Bill Text: IL HB1331 | 2025-2026 | 104th General Assembly | Introduced

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Bill Title: 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.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2025-01-28 - Referred to Rules Committee [HB1331 Detail]

Download: Illinois-2025-HB1331-Introduced.html

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104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1331 Introduced , by Rep. Sonya M. Harper 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.
LRB104 07370 BAB 17410 b
A BILL FOR
HB1331 LRB104 07370 BAB 17410 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Network Adequacy and Transparency Act is
amended by changing Section 10 as follows:
(215 ILCS 124/10)
(Text of Section from P.A. 103-650)
Sec. 10. Network adequacy.
(a) Before issuing, delivering, or renewing a network
plan, an issuer providing a network plan shall file a
description of all of the following with the Director:
(1) The written policies and procedures for adding
providers to meet patient needs based on increases in the
number of beneficiaries, changes in the
patient-to-provider ratio, changes in medical and health
care capabilities, and increased demand for services.
(2) The written policies and procedures for making
referrals within and outside the network.
(3) The written policies and procedures on how the
network plan will provide 24-hour, 7-day per week access
to network-affiliated primary care, emergency services,
and women's principal health care providers.
An issuer shall not prohibit a preferred provider from

HB1331 - 2 - LRB104 07370 BAB 17410 b
discussing any specific or all treatment options with
beneficiaries irrespective of the insurer's position on those
treatment options or from advocating on behalf of
beneficiaries within the utilization review, grievance, or
appeals processes established by the issuer in accordance with
any rights or remedies available under applicable State or
federal law.
(b) Before issuing, delivering, or renewing a network
plan, an issuer must file for review a description of the
services to be offered through a network plan. The description
shall include all of the following:
(1) A geographic map of the area proposed to be served
by the plan by county service area and zip code, including
marked locations for preferred providers.
(2) As deemed necessary by the Department, the names,
addresses, phone numbers, and specialties of the providers
who have entered into preferred provider agreements under
the network plan.
(3) The number of beneficiaries anticipated to be
covered by the network plan.
(4) An Internet website and toll-free telephone number
for beneficiaries and prospective beneficiaries to access
current and accurate lists of preferred providers in each
plan, additional information about the plan, as well as
any other information required by Department rule.
(5) A description of how health care services to be

HB1331 - 3 - LRB104 07370 BAB 17410 b
rendered under the network plan are reasonably accessible
and available to beneficiaries. The description shall
address all of the following:
(A) the type of health care services to be
provided by the network plan;
(B) the ratio of physicians and other providers to
beneficiaries, by specialty and including primary care
physicians and facility-based physicians when
applicable under the contract, necessary to meet the
health care needs and service demands of the currently
enrolled population;
(C) the travel and distance standards for plan
beneficiaries in county service areas; and
(D) a description of how the use of telemedicine,
telehealth, or mobile care services may be used to
partially meet the network adequacy standards, if
applicable.
(6) A provision ensuring that whenever a beneficiary
has made a good faith effort, as evidenced by accessing
the provider directory, calling the network plan, and
calling the provider, to utilize preferred providers for a
covered service and it is determined the insurer does not
have the appropriate preferred providers due to
insufficient number, type, unreasonable travel distance or
delay, or preferred providers refusing to provide a
covered service because it is contrary to the conscience

HB1331 - 4 - LRB104 07370 BAB 17410 b
of the preferred providers, as protected by the Health
Care Right of Conscience Act, the issuer shall ensure,
directly or indirectly, by terms contained in the payer
contract, that the beneficiary will be provided the
covered service at no greater cost to the beneficiary than
if the service had been provided by a preferred provider.
This paragraph (6) does not apply to: (A) a beneficiary
who willfully chooses to access a non-preferred provider
for health care services available through the panel of
preferred providers, or (B) a beneficiary enrolled in a
health maintenance organization. In these circumstances,
the contractual requirements for non-preferred provider
reimbursements shall apply unless Section 356z.3a of the
Illinois Insurance Code requires otherwise. In no event
shall a beneficiary who receives care at a participating
health care facility be required to search for
participating providers under the circumstances described
in subsection (b) or (b-5) of Section 356z.3a of the
Illinois Insurance Code except under the circumstances
described in paragraph (2) of subsection (b-5).
(7) A provision that the beneficiary shall receive
emergency care coverage such that payment for this
coverage is not dependent upon whether the emergency
services are performed by a preferred or non-preferred
provider and the coverage shall be at the same benefit
level as if the service or treatment had been rendered by a

HB1331 - 5 - LRB104 07370 BAB 17410 b
preferred provider. For purposes of this paragraph (7),
"the same benefit level" means that the beneficiary is
provided the covered service at no greater cost to the
beneficiary than if the service had been provided by a
preferred provider. This provision shall be consistent
with Section 356z.3a of the Illinois Insurance Code.
(8) A limitation that, if the plan provides that the
beneficiary will incur a penalty for failing to
pre-certify inpatient hospital treatment, the penalty may
not exceed $1,000 per occurrence in addition to the plan
cost sharing provisions.
(9) For a network plan to be offered through the
Exchange in the individual or small group market, as well
as any off-Exchange mirror of such a network plan,
evidence that the network plan includes essential
community providers in accordance with rules established
by the Exchange that will operate in this State for the
applicable plan year.
(c) The issuer shall demonstrate to the Director a minimum
ratio of providers to plan beneficiaries as required by the
Department for each network plan.
(1) The minimum ratio of physicians or other providers
to plan beneficiaries shall be established by the
Department in consultation with the Department of Public
Health based upon the guidance from the federal Centers
for Medicare and Medicaid Services. The Department shall

HB1331 - 6 - LRB104 07370 BAB 17410 b
not establish ratios for vision or dental providers who
provide services under dental-specific or vision-specific
benefits, except to the extent provided under federal law
for stand-alone dental plans. The Department shall
consider establishing ratios for the following physicians
or other providers:
(A) Primary Care;
(B) Pediatrics;
(C) Cardiology;
(D) Gastroenterology;
(E) General Surgery;
(F) Neurology;
(G) OB/GYN;
(H) Oncology/Radiation;
(I) Ophthalmology;
(J) Urology;
(K) Behavioral Health;
(L) Allergy/Immunology;
(M) Chiropractic;
(N) Dermatology;
(O) Endocrinology;
(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
(Q) Infectious Disease;
(R) Nephrology;
(S) Neurosurgery;
(T) Orthopedic Surgery;

HB1331 - 7 - LRB104 07370 BAB 17410 b
(U) Physiatry/Rehabilitative;
(V) Plastic Surgery;
(W) Pulmonary;
(X) Rheumatology;
(Y) Anesthesiology;
(Z) Pain Medicine;
(AA) Pediatric Specialty Services;
(BB) Outpatient Dialysis; and
(CC) HIV; and .
(DD) Genetic Medicine and Genetic Counseling.
(2) The Director shall establish a process for the
review of the adequacy of these standards, along with an
assessment of additional specialties to be included in the
list under this subsection (c).
(3) Notwithstanding any other law or rule, the minimum
ratio for each provider type shall be no less than any such
ratio established for qualified health plans in
Federally-Facilitated Exchanges by federal law or by the
federal Centers for Medicare and Medicaid Services, even
if the network plan is issued in the large group market or
is otherwise not issued through an exchange. Federal
standards for stand-alone dental plans shall only apply to
such network plans. In the absence of an applicable
Department rule, the federal standards shall apply for the
time period specified in the federal law, regulation, or
guidance. If the Centers for Medicare and Medicaid

HB1331 - 8 - LRB104 07370 BAB 17410 b
Services establish standards that are more stringent than
the standards in effect under any Department rule, the
Department may amend its rules to conform to the more
stringent federal standards.
(d) The network plan shall demonstrate to the Director
maximum travel and distance standards and appointment wait
time standards for plan beneficiaries, which shall be
established by the Department in consultation with the
Department of Public Health based upon the guidance from the
federal Centers for Medicare and Medicaid Services. These
standards shall consist of the maximum minutes or miles to be
traveled by a plan beneficiary for each county type, such as
large counties, metro counties, or rural counties as defined
by Department rule.
The maximum travel time and distance standards must
include standards for each physician and other provider
category listed for which ratios have been established.
The Director shall establish a process for the review of
the adequacy of these standards along with an assessment of
additional specialties to be included in the list under this
subsection (d).
Notwithstanding any other law or Department rule, the
maximum travel time and distance standards and appointment
wait time standards shall be no greater than any such
standards established for qualified health plans in
Federally-Facilitated Exchanges by federal law or by the

HB1331 - 9 - LRB104 07370 BAB 17410 b
federal Centers for Medicare and Medicaid Services, even if
the network plan is issued in the large group market or is
otherwise not issued through an exchange. Federal standards
for stand-alone dental plans shall only apply to such network
plans. In the absence of an applicable Department rule, the
federal standards shall apply for the time period specified in
the federal law, regulation, or guidance. If the Centers for
Medicare and Medicaid Services establish standards that are
more stringent than the standards in effect under any
Department rule, the Department may amend its rules to conform
to the more stringent federal standards.
If the federal area designations for the maximum time or
distance or appointment wait time standards required are
changed by the most recent Letter to Issuers in the
Federally-facilitated Marketplaces, the Department shall post
on its website notice of such changes and may amend its rules
to conform to those designations if the Director deems
appropriate.
(d-5)(1) Every issuer shall ensure that beneficiaries have
timely and proximate access to treatment for mental,
emotional, nervous, or substance use disorders or conditions
in accordance with the provisions of paragraph (4) of
subsection (a) of Section 370c of the Illinois Insurance Code.
Issuers shall use a comparable process, strategy, evidentiary
standard, and other factors in the development and application
of the network adequacy standards for timely and proximate

HB1331 - 10 - LRB104 07370 BAB 17410 b
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions and those for the access
to treatment for medical and surgical conditions. As such, the
network adequacy standards for timely and proximate access
shall equally be applied to treatment facilities and providers
for mental, emotional, nervous, or substance use disorders or
conditions and specialists providing medical or surgical
benefits pursuant to the parity requirements of Section 370c.1
of the Illinois Insurance Code and the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008. Notwithstanding the foregoing, the network
adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions shall, at a minimum, satisfy the
following requirements:
(A) For beneficiaries residing in the metropolitan
counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
network adequacy standards for timely and proximate access
to treatment for mental, emotional, nervous, or substance
use disorders or conditions means a beneficiary shall not
have to travel longer than 30 minutes or 30 miles from the
beneficiary's residence to receive outpatient treatment
for mental, emotional, nervous, or substance use disorders
or conditions. Beneficiaries shall not be required to wait
longer than 10 business days between requesting an initial
appointment and being seen by the facility or provider of

HB1331 - 11 - LRB104 07370 BAB 17410 b
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(B) For beneficiaries residing in Illinois counties
other than those counties listed in subparagraph (A) of
this paragraph, network adequacy standards for timely and
proximate access to treatment for mental, emotional,
nervous, or substance use disorders or conditions means a
beneficiary shall not have to travel longer than 60
minutes or 60 miles from the beneficiary's residence to
receive outpatient treatment for mental, emotional,
nervous, or substance use disorders or conditions.
Beneficiaries shall not be required to wait longer than 10
business days between requesting an initial appointment
and being seen by the facility or provider of mental,
emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of

HB1331 - 12 - LRB104 07370 BAB 17410 b
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(2) For beneficiaries residing in all Illinois counties,
network adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions means a beneficiary shall not have to
travel longer than 60 minutes or 60 miles from the
beneficiary's residence to receive inpatient or residential
treatment for mental, emotional, nervous, or substance use
disorders or conditions.
(3) If there is no in-network facility or provider
available for a beneficiary to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with the
network adequacy standards outlined in this subsection, the
issuer shall provide necessary exceptions to its network to
ensure admission and treatment with a provider or at a
treatment facility in accordance with the network adequacy
standards in this subsection.
(4) If the federal Centers for Medicare and Medicaid
Services establishes or law requires more stringent standards
for qualified health plans in the Federally-Facilitated

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Exchanges, the federal standards shall control for all network
plans for the time period specified in the federal law,
regulation, or guidance, even if the network plan is issued in
the large group market, is issued through a different type of
Exchange, or is otherwise not issued through an Exchange.
(e) Except for network plans solely offered as a group
health plan, these ratio and time and distance standards apply
to the lowest cost-sharing tier of any tiered network.
(f) The network plan may consider use of other health care
service delivery options, such as telemedicine or telehealth,
mobile clinics, and centers of excellence, or other ways of
delivering care to partially meet the requirements set under
this Section.
(g) Except for the requirements set forth in subsection
(d-5), issuers who are not able to comply with the provider
ratios and time and distance or appointment wait time
standards established under this Act or federal law may
request an exception to these requirements from the
Department. The Department may grant an exception in the
following circumstances:
(1) if no providers or facilities meet the specific
time and distance standard in a specific service area and
the issuer (i) discloses information on the distance and
travel time points that beneficiaries would have to travel
beyond the required criterion to reach the next closest
contracted provider outside of the service area and (ii)

HB1331 - 14 - LRB104 07370 BAB 17410 b
provides contact information, including names, addresses,
and phone numbers for the next closest contracted provider
or facility;
(2) if patterns of care in the service area do not
support the need for the requested number of provider or
facility type and the issuer provides data on local
patterns of care, such as claims data, referral patterns,
or local provider interviews, indicating where the
beneficiaries currently seek this type of care or where
the physicians currently refer beneficiaries, or both; or
(3) other circumstances deemed appropriate by the
Department consistent with the requirements of this Act.
(h) Issuers are required to report to the Director any
material change to an approved network plan within 15 business
days after the change occurs and any change that would result
in failure to meet the requirements of this Act. The issuer
shall submit a revised version of the portions of the network
adequacy filing affected by the material change, as determined
by the Director by rule, and the issuer shall attach versions
with the changes indicated for each document that was revised
from the previous version of the filing. Upon notice from the
issuer, the Director shall reevaluate the network plan's
compliance with the network adequacy and transparency
standards of this Act. For every day past 15 business days that
the issuer fails to submit a revised network adequacy filing
to the Director, the Director may order a fine of $5,000 per

HB1331 - 15 - LRB104 07370 BAB 17410 b
day.
(i) If a network plan is inadequate under this Act with
respect to a provider type in a county, and if the network plan
does not have an approved exception for that provider type in
that county pursuant to subsection (g), an issuer shall cover
out-of-network claims for covered health care services
received from that provider type within that county at the
in-network benefit level and shall retroactively adjudicate
and reimburse beneficiaries to achieve that objective if their
claims were processed at the out-of-network level contrary to
this subsection. Nothing in this subsection shall be construed
to supersede Section 356z.3a of the Illinois Insurance Code.
(j) If the Director determines that a network is
inadequate in any county and no exception has been granted
under subsection (g) and the issuer does not have a process in
place to comply with subsection (d-5), the Director may
prohibit the network plan from being issued or renewed within
that county until the Director determines that the network is
adequate apart from processes and exceptions described in
subsections (d-5) and (g). Nothing in this subsection shall be
construed to terminate any beneficiary's health insurance
coverage under a network plan before the expiration of the
beneficiary's policy period if the Director makes a
determination under this subsection after the issuance or
renewal of the beneficiary's policy or certificate because of
a material change. Policies or certificates issued or renewed

HB1331 - 16 - LRB104 07370 BAB 17410 b
in violation of this subsection may subject the issuer to a
civil penalty of $5,000 per policy.
(k) For the Department to enforce any new or modified
federal standard before the Department adopts the standard by
rule, the Department must, no later than May 15 before the
start of the plan year, give public notice to the affected
health insurance issuers through a bulletin.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
102-1117, eff. 1-13-23; 103-650, eff. 1-1-25.)
(Text of Section from P.A. 103-656)
Sec. 10. Network adequacy.
(a) An insurer providing a network plan shall file a
description of all of the following with the Director:
(1) The written policies and procedures for adding
providers to meet patient needs based on increases in the
number of beneficiaries, changes in the
patient-to-provider ratio, changes in medical and health
care capabilities, and increased demand for services.
(2) The written policies and procedures for making
referrals within and outside the network.
(3) The written policies and procedures on how the
network plan will provide 24-hour, 7-day per week access
to network-affiliated primary care, emergency services,
and women's principal health care providers.
An insurer shall not prohibit a preferred provider from

HB1331 - 17 - LRB104 07370 BAB 17410 b
discussing any specific or all treatment options with
beneficiaries irrespective of the insurer's position on those
treatment options or from advocating on behalf of
beneficiaries within the utilization review, grievance, or
appeals processes established by the insurer in accordance
with any rights or remedies available under applicable State
or federal law.
(b) Insurers must file for review a description of the
services to be offered through a network plan. The description
shall include all of the following:
(1) A geographic map of the area proposed to be served
by the plan by county service area and zip code, including
marked locations for preferred providers.
(2) As deemed necessary by the Department, the names,
addresses, phone numbers, and specialties of the providers
who have entered into preferred provider agreements under
the network plan.
(3) The number of beneficiaries anticipated to be
covered by the network plan.
(4) An Internet website and toll-free telephone number
for beneficiaries and prospective beneficiaries to access
current and accurate lists of preferred providers,
additional information about the plan, as well as any
other information required by Department rule.
(5) A description of how health care services to be
rendered under the network plan are reasonably accessible

HB1331 - 18 - LRB104 07370 BAB 17410 b
and available to beneficiaries. The description shall
address all of the following:
(A) the type of health care services to be
provided by the network plan;
(B) the ratio of physicians and other providers to
beneficiaries, by specialty and including primary care
physicians and facility-based physicians when
applicable under the contract, necessary to meet the
health care needs and service demands of the currently
enrolled population;
(C) the travel and distance standards for plan
beneficiaries in county service areas; and
(D) a description of how the use of telemedicine,
telehealth, or mobile care services may be used to
partially meet the network adequacy standards, if
applicable.
(6) A provision ensuring that whenever a beneficiary
has made a good faith effort, as evidenced by accessing
the provider directory, calling the network plan, and
calling the provider, to utilize preferred providers for a
covered service and it is determined the insurer does not
have the appropriate preferred providers due to
insufficient number, type, unreasonable travel distance or
delay, or preferred providers refusing to provide a
covered service because it is contrary to the conscience
of the preferred providers, as protected by the Health

HB1331 - 19 - LRB104 07370 BAB 17410 b
Care Right of Conscience Act, the insurer shall ensure,
directly or indirectly, by terms contained in the payer
contract, that the beneficiary will be provided the
covered service at no greater cost to the beneficiary than
if the service had been provided by a preferred provider.
This paragraph (6) does not apply to: (A) a beneficiary
who willfully chooses to access a non-preferred provider
for health care services available through the panel of
preferred providers, or (B) a beneficiary enrolled in a
health maintenance organization. In these circumstances,
the contractual requirements for non-preferred provider
reimbursements shall apply unless Section 356z.3a of the
Illinois Insurance Code requires otherwise. In no event
shall a beneficiary who receives care at a participating
health care facility be required to search for
participating providers under the circumstances described
in subsection (b) or (b-5) of Section 356z.3a of the
Illinois Insurance Code except under the circumstances
described in paragraph (2) of subsection (b-5).
(7) A provision that the beneficiary shall receive
emergency care coverage such that payment for this
coverage is not dependent upon whether the emergency
services are performed by a preferred or non-preferred
provider and the coverage shall be at the same benefit
level as if the service or treatment had been rendered by a
preferred provider. For purposes of this paragraph (7),

HB1331 - 20 - LRB104 07370 BAB 17410 b
"the same benefit level" means that the beneficiary is
provided the covered service at no greater cost to the
beneficiary than if the service had been provided by a
preferred provider. This provision shall be consistent
with Section 356z.3a of the Illinois Insurance Code.
(8) A limitation that complies with subsections (d)
and (e) of Section 55 of the Prior Authorization Reform
Act.
(c) The network plan shall demonstrate to the Director a
minimum ratio of providers to plan beneficiaries as required
by the Department.
(1) The ratio of physicians or other providers to plan
beneficiaries shall be established annually by the
Department in consultation with the Department of Public
Health based upon the guidance from the federal Centers
for Medicare and Medicaid Services. The Department shall
not establish ratios for vision or dental providers who
provide services under dental-specific or vision-specific
benefits. The Department shall consider establishing
ratios for the following physicians or other providers:
(A) Primary Care;
(B) Pediatrics;
(C) Cardiology;
(D) Gastroenterology;
(E) General Surgery;
(F) Neurology;

HB1331 - 21 - LRB104 07370 BAB 17410 b
(G) OB/GYN;
(H) Oncology/Radiation;
(I) Ophthalmology;
(J) Urology;
(K) Behavioral Health;
(L) Allergy/Immunology;
(M) Chiropractic;
(N) Dermatology;
(O) Endocrinology;
(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
(Q) Infectious Disease;
(R) Nephrology;
(S) Neurosurgery;
(T) Orthopedic Surgery;
(U) Physiatry/Rehabilitative;
(V) Plastic Surgery;
(W) Pulmonary;
(X) Rheumatology;
(Y) Anesthesiology;
(Z) Pain Medicine;
(AA) Pediatric Specialty Services;
(BB) Outpatient Dialysis; and
(CC) HIV; and .
(DD) Genetic Medicine and Genetic Counseling.
(2) The Director shall establish a process for the
review of the adequacy of these standards, along with an

HB1331 - 22 - LRB104 07370 BAB 17410 b
assessment of additional specialties to be included in the
list under this subsection (c).
(d) The network plan shall demonstrate to the Director
maximum travel and distance standards for plan beneficiaries,
which shall be established annually by the Department in
consultation with the Department of Public Health based upon
the guidance from the federal Centers for Medicare and
Medicaid Services. These standards shall consist of the
maximum minutes or miles to be traveled by a plan beneficiary
for each county type, such as large counties, metro counties,
or rural counties as defined by Department rule.
The maximum travel time and distance standards must
include standards for each physician and other provider
category listed for which ratios have been established.
The Director shall establish a process for the review of
the adequacy of these standards along with an assessment of
additional specialties to be included in the list under this
subsection (d).
(d-5)(1) Every insurer shall ensure that beneficiaries
have timely and proximate access to treatment for mental,
emotional, nervous, or substance use disorders or conditions
in accordance with the provisions of paragraph (4) of
subsection (a) of Section 370c of the Illinois Insurance Code.
Insurers shall use a comparable process, strategy, evidentiary
standard, and other factors in the development and application
of the network adequacy standards for timely and proximate

HB1331 - 23 - LRB104 07370 BAB 17410 b
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions and those for the access
to treatment for medical and surgical conditions. As such, the
network adequacy standards for timely and proximate access
shall equally be applied to treatment facilities and providers
for mental, emotional, nervous, or substance use disorders or
conditions and specialists providing medical or surgical
benefits pursuant to the parity requirements of Section 370c.1
of the Illinois Insurance Code and the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008. Notwithstanding the foregoing, the network
adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions shall, at a minimum, satisfy the
following requirements:
(A) For beneficiaries residing in the metropolitan
counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
network adequacy standards for timely and proximate access
to treatment for mental, emotional, nervous, or substance
use disorders or conditions means a beneficiary shall not
have to travel longer than 30 minutes or 30 miles from the
beneficiary's residence to receive outpatient treatment
for mental, emotional, nervous, or substance use disorders
or conditions. Beneficiaries shall not be required to wait
longer than 10 business days between requesting an initial
appointment and being seen by the facility or provider of

HB1331 - 24 - LRB104 07370 BAB 17410 b
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(B) For beneficiaries residing in Illinois counties
other than those counties listed in subparagraph (A) of
this paragraph, network adequacy standards for timely and
proximate access to treatment for mental, emotional,
nervous, or substance use disorders or conditions means a
beneficiary shall not have to travel longer than 60
minutes or 60 miles from the beneficiary's residence to
receive outpatient treatment for mental, emotional,
nervous, or substance use disorders or conditions.
Beneficiaries shall not be required to wait longer than 10
business days between requesting an initial appointment
and being seen by the facility or provider of mental,
emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of

HB1331 - 25 - LRB104 07370 BAB 17410 b
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(2) For beneficiaries residing in all Illinois counties,
network adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions means a beneficiary shall not have to
travel longer than 60 minutes or 60 miles from the
beneficiary's residence to receive inpatient or residential
treatment for mental, emotional, nervous, or substance use
disorders or conditions.
(3) If there is no in-network facility or provider
available for a beneficiary to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with the
network adequacy standards outlined in this subsection, the
insurer shall provide necessary exceptions to its network to
ensure admission and treatment with a provider or at a
treatment facility in accordance with the network adequacy
standards in this subsection.
(e) Except for network plans solely offered as a group
health plan, these ratio and time and distance standards apply
to the lowest cost-sharing tier of any tiered network.

HB1331 - 26 - LRB104 07370 BAB 17410 b
(f) The network plan may consider use of other health care
service delivery options, such as telemedicine or telehealth,
mobile clinics, and centers of excellence, or other ways of
delivering care to partially meet the requirements set under
this Section.
(g) Except for the requirements set forth in subsection
(d-5), insurers who are not able to comply with the provider
ratios and time and distance standards established by the
Department may request an exception to these requirements from
the Department. The Department may grant an exception in the
following circumstances:
(1) if no providers or facilities meet the specific
time and distance standard in a specific service area and
the insurer (i) discloses information on the distance and
travel time points that beneficiaries would have to travel
beyond the required criterion to reach the next closest
contracted provider outside of the service area and (ii)
provides contact information, including names, addresses,
and phone numbers for the next closest contracted provider
or facility;
(2) if patterns of care in the service area do not
support the need for the requested number of provider or
facility type and the insurer provides data on local
patterns of care, such as claims data, referral patterns,
or local provider interviews, indicating where the
beneficiaries currently seek this type of care or where

HB1331 - 27 - LRB104 07370 BAB 17410 b
the physicians currently refer beneficiaries, or both; or
(3) other circumstances deemed appropriate by the
Department consistent with the requirements of this Act.
(h) Insurers are required to report to the Director any
material change to an approved network plan within 15 days
after the change occurs and any change that would result in
failure to meet the requirements of this Act. Upon notice from
the insurer, the Director shall reevaluate the network plan's
compliance with the network adequacy and transparency
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
102-1117, eff. 1-13-23; 103-656, eff. 1-1-25.)
(Text of Section from P.A. 103-718)
Sec. 10. Network adequacy.
(a) An insurer providing a network plan shall file a
description of all of the following with the Director:
(1) The written policies and procedures for adding
providers to meet patient needs based on increases in the
number of beneficiaries, changes in the
patient-to-provider ratio, changes in medical and health
care capabilities, and increased demand for services.
(2) The written policies and procedures for making
referrals within and outside the network.
(3) The written policies and procedures on how the
network plan will provide 24-hour, 7-day per week access

HB1331 - 28 - LRB104 07370 BAB 17410 b
to network-affiliated primary care, emergency services,
and obstetrical and gynecological health care
professionals.
An insurer shall not prohibit a preferred provider from
discussing any specific or all treatment options with
beneficiaries irrespective of the insurer's position on those
treatment options or from advocating on behalf of
beneficiaries within the utilization review, grievance, or
appeals processes established by the insurer in accordance
with any rights or remedies available under applicable State
or federal law.
(b) Insurers must file for review a description of the
services to be offered through a network plan. The description
shall include all of the following:
(1) A geographic map of the area proposed to be served
by the plan by county service area and zip code, including
marked locations for preferred providers.
(2) As deemed necessary by the Department, the names,
addresses, phone numbers, and specialties of the providers
who have entered into preferred provider agreements under
the network plan.
(3) The number of beneficiaries anticipated to be
covered by the network plan.
(4) An Internet website and toll-free telephone number
for beneficiaries and prospective beneficiaries to access
current and accurate lists of preferred providers,

HB1331 - 29 - LRB104 07370 BAB 17410 b
additional information about the plan, as well as any
other information required by Department rule.
(5) A description of how health care services to be
rendered under the network plan are reasonably accessible
and available to beneficiaries. The description shall
address all of the following:
(A) the type of health care services to be
provided by the network plan;
(B) the ratio of physicians and other providers to
beneficiaries, by specialty and including primary care
physicians and facility-based physicians when
applicable under the contract, necessary to meet the
health care needs and service demands of the currently
enrolled population;
(C) the travel and distance standards for plan
beneficiaries in county service areas; and
(D) a description of how the use of telemedicine,
telehealth, or mobile care services may be used to
partially meet the network adequacy standards, if
applicable.
(6) A provision ensuring that whenever a beneficiary
has made a good faith effort, as evidenced by accessing
the provider directory, calling the network plan, and
calling the provider, to utilize preferred providers for a
covered service and it is determined the insurer does not
have the appropriate preferred providers due to

HB1331 - 30 - LRB104 07370 BAB 17410 b
insufficient number, type, unreasonable travel distance or
delay, or preferred providers refusing to provide a
covered service because it is contrary to the conscience
of the preferred providers, as protected by the Health
Care Right of Conscience Act, the insurer shall ensure,
directly or indirectly, by terms contained in the payer
contract, that the beneficiary will be provided the
covered service at no greater cost to the beneficiary than
if the service had been provided by a preferred provider.
This paragraph (6) does not apply to: (A) a beneficiary
who willfully chooses to access a non-preferred provider
for health care services available through the panel of
preferred providers, or (B) a beneficiary enrolled in a
health maintenance organization. In these circumstances,
the contractual requirements for non-preferred provider
reimbursements shall apply unless Section 356z.3a of the
Illinois Insurance Code requires otherwise. In no event
shall a beneficiary who receives care at a participating
health care facility be required to search for
participating providers under the circumstances described
in subsection (b) or (b-5) of Section 356z.3a of the
Illinois Insurance Code except under the circumstances
described in paragraph (2) of subsection (b-5).
(7) A provision that the beneficiary shall receive
emergency care coverage such that payment for this
coverage is not dependent upon whether the emergency

HB1331 - 31 - LRB104 07370 BAB 17410 b
services are performed by a preferred or non-preferred
provider and the coverage shall be at the same benefit
level as if the service or treatment had been rendered by a
preferred provider. For purposes of this paragraph (7),
"the same benefit level" means that the beneficiary is
provided the covered service at no greater cost to the
beneficiary than if the service had been provided by a
preferred provider. This provision shall be consistent
with Section 356z.3a of the Illinois Insurance Code.
(8) A limitation that, if the plan provides that the
beneficiary will incur a penalty for failing to
pre-certify inpatient hospital treatment, the penalty may
not exceed $1,000 per occurrence in addition to the plan
cost-sharing provisions.
(c) The network plan shall demonstrate to the Director a
minimum ratio of providers to plan beneficiaries as required
by the Department.
(1) The ratio of physicians or other providers to plan
beneficiaries shall be established annually by the
Department in consultation with the Department of Public
Health based upon the guidance from the federal Centers
for Medicare and Medicaid Services. The Department shall
not establish ratios for vision or dental providers who
provide services under dental-specific or vision-specific
benefits. The Department shall consider establishing
ratios for the following physicians or other providers:

HB1331 - 32 - LRB104 07370 BAB 17410 b
(A) Primary Care;
(B) Pediatrics;
(C) Cardiology;
(D) Gastroenterology;
(E) General Surgery;
(F) Neurology;
(G) OB/GYN;
(H) Oncology/Radiation;
(I) Ophthalmology;
(J) Urology;
(K) Behavioral Health;
(L) Allergy/Immunology;
(M) Chiropractic;
(N) Dermatology;
(O) Endocrinology;
(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
(Q) Infectious Disease;
(R) Nephrology;
(S) Neurosurgery;
(T) Orthopedic Surgery;
(U) Physiatry/Rehabilitative;
(V) Plastic Surgery;
(W) Pulmonary;
(X) Rheumatology;
(Y) Anesthesiology;
(Z) Pain Medicine;

HB1331 - 33 - LRB104 07370 BAB 17410 b
(AA) Pediatric Specialty Services;
(BB) Outpatient Dialysis; and
(CC) HIV; and .
(DD) Genetic Medicine and Genetic Counseling.
(2) The Director shall establish a process for the
review of the adequacy of these standards, along with an
assessment of additional specialties to be included in the
list under this subsection (c).
(d) The network plan shall demonstrate to the Director
maximum travel and distance standards for plan beneficiaries,
which shall be established annually by the Department in
consultation with the Department of Public Health based upon
the guidance from the federal Centers for Medicare and
Medicaid Services. These standards shall consist of the
maximum minutes or miles to be traveled by a plan beneficiary
for each county type, such as large counties, metro counties,
or rural counties as defined by Department rule.
The maximum travel time and distance standards must
include standards for each physician and other provider
category listed for which ratios have been established.
The Director shall establish a process for the review of
the adequacy of these standards along with an assessment of
additional specialties to be included in the list under this
subsection (d).
(d-5)(1) Every insurer shall ensure that beneficiaries
have timely and proximate access to treatment for mental,

HB1331 - 34 - LRB104 07370 BAB 17410 b
emotional, nervous, or substance use disorders or conditions
in accordance with the provisions of paragraph (4) of
subsection (a) of Section 370c of the Illinois Insurance Code.
Insurers shall use a comparable process, strategy, evidentiary
standard, and other factors in the development and application
of the network adequacy standards for timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions and those for the access
to treatment for medical and surgical conditions. As such, the
network adequacy standards for timely and proximate access
shall equally be applied to treatment facilities and providers
for mental, emotional, nervous, or substance use disorders or
conditions and specialists providing medical or surgical
benefits pursuant to the parity requirements of Section 370c.1
of the Illinois Insurance Code and the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008. Notwithstanding the foregoing, the network
adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions shall, at a minimum, satisfy the
following requirements:
(A) For beneficiaries residing in the metropolitan
counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
network adequacy standards for timely and proximate access
to treatment for mental, emotional, nervous, or substance
use disorders or conditions means a beneficiary shall not

HB1331 - 35 - LRB104 07370 BAB 17410 b
have to travel longer than 30 minutes or 30 miles from the
beneficiary's residence to receive outpatient treatment
for mental, emotional, nervous, or substance use disorders
or conditions. Beneficiaries shall not be required to wait
longer than 10 business days between requesting an initial
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(B) For beneficiaries residing in Illinois counties
other than those counties listed in subparagraph (A) of
this paragraph, network adequacy standards for timely and
proximate access to treatment for mental, emotional,
nervous, or substance use disorders or conditions means a
beneficiary shall not have to travel longer than 60
minutes or 60 miles from the beneficiary's residence to
receive outpatient treatment for mental, emotional,
nervous, or substance use disorders or conditions.
Beneficiaries shall not be required to wait longer than 10

HB1331 - 36 - LRB104 07370 BAB 17410 b
business days between requesting an initial appointment
and being seen by the facility or provider of mental,
emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(2) For beneficiaries residing in all Illinois counties,
network adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions means a beneficiary shall not have to
travel longer than 60 minutes or 60 miles from the
beneficiary's residence to receive inpatient or residential
treatment for mental, emotional, nervous, or substance use
disorders or conditions.
(3) If there is no in-network facility or provider
available for a beneficiary to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with the
network adequacy standards outlined in this subsection, the
insurer shall provide necessary exceptions to its network to

HB1331 - 37 - LRB104 07370 BAB 17410 b
ensure admission and treatment with a provider or at a
treatment facility in accordance with the network adequacy
standards in this subsection.
(e) Except for network plans solely offered as a group
health plan, these ratio and time and distance standards apply
to the lowest cost-sharing tier of any tiered network.
(f) The network plan may consider use of other health care
service delivery options, such as telemedicine or telehealth,
mobile clinics, and centers of excellence, or other ways of
delivering care to partially meet the requirements set under
this Section.
(g) Except for the requirements set forth in subsection
(d-5), insurers who are not able to comply with the provider
ratios and time and distance standards established by the
Department may request an exception to these requirements from
the Department. The Department may grant an exception in the
following circumstances:
(1) if no providers or facilities meet the specific
time and distance standard in a specific service area and
the insurer (i) discloses information on the distance and
travel time points that beneficiaries would have to travel
beyond the required criterion to reach the next closest
contracted provider outside of the service area and (ii)
provides contact information, including names, addresses,
and phone numbers for the next closest contracted provider
or facility;

HB1331 - 38 - LRB104 07370 BAB 17410 b
(2) if patterns of care in the service area do not
support the need for the requested number of provider or
facility type and the insurer provides data on local
patterns of care, such as claims data, referral patterns,
or local provider interviews, indicating where the
beneficiaries currently seek this type of care or where
the physicians currently refer beneficiaries, or both; or
(3) other circumstances deemed appropriate by the
Department consistent with the requirements of this Act.
(h) Insurers are required to report to the Director any
material change to an approved network plan within 15 days
after the change occurs and any change that would result in
failure to meet the requirements of this Act. Upon notice from
the insurer, the Director shall reevaluate the network plan's
compliance with the network adequacy and transparency
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
102-1117, eff. 1-13-23; 103-718, eff. 7-19-24.)
(Text of Section from P.A. 103-777)
Sec. 10. Network adequacy.
(a) An insurer providing a network plan shall file a
description of all of the following with the Director:
(1) The written policies and procedures for adding
providers to meet patient needs based on increases in the
number of beneficiaries, changes in the

HB1331 - 39 - LRB104 07370 BAB 17410 b
patient-to-provider ratio, changes in medical and health
care capabilities, and increased demand for services.
(2) The written policies and procedures for making
referrals within and outside the network.
(3) The written policies and procedures on how the
network plan will provide 24-hour, 7-day per week access
to network-affiliated primary care, emergency services,
and women's principal health care providers.
An insurer shall not prohibit a preferred provider from
discussing any specific or all treatment options with
beneficiaries irrespective of the insurer's position on those
treatment options or from advocating on behalf of
beneficiaries within the utilization review, grievance, or
appeals processes established by the insurer in accordance
with any rights or remedies available under applicable State
or federal law.
(b) Insurers must file for review a description of the
services to be offered through a network plan. The description
shall include all of the following:
(1) A geographic map of the area proposed to be served
by the plan by county service area and zip code, including
marked locations for preferred providers.
(2) As deemed necessary by the Department, the names,
addresses, phone numbers, and specialties of the providers
who have entered into preferred provider agreements under
the network plan.

HB1331 - 40 - LRB104 07370 BAB 17410 b
(3) The number of beneficiaries anticipated to be
covered by the network plan.
(4) An Internet website and toll-free telephone number
for beneficiaries and prospective beneficiaries to access
current and accurate lists of preferred providers,
additional information about the plan, as well as any
other information required by Department rule.
(5) A description of how health care services to be
rendered under the network plan are reasonably accessible
and available to beneficiaries. The description shall
address all of the following:
(A) the type of health care services to be
provided by the network plan;
(B) the ratio of physicians and other providers to
beneficiaries, by specialty and including primary care
physicians and facility-based physicians when
applicable under the contract, necessary to meet the
health care needs and service demands of the currently
enrolled population;
(C) the travel and distance standards for plan
beneficiaries in county service areas; and
(D) a description of how the use of telemedicine,
telehealth, or mobile care services may be used to
partially meet the network adequacy standards, if
applicable.
(6) A provision ensuring that whenever a beneficiary

HB1331 - 41 - LRB104 07370 BAB 17410 b
has made a good faith effort, as evidenced by accessing
the provider directory, calling the network plan, and
calling the provider, to utilize preferred providers for a
covered service and it is determined the insurer does not
have the appropriate preferred providers due to
insufficient number, type, unreasonable travel distance or
delay, or preferred providers refusing to provide a
covered service because it is contrary to the conscience
of the preferred providers, as protected by the Health
Care Right of Conscience Act, the insurer shall ensure,
directly or indirectly, by terms contained in the payer
contract, that the beneficiary will be provided the
covered service at no greater cost to the beneficiary than
if the service had been provided by a preferred provider.
This paragraph (6) does not apply to: (A) a beneficiary
who willfully chooses to access a non-preferred provider
for health care services available through the panel of
preferred providers, or (B) a beneficiary enrolled in a
health maintenance organization. In these circumstances,
the contractual requirements for non-preferred provider
reimbursements shall apply unless Section 356z.3a of the
Illinois Insurance Code requires otherwise. In no event
shall a beneficiary who receives care at a participating
health care facility be required to search for
participating providers under the circumstances described
in subsection (b) or (b-5) of Section 356z.3a of the

HB1331 - 42 - LRB104 07370 BAB 17410 b
Illinois Insurance Code except under the circumstances
described in paragraph (2) of subsection (b-5).
(7) A provision that the beneficiary shall receive
emergency care coverage such that payment for this
coverage is not dependent upon whether the emergency
services are performed by a preferred or non-preferred
provider and the coverage shall be at the same benefit
level as if the service or treatment had been rendered by a
preferred provider. For purposes of this paragraph (7),
"the same benefit level" means that the beneficiary is
provided the covered service at no greater cost to the
beneficiary than if the service had been provided by a
preferred provider. This provision shall be consistent
with Section 356z.3a of the Illinois Insurance Code.
(8) A limitation that, if the plan provides that the
beneficiary will incur a penalty for failing to
pre-certify inpatient hospital treatment, the penalty may
not exceed $1,000 per occurrence in addition to the plan
cost sharing provisions.
(c) The network plan shall demonstrate to the Director a
minimum ratio of providers to plan beneficiaries as required
by the Department.
(1) The ratio of physicians or other providers to plan
beneficiaries shall be established annually by the
Department in consultation with the Department of Public
Health based upon the guidance from the federal Centers

HB1331 - 43 - LRB104 07370 BAB 17410 b
for Medicare and Medicaid Services. The Department shall
not establish ratios for vision or dental providers who
provide services under dental-specific or vision-specific
benefits, except to the extent provided under federal law
for stand-alone dental plans. The Department shall
consider establishing ratios for the following physicians
or other providers:
(A) Primary Care;
(B) Pediatrics;
(C) Cardiology;
(D) Gastroenterology;
(E) General Surgery;
(F) Neurology;
(G) OB/GYN;
(H) Oncology/Radiation;
(I) Ophthalmology;
(J) Urology;
(K) Behavioral Health;
(L) Allergy/Immunology;
(M) Chiropractic;
(N) Dermatology;
(O) Endocrinology;
(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
(Q) Infectious Disease;
(R) Nephrology;
(S) Neurosurgery;

HB1331 - 44 - LRB104 07370 BAB 17410 b
(T) Orthopedic Surgery;
(U) Physiatry/Rehabilitative;
(V) Plastic Surgery;
(W) Pulmonary;
(X) Rheumatology;
(Y) Anesthesiology;
(Z) Pain Medicine;
(AA) Pediatric Specialty Services;
(BB) Outpatient Dialysis; and
(CC) HIV; and .
(DD) Genetic Medicine and Genetic Counseling.
(2) The Director shall establish a process for the
review of the adequacy of these standards, along with an
assessment of additional specialties to be included in the
list under this subsection (c).
(3) If the federal Centers for Medicare and Medicaid
Services establishes minimum provider ratios for
stand-alone dental plans in the type of exchange in use in
this State for a given plan year, the Department shall
enforce those standards for stand-alone dental plans for
that plan year.
(d) The network plan shall demonstrate to the Director
maximum travel and distance standards for plan beneficiaries,
which shall be established annually by the Department in
consultation with the Department of Public Health based upon
the guidance from the federal Centers for Medicare and

HB1331 - 45 - LRB104 07370 BAB 17410 b
Medicaid Services. These standards shall consist of the
maximum minutes or miles to be traveled by a plan beneficiary
for each county type, such as large counties, metro counties,
or rural counties as defined by Department rule.
The maximum travel time and distance standards must
include standards for each physician and other provider
category listed for which ratios have been established.
The Director shall establish a process for the review of
the adequacy of these standards along with an assessment of
additional specialties to be included in the list under this
subsection (d).
If the federal Centers for Medicare and Medicaid Services
establishes appointment wait-time standards for qualified
health plans, including stand-alone dental plans, in the type
of exchange in use in this State for a given plan year, the
Department shall enforce those standards for the same types of
qualified health plans for that plan year. If the federal
Centers for Medicare and Medicaid Services establishes time
and distance standards for stand-alone dental plans in the
type of exchange in use in this State for a given plan year,
the Department shall enforce those standards for stand-alone
dental plans for that plan year.
(d-5)(1) Every insurer shall ensure that beneficiaries
have timely and proximate access to treatment for mental,
emotional, nervous, or substance use disorders or conditions
in accordance with the provisions of paragraph (4) of

HB1331 - 46 - LRB104 07370 BAB 17410 b
subsection (a) of Section 370c of the Illinois Insurance Code.
Insurers shall use a comparable process, strategy, evidentiary
standard, and other factors in the development and application
of the network adequacy standards for timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions and those for the access
to treatment for medical and surgical conditions. As such, the
network adequacy standards for timely and proximate access
shall equally be applied to treatment facilities and providers
for mental, emotional, nervous, or substance use disorders or
conditions and specialists providing medical or surgical
benefits pursuant to the parity requirements of Section 370c.1
of the Illinois Insurance Code and the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008. Notwithstanding the foregoing, the network
adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions shall, at a minimum, satisfy the
following requirements:
(A) For beneficiaries residing in the metropolitan
counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
network adequacy standards for timely and proximate access
to treatment for mental, emotional, nervous, or substance
use disorders or conditions means a beneficiary shall not
have to travel longer than 30 minutes or 30 miles from the
beneficiary's residence to receive outpatient treatment

HB1331 - 47 - LRB104 07370 BAB 17410 b
for mental, emotional, nervous, or substance use disorders
or conditions. Beneficiaries shall not be required to wait
longer than 10 business days between requesting an initial
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(B) For beneficiaries residing in Illinois counties
other than those counties listed in subparagraph (A) of
this paragraph, network adequacy standards for timely and
proximate access to treatment for mental, emotional,
nervous, or substance use disorders or conditions means a
beneficiary shall not have to travel longer than 60
minutes or 60 miles from the beneficiary's residence to
receive outpatient treatment for mental, emotional,
nervous, or substance use disorders or conditions.
Beneficiaries shall not be required to wait longer than 10
business days between requesting an initial appointment
and being seen by the facility or provider of mental,

HB1331 - 48 - LRB104 07370 BAB 17410 b
emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(2) For beneficiaries residing in all Illinois counties,
network adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions means a beneficiary shall not have to
travel longer than 60 minutes or 60 miles from the
beneficiary's residence to receive inpatient or residential
treatment for mental, emotional, nervous, or substance use
disorders or conditions.
(3) If there is no in-network facility or provider
available for a beneficiary to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with the
network adequacy standards outlined in this subsection, the
insurer shall provide necessary exceptions to its network to
ensure admission and treatment with a provider or at a
treatment facility in accordance with the network adequacy

HB1331 - 49 - LRB104 07370 BAB 17410 b
standards in this subsection.
(4) If the federal Centers for Medicare and Medicaid
Services establishes a more stringent standard in any county
than specified in paragraph (1) or (2) of this subsection
(d-5) for qualified health plans in the type of exchange in use
in this State for a given plan year, the federal standard shall
apply in lieu of the standard in paragraph (1) or (2) of this
subsection (d-5) for qualified health plans for that plan
year.
(e) Except for network plans solely offered as a group
health plan, these ratio and time and distance standards apply
to the lowest cost-sharing tier of any tiered network.
(f) The network plan may consider use of other health care
service delivery options, such as telemedicine or telehealth,
mobile clinics, and centers of excellence, or other ways of
delivering care to partially meet the requirements set under
this Section.
(g) Except for the requirements set forth in subsection
(d-5), insurers who are not able to comply with the provider
ratios, time and distance standards, and appointment wait-time
standards established under this Act or federal law may
request an exception to these requirements from the
Department. The Department may grant an exception in the
following circumstances:
(1) if no providers or facilities meet the specific
time and distance standard in a specific service area and

HB1331 - 50 - LRB104 07370 BAB 17410 b
the insurer (i) discloses information on the distance and
travel time points that beneficiaries would have to travel
beyond the required criterion to reach the next closest
contracted provider outside of the service area and (ii)
provides contact information, including names, addresses,
and phone numbers for the next closest contracted provider
or facility;
(2) if patterns of care in the service area do not
support the need for the requested number of provider or
facility type and the insurer provides data on local
patterns of care, such as claims data, referral patterns,
or local provider interviews, indicating where the
beneficiaries currently seek this type of care or where
the physicians currently refer beneficiaries, or both; or
(3) other circumstances deemed appropriate by the
Department consistent with the requirements of this Act.
(h) Insurers are required to report to the Director any
material change to an approved network plan within 15 days
after the change occurs and any change that would result in
failure to meet the requirements of this Act. Upon notice from
the insurer, the Director shall reevaluate the network plan's
compliance with the network adequacy and transparency
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
102-1117, eff. 1-13-23; 103-777, eff. 1-1-25.)

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(Text of Section from P.A. 103-906)
Sec. 10. Network adequacy.
(a) An insurer providing a network plan shall file a
description of all of the following with the Director:
(1) The written policies and procedures for adding
providers to meet patient needs based on increases in the
number of beneficiaries, changes in the
patient-to-provider ratio, changes in medical and health
care capabilities, and increased demand for services.
(2) The written policies and procedures for making
referrals within and outside the network.
(3) The written policies and procedures on how the
network plan will provide 24-hour, 7-day per week access
to network-affiliated primary care, emergency services,
and women's principal health care providers.
An insurer shall not prohibit a preferred provider from
discussing any specific or all treatment options with
beneficiaries irrespective of the insurer's position on those
treatment options or from advocating on behalf of
beneficiaries within the utilization review, grievance, or
appeals processes established by the insurer in accordance
with any rights or remedies available under applicable State
or federal law.
(b) Insurers must file for review a description of the
services to be offered through a network plan. The description
shall include all of the following:

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(1) A geographic map of the area proposed to be served
by the plan by county service area and zip code, including
marked locations for preferred providers.
(2) As deemed necessary by the Department, the names,
addresses, phone numbers, and specialties of the providers
who have entered into preferred provider agreements under
the network plan.
(3) The number of beneficiaries anticipated to be
covered by the network plan.
(4) An Internet website and toll-free telephone number
for beneficiaries and prospective beneficiaries to access
current and accurate lists of preferred providers,
additional information about the plan, as well as any
other information required by Department rule.
(5) A description of how health care services to be
rendered under the network plan are reasonably accessible
and available to beneficiaries. The description shall
address all of the following:
(A) the type of health care services to be
provided by the network plan;
(B) the ratio of physicians and other providers to
beneficiaries, by specialty and including primary care
physicians and facility-based physicians when
applicable under the contract, necessary to meet the
health care needs and service demands of the currently
enrolled population;

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(C) the travel and distance standards for plan
beneficiaries in county service areas; and
(D) a description of how the use of telemedicine,
telehealth, or mobile care services may be used to
partially meet the network adequacy standards, if
applicable.
(6) A provision ensuring that whenever a beneficiary
has made a good faith effort, as evidenced by accessing
the provider directory, calling the network plan, and
calling the provider, to utilize preferred providers for a
covered service and it is determined the insurer does not
have the appropriate preferred providers due to
insufficient number, type, unreasonable travel distance or
delay, or preferred providers refusing to provide a
covered service because it is contrary to the conscience
of the preferred providers, as protected by the Health
Care Right of Conscience Act, the insurer shall ensure,
directly or indirectly, by terms contained in the payer
contract, that the beneficiary will be provided the
covered service at no greater cost to the beneficiary than
if the service had been provided by a preferred provider.
This paragraph (6) does not apply to: (A) a beneficiary
who willfully chooses to access a non-preferred provider
for health care services available through the panel of
preferred providers, or (B) a beneficiary enrolled in a
health maintenance organization. In these circumstances,

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the contractual requirements for non-preferred provider
reimbursements shall apply unless Section 356z.3a of the
Illinois Insurance Code requires otherwise. In no event
shall a beneficiary who receives care at a participating
health care facility be required to search for
participating providers under the circumstances described
in subsection (b) or (b-5) of Section 356z.3a of the
Illinois Insurance Code except under the circumstances
described in paragraph (2) of subsection (b-5).
(7) A provision that the beneficiary shall receive
emergency care coverage such that payment for this
coverage is not dependent upon whether the emergency
services are performed by a preferred or non-preferred
provider and the coverage shall be at the same benefit
level as if the service or treatment had been rendered by a
preferred provider. For purposes of this paragraph (7),
"the same benefit level" means that the beneficiary is
provided the covered service at no greater cost to the
beneficiary than if the service had been provided by a
preferred provider. This provision shall be consistent
with Section 356z.3a of the Illinois Insurance Code.
(8) A limitation that, if the plan provides that the
beneficiary will incur a penalty for failing to
pre-certify inpatient hospital treatment, the penalty may
not exceed $1,000 per occurrence in addition to the plan
cost sharing provisions.

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(c) The network plan shall demonstrate to the Director a
minimum ratio of providers to plan beneficiaries as required
by the Department.
(1) The ratio of physicians or other providers to plan
beneficiaries shall be established annually by the
Department in consultation with the Department of Public
Health based upon the guidance from the federal Centers
for Medicare and Medicaid Services. The Department shall
not establish ratios for vision or dental providers who
provide services under dental-specific or vision-specific
benefits. The Department shall consider establishing
ratios for the following physicians or other providers:
(A) Primary Care;
(B) Pediatrics;
(C) Cardiology;
(D) Gastroenterology;
(E) General Surgery;
(F) Neurology;
(G) OB/GYN;
(H) Oncology/Radiation;
(I) Ophthalmology;
(J) Urology;
(K) Behavioral Health;
(L) Allergy/Immunology;
(M) Chiropractic;
(N) Dermatology;

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(O) Endocrinology;
(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
(Q) Infectious Disease;
(R) Nephrology;
(S) Neurosurgery;
(T) Orthopedic Surgery;
(U) Physiatry/Rehabilitative;
(V) Plastic Surgery;
(W) Pulmonary;
(X) Rheumatology;
(Y) Anesthesiology;
(Z) Pain Medicine;
(AA) Pediatric Specialty Services;
(BB) Outpatient Dialysis; and
(CC) HIV; and .
(DD) Genetic Medicine and Genetic Counseling.
(1.5) Beginning January 1, 2026, every insurer shall
demonstrate to the Director that each in-network hospital
has at least one radiologist, pathologist,
anesthesiologist, and emergency room physician as a
preferred provider in a network plan. The Department may,
by rule, require additional types of hospital-based
medical specialists to be included as preferred providers
in each in-network hospital in a network plan.
(2) The Director shall establish a process for the
review of the adequacy of these standards, along with an

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assessment of additional specialties to be included in the
list under this subsection (c).
(d) The network plan shall demonstrate to the Director
maximum travel and distance standards for plan beneficiaries,
which shall be established annually by the Department in
consultation with the Department of Public Health based upon
the guidance from the federal Centers for Medicare and
Medicaid Services. These standards shall consist of the
maximum minutes or miles to be traveled by a plan beneficiary
for each county type, such as large counties, metro counties,
or rural counties as defined by Department rule.
The maximum travel time and distance standards must
include standards for each physician and other provider
category listed for which ratios have been established.
The Director shall establish a process for the review of
the adequacy of these standards along with an assessment of
additional specialties to be included in the list under this
subsection (d).
(d-5)(1) Every insurer shall ensure that beneficiaries
have timely and proximate access to treatment for mental,
emotional, nervous, or substance use disorders or conditions
in accordance with the provisions of paragraph (4) of
subsection (a) of Section 370c of the Illinois Insurance Code.
Insurers shall use a comparable process, strategy, evidentiary
standard, and other factors in the development and application
of the network adequacy standards for timely and proximate

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access to treatment for mental, emotional, nervous, or
substance use disorders or conditions and those for the access
to treatment for medical and surgical conditions. As such, the
network adequacy standards for timely and proximate access
shall equally be applied to treatment facilities and providers
for mental, emotional, nervous, or substance use disorders or
conditions and specialists providing medical or surgical
benefits pursuant to the parity requirements of Section 370c.1
of the Illinois Insurance Code and the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008. Notwithstanding the foregoing, the network
adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions shall, at a minimum, satisfy the
following requirements:
(A) For beneficiaries residing in the metropolitan
counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
network adequacy standards for timely and proximate access
to treatment for mental, emotional, nervous, or substance
use disorders or conditions means a beneficiary shall not
have to travel longer than 30 minutes or 30 miles from the
beneficiary's residence to receive outpatient treatment
for mental, emotional, nervous, or substance use disorders
or conditions. Beneficiaries shall not be required to wait
longer than 10 business days between requesting an initial
appointment and being seen by the facility or provider of

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mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(B) For beneficiaries residing in Illinois counties
other than those counties listed in subparagraph (A) of
this paragraph, network adequacy standards for timely and
proximate access to treatment for mental, emotional,
nervous, or substance use disorders or conditions means a
beneficiary shall not have to travel longer than 60
minutes or 60 miles from the beneficiary's residence to
receive outpatient treatment for mental, emotional,
nervous, or substance use disorders or conditions.
Beneficiaries shall not be required to wait longer than 10
business days between requesting an initial appointment
and being seen by the facility or provider of mental,
emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of

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mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(2) For beneficiaries residing in all Illinois counties,
network adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions means a beneficiary shall not have to
travel longer than 60 minutes or 60 miles from the
beneficiary's residence to receive inpatient or residential
treatment for mental, emotional, nervous, or substance use
disorders or conditions.
(3) If there is no in-network facility or provider
available for a beneficiary to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with the
network adequacy standards outlined in this subsection, the
insurer shall provide necessary exceptions to its network to
ensure admission and treatment with a provider or at a
treatment facility in accordance with the network adequacy
standards in this subsection.
(e) Except for network plans solely offered as a group
health plan, these ratio and time and distance standards apply
to the lowest cost-sharing tier of any tiered network.

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(f) The network plan may consider use of other health care
service delivery options, such as telemedicine or telehealth,
mobile clinics, and centers of excellence, or other ways of
delivering care to partially meet the requirements set under
this Section.
(g) Except for the requirements set forth in subsection
(d-5), insurers who are not able to comply with the provider
ratios and time and distance standards established by the
Department may request an exception to these requirements from
the Department. The Department may grant an exception in the
following circumstances:
(1) if no providers or facilities meet the specific
time and distance standard in a specific service area and
the insurer (i) discloses information on the distance and
travel time points that beneficiaries would have to travel
beyond the required criterion to reach the next closest
contracted provider outside of the service area and (ii)
provides contact information, including names, addresses,
and phone numbers for the next closest contracted provider
or facility;
(2) if patterns of care in the service area do not
support the need for the requested number of provider or
facility type and the insurer provides data on local
patterns of care, such as claims data, referral patterns,
or local provider interviews, indicating where the
beneficiaries currently seek this type of care or where

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