and distance standards for plan beneficiaries,
225+12 which shall be established annually by the Department in
226+13 consultation with the Department of Public Health based upon
227+14 the guidance from the federal Centers for Medicare and
228+15 Medicaid Services. These standards shall consist of the
229+16 maximum minutes or miles to be traveled by a plan beneficiary
230+17 for each county type, such as large counties, metro counties,
231+18 or rural counties as defined by Department rule.
232+19 The maximum travel time and distance standards must
233+20 include standards for each physician and other provider
234+21 category listed for which ratios have been established.
235+22 The Director shall establish a process for the review of
236+23 the adequacy of these standards along with an assessment of
237+24 additional specialties to be included in the list under this
238+25 subsection (d).
239+26 (d-5)(1) Every insurer shall ensure that beneficiaries
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250+1 have timely and proximate access to treatment for mental,
251+2 emotional, nervous, or substance use disorders or conditions
252+3 in accordance with the provisions of paragraph (4) of
253+4 subsection (a) of Section 370c of the Illinois Insurance Code.
254+5 Insurers shall use a comparable process, strategy, evidentiary
255+6 standard, and other factors in the development and application
256+7 of the network adequacy standards for timely and proximate
257+8 access to treatment for mental, emotional, nervous, or
258+9 substance use disorders or conditions and those for the access
259+10 to treatment for medical and surgical conditions. As such, the
260+11 network adequacy standards for timely and proximate access
261+12 shall equally be applied to treatment facilities and providers
262+13 for mental, emotional, nervous, or substance use disorders or
263+14 conditions and specialists providing medical or surgical
264+15 benefits pursuant to the parity requirements of Section 370c.1
265+16 of the Illinois Insurance Code and the federal Paul Wellstone
266+17 and Pete Domenici Mental Health Parity and Addiction Equity
267+18 Act of 2008. Notwithstanding the foregoing, the network
268+19 adequacy standards for timely and proximate access to
269+20 treatment for mental, emotional, nervous, or substance use
270+21 disorders or conditions shall, at a minimum, satisfy the
271+22 following requirements:
272+23 (A) For beneficiaries residing in the metropolitan
273+24 counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
274+25 network adequacy standards for timely and proximate access
275+26 to treatment for mental, emotional, nervous, or substance
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286+1 use disorders or conditions means a beneficiary shall not
287+2 have to travel longer than 30 minutes or 30 miles from the
288+3 beneficiary's residence to receive outpatient treatment
289+4 for mental, emotional, nervous, or substance use disorders
290+5 or conditions. Beneficiaries shall not be required to wait
291+6 longer than 10 business days between requesting an initial
292+7 appointment and being seen by the facility or provider of
293+8 mental, emotional, nervous, or substance use disorders or
294+9 conditions for outpatient treatment or to wait longer than
295+10 20 business days between requesting a repeat or follow-up
296+11 appointment and being seen by the facility or provider of
297+12 mental, emotional, nervous, or substance use disorders or
298+13 conditions for outpatient treatment; however, subject to
299+14 the protections of paragraph (3) of this subsection, a
300+15 network plan shall not be held responsible if the
301+16 beneficiary or provider voluntarily chooses to schedule an
302+17 appointment outside of these required time frames.
303+18 (B) For beneficiaries residing in Illinois counties
304+19 other than those counties listed in subparagraph (A) of
305+20 this paragraph, network adequacy standards for timely and
306+21 proximate access to treatment for mental, emotional,
307+22 nervous, or substance use disorders or conditions means a
308+23 beneficiary shall not have to travel longer than 60
309+24 minutes or 60 miles from the beneficiary's residence to
310+25 receive outpatient treatment for mental, emotional,
311+26 nervous, or substance use disorders or conditions.
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322+1 Beneficiaries shall not be required to wait longer than 10
323+2 business days between requesting an initial appointment
324+3 and being seen by the facility or provider of mental,
325+4 emotional, nervous, or substance use disorders or
326+5 conditions for outpatient treatment or to wait longer than
327+6 20 business days between requesting a repeat or follow-up
328+7 appointment and being seen by the facility or provider of
329+8 mental, emotional, nervous, or substance use disorders or
330+9 conditions for outpatient treatment; however, subject to
331+10 the protections of paragraph (3) of this subsection, a
332+11 network plan shall not be held responsible if the
333+12 beneficiary or provider voluntarily chooses to schedule an
334+13 appointment outside of these required time frames.
335+14 (2) For beneficiaries residing in all Illinois counties,
336+15 network adequacy standards for timely and proximate access to
337+16 treatment for mental, emotional, nervous, or substance use
338+17 disorders or conditions means a beneficiary shall not have to
339+18 travel longer than 60 minutes or 60 miles from the
340+19 beneficiary's residence to receive inpatient or residential
341+20 treatment for mental, emotional, nervous, or substance use
342+21 disorders or conditions.
343+22 (3) If there is no in-network facility or provider
344+23 available for a beneficiary to receive timely and proximate
345+24 access to treatment for mental, emotional, nervous, or
346+25 substance use disorders or conditions in accordance with the
347+26 network adequacy standards outlined in this subsection, the
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358+1 insurer shall provide necessary exceptions to its network to
359+2 ensure admission and treatment with a provider or at a
360+3 treatment facility in accordance with the network adequacy
361+4 standards in this subsection.
362+5 (e) Except for network plans solely offered as a group
363+6 health plan, these ratio and time and distance standards apply
364+7 to the lowest cost-sharing tier of any tiered network.
365+8 (f) The network plan may consider use of other health care
366+9 service delivery options, such as telemedicine or telehealth,
367+10 mobile clinics, and centers of excellence, or other ways of
368+11 delivering care to partially meet the requirements set under
369+12 this Section.
370+13 (g) Except for the requirements set forth in subsection
371+14 (d-5), insurers who are not able to comply with the provider
372+15 ratios and time and distance standards established by the
373+16 Department may request an exception to these requirements from
374+17 the Department. The Department may grant an exception in the
375+18 following circumstances:
376+19 (1) if no providers or facilities meet the specific
377+20 time and distance standard in a specific service area and
378+21 the insurer (i) discloses information on the distance and
379+22 travel time points that beneficiaries would have to travel
380+23 beyond the required criterion to reach the next closest
381+24 contracted provider outside of the service area and (ii)
382+25 provides contact information, including names, addresses,
383+26 and phone numbers for the next closest contracted provider
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