Illinois-2023-HB4126-Introduced

103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4126

Introduced , by Rep. Sue Scherer

SYNOPSIS AS INTRODUCED:

See Index

Amends the Illinois Insurance Code. Adds provisions concerning market analysis and market conduct actions. Makes changes to provisions concerning market conduct and non-financial examinations, examination reports, insurance compliance self-evaluative privilege, confidentiality, fees and charges, examination, and fiduciary and bonding requirements. Amends the Network Adequacy and Transparency Act. Adds definitions. Establishes minimum ratios of providers to beneficiaries for network plans issued, delivered, amended, or renewed during 2024. Makes changes to provisions concerning network adequacy, notice of nonrenewal or termination, transition of services, network transparency, administration and enforcement, and provider requirements. Amends the Managed Care Reform and Patient Rights Act. Makes changes to provisions concerning notice of nonrenewal or termination and transition of services. Amends the Illinois Administrative Procedure Act to authorize the Department of Insurance to adopt emergency rules implementing federal standards for provider ratios, time and distance, or appointment wait times when such standards apply to health insurance coverage regulated by the Department of Insurance and are more stringent than the State standards extant at the time the final

federal standards are published. Effective immediately.

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A BILL FOR

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1 AN ACT concerning regulation.

2 Be it enacted by the People of the State of Illinois,

3 represented in the General Assembly:

4 Section 5. The Illinois Administrative Procedure Act is

5 amended by adding Section 5-45.21 as follows:

6 (5 ILCS 100/5-45.21 new)

7 Sec. 5-45.21. Emergency rulemaking; Network Adequacy and

8 Transparency Act. To provide for the expeditious and timely

9 implementation of the Network Adequacy and Transparency Act,

10 emergency rules implementing federal standards for provider

11 ratios, travel time and distance, and appointment wait times

12 if such standards apply to health insurance coverage regulated

13 by the Department of Insurance and are more stringent than the

14 State standards extant at the time the final federal standards

15 are published may be adopted in accordance with Section 5-45

16 by the Department of Insurance. The adoption of emergency

17 rules authorized by Section 5-45 and this Section is deemed to

18 be necessary for the public interest, safety, and welfare.

19 Section 10. The Illinois Insurance Code is amended by

20 changing Sections 132, 132.5, 155.35, 402, 408, 511.109,

21 512-3, 512-5, and 513b3 and by adding Section 512-11 as

22 follows:

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1 (215 ILCS 5/132) (from Ch. 73, par. 744)

2 Sec. 132. Market conduct and non-financial examinations.

3 (a) Definitions.

4 As used in this Section:

5 "Desk examination" means an examination conducted by

6 market conduct surveillance personnel at a location other than

7 the regulated person's premises. A "desk examination" is

8 usually performed at the Department's offices with the insurer

9 providing requested documents by hard copy, microfiche, discs,

10 or other electronic media for review without an on-site

11 examination.

12 "Market analysis" means a process whereby market conduct

13 surveillance personnel collect and analyze information from

14 filed schedules, surveys, data calls, required reports, and

15 other sources in order to develop a baseline understanding of

16 the marketplace and to identify patterns or practices of

17 regulated persons that deviate significantly from the norm or

18 that may pose a potential risk to the insurance consumer.

19 "Market conduct action" means any of the full range of

20 activities that the Director may initiate to assess and

21 address the market practices of regulated persons, including,

22 but not limited to, market analysis and market conduct

23 examinations. "Market conduct action" does not include the

24 Department's consumer complaint process outlined in 50 Ill.

25 Adm. Code 926; however, the Department may initiate market

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1 conduct actions based on information gathered during that

2 process. Examples of "market conduct action" include, but are

3 not limited to:

4 (1) correspondence with the company or person;

5 (2) interviews with the company or person;

6 (3) information gathering;

7 (4) reviews of policies and procedures;

8 (5) interrogatories;

9 (6) reviews of self-evaluations and voluntary

10 compliance programs of the person or company;

11 (7) self-audits; and

12 (8) market conduct examinations.

13 "Market conduct examination" or "examination" means any

14 type of examination described in the NAIC Market Regulation

15 Handbook that may be used to assess a regulated person's

16 compliance with the laws, rules, and regulations applicable to

17 the examinee. "Market conduct examination" includes

18 comprehensive examinations, targeted examinations, and

19 follow-up examinations. Market conduct examinations may be

20 conducted as desk examinations, on-site examinations, or a

21 combination of those 2 types of examinations.

22 "Market conduct surveillance" means market analysis or a

23 market conduct action.

24 "Market conduct surveillance personnel" means those

25 individuals employed or retained by the Department and

26 designated by the Director to collect, analyze, review, or act

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1 on information in the insurance marketplace that identifies

2 patterns or practices of insurers. "Market conduct

3 surveillance personnel" includes all persons identified as an

4 examiner in the insurance laws or rules of this State if the

5 Director has designated those persons to assist the Director

6 in ascertaining the non-financial business practices,

7 performance, and operations of a company or person subject to

8 the Director's jurisdiction.

9 "NAIC" means the National Association of Insurance

10 Commissioners.

11 "On-site examination" means an examination conducted at

12 the insurer's home office or the location where the records

13 under review are stored.

14 (b) Examinations. ~~(1)~~

15 The Director, for the purposes of ascertaining the

16 non-financial business practices, performance, and operations

17 of any company, may make examinations of:

18 (1) ~~(a)~~ any company transacting or being organized to

19 transact business in this State;

20 (2) ~~(b)~~ any person engaged in or proposing to be

21 engaged in the organization, promotion, or solicitation of

22 shares or capital contributions to or aiding in the

23 formation of a company;

24 (3) ~~(c)~~ any person having a contract, written or oral,

25 pertaining to the management or control of a company as

26 general agent, managing agent, or attorney-in-fact;

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1 (4) ~~(d)~~any licensed or registered producer, firm, or

2 administrator, or any person, organization, or corporation

3 making application for any licenses or registration;

4 (5) ~~(e)~~ any person engaged in the business of

5 adjusting losses or financing premiums; or

6 (6) ~~(f)~~ any person, organization, trust, or

7 corporation having custody or control of information

8 reasonably related to the operation, performance, or

9 conduct of a company or person subject to the jurisdiction

10 of the Director.

11 (c) Market analysis and market conduct actions.

12 (1) The Director may perform market analysis by

13 gathering and analyzing information from data currently

14 available to the Director, information from surveys or

15 reports that are submitted regularly to the Director or

16 required in a data call, information collected by the

17 NAIC, and information from a variety of other sources in

18 both the public and private domain in order to develop a

19 baseline understanding of the marketplace and to identify

20 for further review practices that deviate from the norm or

21 that may pose a potential risk to the insurance consumer.

22 The Director shall use the NAIC Market Regulation Handbook

23 as a guide in performing market analysis.

24 (2) If the Director determines that further inquiry

25 into a particular person or practice is needed, the

26 Director may consider one or more market conduct actions.

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1 The Director shall inform the examinee in writing of the

2 type of market conduct action selected and shall use the

3 NAIC Market Regulation Handbook as a guide in performing

4 the market conduct action. The Director may coordinate a

5 market conduct action and findings of this State with

6 market conduct actions and findings of other states.

7 (3) Nothing in this Section requires the Director to

8 conduct market analysis prior to initiating any market

9 conduct action.

10 (4) Nothing in this Section restricts the Director to

11 the type of market conduct action initially selected. The

12 Director shall inform the examinee in writing of any

13 change in the type of market conduct action being

14 conducted.

15 (d) Access to books and records; oaths and examinations.

16 ~~(2)~~ Every examinee ~~company or person being examined~~ and

17 its officers, directors, and agents must provide to the

18 Director convenient and free access at all reasonable hours at

19 its office or location to all books, records, documents,

20 including consumer communications, and any or all papers

21 relating to the business, performance, operations, and affairs

22 of the examinee ~~company~~. The officers, directors, and agents

23 of the examinee ~~company or person~~ must facilitate the market

24 conduct action ~~examination~~and aid in theaction ~~examination~~

25 so far as it is in their power to do so.

26 The Director and any authorized market conduct

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1 surveillance personnel ~~examiner~~have the power to administer

2 oaths and examine under oath any person relative to the

3 business of the examinee ~~company being examined~~. Any delay of

4 more than 5 business days in the transmission of requested

5 documents without an extension approved by the Director or

6 designated market conduct surveillance personnel is a

7 violation of this Section.

8 (e) Examination report.

9 ~~(3)~~ The market conduct surveillance personnel ~~examiners~~

10 designated by the Director under Section 402 must make a full

11 and true report of every examination made by them, which

12 contains only facts ascertained from the books, papers,

13 records, or documents, and other evidence obtained by

14 investigation and examined by them or ascertained from the

15 testimony of officers or agents or other persons examined

16 under oath concerning the business, affairs, conduct, and

17 performance of the examinee~~company or person~~. The report of

18 examination must be verified by the oath of the examiner in

19 charge thereof, and when so verified is prima facie evidence

20 in any action or proceeding in the name of the State against

21 the company, its officers, or agents upon the facts stated

22 therein.

23 (f) Examinee acceptance of examination report.

24 The Department and the examinee shall adhere to the

25 following timeline, unless a mutual agreement is reached to

26 modify the timeline:

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1 (1) The Department shall deliver the draft report to

2 the examinee within 60 days after completion of the

3 examination. "Completion of the examination" means the

4 date the Department confirms in writing that the

5 examination is completed. Nothing in this Section prevents

6 the Department from sharing an earlier draft of the report

7 with the examinee before confirming that the examination

8 is completed.

9 (2) If the examinee chooses to respond with written

10 submissions or rebuttals, the examinee must do so within

11 30 days after receipt of any draft report delivered after

12 the completion of the examination.

13 (3) After receipt of any written submissions or

14 rebuttals, the Department shall issue a final report. At

15 any time, the Department may share draft corrections or

16 changes to the report with the examinee before issuing a

17 final report, and the examinee shall have 30 days to

18 respond to the draft.

19 (4) The examinee shall, within 10 days after the

20 issuance of the final report, accept the final report or

21 request a hearing in writing. Failure to take either

22 action within 10 days shall be deemed an acceptance of the

23 final report. If the examinee accepts the examination

24 report, the Director shall continue to hold the content of

25 the examination report as private and confidential for a

26 period of 30 days, except to the extent provided for in

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1 subsection (h) and in paragraph (10) of subsection (g).

2 Thereafter, the Director shall open the report for public

3 inspection if no court of competent jurisdiction has

4 stayed its publication.

5 (g) Written hearing.

6 Notwithstanding anything to the contrary in this Code or

7 Department rules, if the examinee requests a hearing, the

8 following procedures apply:

9 (1) The examinee shall request the hearing in writing

10 and shall specify the issues in the final report that the

11 examinee is challenging. The examinee is limited to

12 challenging the issues that were previously challenged in

13 the examinee's written submission and rebuttal or

14 supplemental submission and rebuttal as provided pursuant

15 to paragraphs (2) and (3) of subsection (f).

16 (2) The hearing shall be conducted by written

17 arguments submitted to the Director.

18 (3) Discovery is limited to the market conduct

19 surveillance personnel's work papers that are relevant to

20 the issues the examinee is challenging. The relevant

21 market conduct surveillance personnel's work papers shall

22 be deemed admitted into and included in the record. No

23 other forms of discovery, including depositions and

24 interrogatories, are allowed, except upon written

25 agreement of the examinee and the Department's counsel.

26 (4) Only the examinee and the Department's counsel may

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1 submit written arguments.

2 (5) The examinee shall submit its written argument

3 within 30 days after the Department's counsel serves a

4 formal notice of hearing.

5 (6) The Department's counsel shall submit its written

6 response within 30 days after the examinee submits its

7 written argument.

8 (7) The Director shall issue a decision accompanied by

9 findings and conclusions resulting from the Director's

10 consideration and review of the written arguments, the

11 final report, relevant market conduct surveillance

12 personnel work papers, and any written submissions or

13 rebuttals. The Director's order is a final agency action

14 and shall be served upon the examinee by electronic mail

15 together with a copy of the final report pursuant to

16 Section 10-75 of the Illinois Administrative Procedure

17 Act.

18 (8) Any portion of the final examination report that

19 was not challenged by the examinee is incorporated into

20 the decision of the Director.

21 (9) Findings of fact and conclusions of law in the

22 Director's final agency action are prima facie evidence in

23 any legal or regulatory action.

24 (10) If an examinee has requested a hearing, the

25 Director shall continue to hold the content of any

26 examination report or other final agency action of a

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1 market conduct examination as private and confidential for

2 a period of 49 days after the final agency action. After

3 the 49-day period expires, the Director shall open the

4 final agency action for public inspection if a court of

5 competent jurisdiction has not stayed its publication.

6 (h) Nothing in this Section prevents the Director from

7 disclosing at any time the content of an examination report,

8 preliminary examination report, or results, or any matter

9 relating to a report or results, to the division or to the

10 insurance division of any other state or agency or office of

11 the federal government at any time if the division, agency, or

12 office receiving the report or related matters agrees and has

13 the legal authority to hold it confidential in a manner

14 consistent with this Section.

15 (i) Confidentiality.

16 (1) The Director and any other person in the course of

17 market conduct surveillance shall keep confidential all

18 documents pertaining to the market conduct surveillance,

19 including working papers, third-party models, or products,

20 complaint logs, and copies of any documents created by,

21 produced by, obtained by, or disclosed to the Director,

22 market conduct surveillance personnel, or any other person

23 in the course of market conduct surveillance conducted

24 pursuant to this Section, and all documents obtained by

25 the NAIC as a result of this Section. The documents shall

26 remain confidential after termination of the market

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1 conduct surveillance, are not subject to subpoena, are not

2 subject to discovery or admissible as evidence in private

3 civil litigation, are not subject to disclosure under the

4 Freedom of Information Act, and shall not be made public

5 at any time or used by the Director or any other person,

6 except as provided in paragraphs (3), (4), and (6) of this

7 subsection and in subsection (l).

8 (2) The Director, the Department, and any other person

9 in the course of market conduct surveillance shall keep

10 confidential any self-evaluation or voluntary compliance

11 program documents disclosed to the Director or other

12 person by an examinee and the data collected via the NAIC

13 market conduct annual statement. The documents are not

14 subject to subpoena, are not subject to discovery or

15 admissible as evidence in private civil litigation, are

16 not subject to disclosure under the Freedom of Information

17 Act, and shall not be made public or used by the Director

18 or any other person, except as provided in paragraphs (3),

19 (4), and (6) of this subsection, in subsection (l), or in

20 Section 155.35 of this Code.

21 (3) Notwithstanding paragraphs (1) and (2), and

22 consistent with paragraph (5), in order to assist in the

23 performance of the Director's duties, the Director may:

24 (A) share documents, materials, communications, or

25 other information, including the confidential and

26 privileged documents, materials, or information

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1 described in this subsection, with other State,

2 federal, alien, and international regulatory agencies

3 and law enforcement authorities and the NAIC, its

4 affiliates, and subsidiaries, if the recipient agrees

5 to and has the legal authority to maintain the

6 confidentiality and privileged status of the document,

7 material, communication, or other information;

8 (B) receive documents, materials, communications,

9 or information, including otherwise confidential and

10 privileged documents, materials, or information, from

11 the NAIC and its affiliates or subsidiaries, and from

12 regulatory and law enforcement officials of other

13 domestic, alien, or international jurisdictions,

14 authorities, and agencies, and shall maintain as

15 confidential or privileged any document, material,

16 communication, or information received with notice or

17 the understanding that it is confidential or

18 privileged under the laws of the jurisdiction that is

19 the source of the document, material, communication,

20 or information;

21 (C) enter into agreements governing the sharing

22 and use of information consistent with this Section;

23 and

24 (D) when the Director performs any type of market

25 conduct surveillance that does not rise to the level

26 of a market conduct examination, make the final

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1 results of the market conduct surveillance, in an

2 aggregated format, available for public inspection in

3 a manner deemed appropriate by the Director.

4 (4) Nothing in this Section limits:

5 (A) the Director's authority to use, if consistent

6 with subsection (5) of Section 188.1, any final or

7 preliminary examination report, any market conduct

8 surveillance or examinee work papers or other

9 documents, or any other information discovered or

10 developed during the course of any market conduct

11 surveillance, in the furtherance of any legal or

12 regulatory action initiated by the Director that the

13 Director may, in the Director's sole discretion, deem

14 appropriate; or

15 (B) the ability of an examinee to conduct

16 discovery in accordance with paragraph (3) of

17 subsection (g).

18 (5) Disclosure to the Director of documents,

19 materials, communications, or information required as part

20 of any type of market conduct surveillance does not waive

21 any applicable privilege or claim of confidentiality in

22 the documents, materials, communications, or information.

23 (6) If the Director deems fit, the Director may

24 publicly acknowledge the existence of an ongoing

25 examination before filing the examination report but shall

26 not disclose any other information protected under this

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1 subsection.

2 (j) Corrective actions; sanctions.

3 (1) As a result of any market conduct action other

4 than market analysis, the Director may order the examinee

5 to take any action the Director considers necessary or

6 appropriate in accordance with the report of examination

7 or any hearing thereon, including, but not limited to,

8 requiring the regulated person to undertake corrective

9 actions to cease and desist an identified violation or

10 institute processes and practices to comply with

11 applicable standards, requiring reimbursement or

12 restitution to persons harmed by the regulated person's

13 violation, or imposing civil penalties, for acts in

14 violation of any law, rule, or prior lawful order of the

15 Director. Civil penalties imposed as a result of a market

16 conduct action shall be consistent, reasonable, and

17 justifiable.

18 (2) If any other provision of this Code or any other

19 law or rule under the Director's jurisdiction prescribes

20 an amount or range of penalties for a violation of a

21 particular statute, that provision shall apply. If no

22 penalty is already provided by law or rule for a violation

23 and the violation is quantifiable, then the Director may

24 order a penalty of up to $3,000 for every act in violation

25 of any law, rule, or prior lawful order of the Director. If

26 the examination report finds a violation by the examinee

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1 that the report is unable to quantify, such as, an

2 operational policy or procedure that conflicts with

3 applicable law, then the Director may order a penalty of

4 up to $10,000 for that violation. A violation of

5 subsection (d) is punishable by a fine of $2,000 per day up

6 to a maximum of $500,000.

7 (k) Participation in national market conduct databases.

8 The Director shall collect and report market data to the

9 NAIC's market information systems, including, but not limited

10 to, the Complaint Database System, the Examination Tracking

11 System, and the Regulatory Information Retrieval System, or

12 other successor NAIC products as determined by the Director.

13 Information collected and maintained by the Department for

14 inclusion in these NAIC market information systems shall be

15 compiled in a manner that meets the requirements of the NAIC.

16 ~~(4) The Director must notify the company or person made~~

17 ~~the subject of any examination hereunder of the contents of~~

18 ~~the verified examination report before filing it and making~~

19 ~~the report public of any matters relating thereto, and must~~

20 ~~afford the company or person an opportunity to demand a~~

21 ~~hearing with reference to the facts and other evidence therein~~

22 ~~contained.~~

23 ~~The company or person may request a hearing within 10 days~~

24 ~~after receipt of the examination report by giving the Director~~

25 ~~written notice of that request, together with a statement of~~

26 ~~its objections. The Director must then conduct a hearing in~~

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1 ~~accordance with Sections 402 and 403. He must issue a written~~

2 ~~order based upon the examination report and upon the hearing~~

3 ~~within 90 days after the report is filed or within 90 days~~

4 ~~after the hearing.~~

5 ~~If the examination reveals that the company is operating~~

6 ~~in violation of any law, regulation, or prior order, the~~

7 ~~Director in the written order may require the company or~~

8 ~~person to take any action he considers necessary or~~

9 ~~appropriate in accordance with the report of examination or~~

10 ~~any hearing thereon. The order is subject to judicial review~~

11 ~~under the Administrative Review Law. The Director may withhold~~

12 ~~any report from public inspection for such time as he may deem~~

13 ~~proper and may, after filing the same, publish any part or all~~

14 ~~of the report as he considers to be in the interest of the~~

15 ~~public, in one or more newspapers in this State, without~~

16 ~~expense to the company.~~

17 ~~(5) Any company which or person who violates or aids and~~

18 ~~abets any violation of a written order issued under this~~

19 ~~Section shall be guilty of a business offense and may be fined~~

20 ~~not more than $5,000. The penalty shall be paid into the~~

21 ~~General Revenue fund of the State of Illinois.~~

22 (Source: P.A. 87-108.)

23 (215 ILCS 5/132.5) (from Ch. 73, par. 744.5)

24 Sec. 132.5. Examination reports.

25 (a) General description. All examination reports shall be

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1 comprised of only facts appearing upon the books, records, or

2 other documents of the company, its agents, or other persons

3 examined or as ascertained from the testimony of its officers,

4 agents, or other persons examined concerning its affairs and

5 the conclusions and recommendations as the examiners find

6 reasonably warranted from those facts.

7 (b) Filing of examination report. No later than 60 days

8 following completion of the examination, the examiner in

9 charge shall file with the Department a verified written

10 report of examination under oath. Upon receipt of the verified

11 report, the Department shall transmit the report to the

12 company examined, together with a notice that affords the

13 company examined a reasonable opportunity of not more than 30

14 days to make a written submission or rebuttal with respect to

15 any matters contained in the examination report.

16 (c) Adoption of the report on examination. Within 30 days

17 of the end of the period allowed for the receipt of written

18 submissions or rebuttals, the Director shall fully consider

19 and review the report, together with any written submissions

20 or rebuttals and any relevant portions of the examiners work

21 papers and enter an order:

22 (1) Adopting the examination report as filed or with

23 modification or corrections. If the examination report

24 reveals that the company is operating in violation of any

25 law, regulation, or prior order of the Director, the

26 Director may order the company to take any action the

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1 Director considers necessary and appropriate to cure the

2 violation.

3 (2) Rejecting the examination report with directions

4 to the examiners to reopen the examination for purposes of

5 obtaining additional data, documentation, or information

6 and refiling under subsection (b).

7 (3) Calling for an investigatory hearing with no less

8 than 20 days notice to the company for purposes of

9 obtaining additional documentation, data, information, and

10 testimony.

11 (d) Order and procedures. All orders entered under

12 paragraph (1) of subsection (c) shall be accompanied by

13 findings and conclusions resulting from the Director's

14 consideration and review of the examination report, relevant

15 examiner work papers, and any written submissions or

16 rebuttals. The order shall be considered a final

17 administrative decision and may be appealed in accordance with

18 the Administrative Review Law. The order shall be served upon

19 the company by certified mail, together with a copy of the

20 adopted examination report. Within 30 days of the issuance of

21 the adopted report, the company shall file affidavits executed

22 by each of its directors stating under oath that they have

23 received a copy of the adopted report and related orders.

24 Any hearing conducted under paragraph (3) of subsection

25 (c) by the Director or an authorized representative shall be

26 conducted as a nonadversarial confidential investigatory

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1 proceeding as necessary for the resolution of any

2 inconsistencies, discrepancies, or disputed issues apparent

3 upon the face of the filed examination report or raised by or

4 as a result of the Director's review of relevant work papers or

5 by the written submission or rebuttal of the company. Within

6 20 days of the conclusion of any hearing, the Director shall

7 enter an order under paragraph (1) of subsection (c).

8 The Director shall not appoint an examiner as an

9 authorized representative to conduct the hearing. The hearing

10 shall proceed expeditiously with discovery by the company

11 limited to the examiner's work papers that tend to

12 substantiate any assertions set forth in any written

13 submission or rebuttal. The Director or his representative may

14 issue subpoenas for the attendance of any witnesses or the

15 production of any documents deemed relevant to the

16 investigation, whether under the control of the Department,

17 the company, or other persons. The documents produced shall be

18 included in the record, and testimony taken by the Director or

19 his representative shall be under oath and preserved for the

20 record. Nothing contained in this Section shall require the

21 Department to disclose any information or records that would

22 indicate or show the existence or content of any investigation

23 or activity of a criminal justice agency.

24 The hearing shall proceed with the Director or his

25 representative posing questions to the persons subpoenaed.

26 Thereafter the company and the Department may present

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1 testimony relevant to the investigation. Cross-examination

2 shall be conducted only by the Director or his representative.

3 The company and the Department shall be permitted to make

4 closing statements and may be represented by counsel of their

5 choice.

6 (e) Publication and use. Upon the adoption of the

7 examination report under paragraph (1) of subsection (c), the

8 Director shall continue to hold the content of the examination

9 report as private and confidential information for a period of

10 35 days, except to the extent provided in subsection (b).

11 Thereafter, the Director may open the report for public

12 inspection so long as no court of competent jurisdiction has

13 stayed its publication.

14 Nothing contained in this Code shall prevent or be

15 construed as prohibiting the Director from disclosing the

16 content of an examination report, preliminary examination

17 report or results, or any matter relating thereto, to the

18 insurance department of any other state or country or to law

19 enforcement officials of this or any other state or agency of

20 the federal government at any time, so long as the agency or

21 office receiving the report or matters relating thereto agrees

22 in writing to hold it confidential and in a manner consistent

23 with this Code.

24 In the event the Director determines that regulatory

25 action is appropriate as a result of any examination, he may

26 initiate any proceedings or actions as provided by law.

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1 (f) Confidentiality of ancillary information. All working

2 papers, recorded information, documents, and copies thereof

3 produced by, obtained by, or disclosed to the Director or any

4 other person in the course of any examination must be given

5 confidential treatment, are not subject to subpoena, and may

6 not be made public by the Director or any other persons, except

7 to the extent provided in subsection (e). Access may also be

8 granted to the National Association of Insurance

9 Commissioners. Those parties must agree in writing before

10 receiving the information to provide to it the same

11 confidential treatment as required by this Section, unless the

12 prior written consent of the company to which it pertains has

13 been obtained.

14 ~~This subsection (f) applies to market conduct examinations~~

15 ~~described in Section 132 of this Code.~~

16 (g) Disclosure. Nothing contained in this Code shall

17 prevent or be construed as prohibiting the Director from

18 disclosing the information described in subsections (e) and

19 (f) to the Illinois Insurance Guaranty Fund regarding any

20 member company defined in Section 534.5 if the member company

21 has an authorized control level event as defined in Section

22 35A-25. The Director may disclose the information described in

23 this subsection so long as the Fund agrees in writing to hold

24 that information confidential, in a manner consistent with

25 this Code, and uses that information to prepare for the

26 possible liquidation of the member company. Access to the

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1 information disclosed by the Director to the Fund shall be

2 limited to the Fund's staff and its counsel. The Board of

3 Directors of the Fund may have access to the information

4 disclosed by the Director to the Fund once the member company

5 is subject to a delinquency proceeding under Article XIII

6 subject to any terms and conditions established by the

7 Director.

8 (Source: P.A. 102-929, eff. 5-27-22.)

9 (215 ILCS 5/155.35)

10 Sec. 155.35. Insurance compliance self-evaluative

11 privilege.

12 (a) To encourage insurance companies and persons

13 conducting activities regulated under this Code, both to

14 conduct voluntary internal audits of their compliance programs

15 and management systems and to assess and improve compliance

16 with State and federal statutes, rules, and orders, an

17 insurance compliance self-evaluative privilege is recognized

18 to protect the confidentiality of communications relating to

19 voluntary internal compliance audits. The General Assembly

20 hereby finds and declares that protection of insurance

21 consumers is enhanced by companies' voluntary compliance with

22 this State's insurance and other laws and that the public will

23 benefit from incentives to identify and remedy insurance and

24 other compliance issues. It is further declared that limited

25 expansion of the protection against disclosure will encourage

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1 voluntary compliance and improve insurance market conduct

2 quality and that the voluntary provisions of this Section will

3 not inhibit the exercise of the regulatory authority by those

4 entrusted with protecting insurance consumers.

5 (b)(1) An insurance compliance self-evaluative audit

6 document is privileged information and is not admissible as

7 evidence in any legal action in any civil, criminal, or

8 administrative proceeding, except as provided in subsections

9 (c) and (d) of this Section. Documents, communications, data,

10 reports, or other information created as a result of a claim

11 involving personal injury or workers' compensation made

12 against an insurance policy are not insurance compliance

13 self-evaluative audit documents and are admissible as evidence

14 in civil proceedings as otherwise provided by applicable rules

15 of evidence or civil procedure, subject to any applicable

16 statutory or common law privilege, including but not limited

17 to the work product doctrine, the attorney-client privilege,

18 or the subsequent remedial measures exclusion.

19 (2) If any company, person, or entity performs or directs

20 the performance of an insurance compliance audit, an officer

21 or employee involved with the insurance compliance audit, or

22 any consultant who is hired for the purpose of performing the

23 insurance compliance audit, may not be examined in any civil,

24 criminal, or administrative proceeding as to the insurance

25 compliance audit or any insurance compliance self-evaluative

26 audit document, as defined in this Section. This subsection

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1 (b)(2) does not apply if the privilege set forth in subsection

2 (b)(1) of this Section is determined under subsection (c) or

3 (d) not to apply.

4 (3) A company may voluntarily submit, in connection with

5 examinations conducted under this Article, an insurance

6 compliance self-evaluative audit document to the Director, or

7 his or her designee, as a confidential document under

8 subsection (i) of Section 132 or subsection (f) of Section

9 132.5 of this Code, as applicable,without waiving the

10 privilege set forth in this Section to which the company would

11 otherwise be entitled; provided, however, that the provisions

12 in Sections 132 and ~~subsection (f) of Section~~132.5 permitting

13 the Director to make confidential documents public ~~pursuant to~~

14 ~~subsection (e) of Section 132.5~~ and grant access to the

15 National Association of Insurance Commissioners shall not

16 apply to the insurance compliance self-evaluative audit

17 document so voluntarily submitted. Nothing contained in this

18 subsection shall give the Director any authority to compel a

19 company to disclose involuntarily or otherwise provide an

20 insurance compliance self-evaluative audit document.

21 (c)(1) The privilege set forth in subsection (b) of this

22 Section does not apply to the extent that it is expressly

23 waived by the company that prepared or caused to be prepared

24 the insurance compliance self-evaluative audit document.

25 (2) In a civil or administrative proceeding, a court of

26 record may, after an in camera review, require disclosure of

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1 material for which the privilege set forth in subsection (b)

2 of this Section is asserted, if the court determines one of the

3 following:

4 (A) the privilege is asserted for a fraudulent

5 purpose;

6 (B) the material is not subject to the privilege; or

7 (C) even if subject to the privilege, the material

8 shows evidence of noncompliance with State and federal

9 statutes, rules and orders and the company failed to

10 undertake reasonable corrective action or eliminate the

11 noncompliance within a reasonable time.

12 (3) In a criminal proceeding, a court of record may, after

13 an in camera review, require disclosure of material for which

14 the privilege described in subsection (b) of this Section is

15 asserted, if the court determines one of the following:

16 (A) the privilege is asserted for a fraudulent

17 purpose;

18 (B) the material is not subject to the privilege;

19 (C) even if subject to the privilege, the material

20 shows evidence of noncompliance with State and federal

21 statutes, rules and orders and the company failed to

22 undertake reasonable corrective action or eliminate such

23 noncompliance within a reasonable time; or

24 (D) the material contains evidence relevant to

25 commission of a criminal offense under this Code, and all

26 of the following factors are present:

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1 (i) the Director, State's Attorney, or Attorney

2 General has a compelling need for the information;

3 (ii) the information is not otherwise available;

4 and

5 (iii) the Director, State's Attorney, or Attorney

6 General is unable to obtain the substantial equivalent

7 of the information by any means without incurring

8 unreasonable cost and delay.

9 (d)(1) Within 30 days after the Director, State's

10 Attorney, or Attorney General makes a written request by

11 certified mail for disclosure of an insurance compliance

12 self-evaluative audit document under this subsection, the

13 company that prepared or caused the document to be prepared

14 may file with the appropriate court a petition requesting an

15 in camera hearing on whether the insurance compliance

16 self-evaluative audit document or portions of the document are

17 privileged under this Section or subject to disclosure. The

18 court has jurisdiction over a petition filed by a company

19 under this subsection requesting an in camera hearing on

20 whether the insurance compliance self-evaluative audit

21 document or portions of the document are privileged or subject

22 to disclosure. Failure by the company to file a petition

23 waives the privilege.

24 (2) A company asserting the insurance compliance

25 self-evaluative privilege in response to a request for

26 disclosure under this subsection shall include in its request

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1 for an in camera hearing all of the information set forth in

2 subsection (d)(5) of this Section.

3 (3) Upon the filing of a petition under this subsection,

4 the court shall issue an order scheduling, within 45 days

5 after the filing of the petition, an in camera hearing to

6 determine whether the insurance compliance self-evaluative

7 audit document or portions of the document are privileged

8 under this Section or subject to disclosure.

9 (4) The court, after an in camera review, may require

10 disclosure of material for which the privilege in subsection

11 (b) of this Section is asserted if the court determines, based

12 upon its in camera review, that any one of the conditions set

13 forth in subsection (c)(2)(A) through (C) is applicable as to

14 a civil or administrative proceeding or that any one of the

15 conditions set forth in subsection (c)(3)(A) through (D) is

16 applicable as to a criminal proceeding. Upon making such a

17 determination, the court may only compel the disclosure of

18 those portions of an insurance compliance self-evaluative

19 audit document relevant to issues in dispute in the underlying

20 proceeding. Any compelled disclosure will not be considered to

21 be a public document or be deemed to be a waiver of the

22 privilege for any other civil, criminal, or administrative

23 proceeding. A party unsuccessfully opposing disclosure may

24 apply to the court for an appropriate order protecting the

25 document from further disclosure.

26 (5) A company asserting the insurance compliance

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1 self-evaluative privilege in response to a request for

2 disclosure under this subsection (d) shall provide to the

3 Director, State's Attorney, or Attorney General, as the case

4 may be, at the time of filing any objection to the disclosure,

5 all of the following information:

6 (A) The date of the insurance compliance

7 self-evaluative audit document.

8 (B) The identity of the entity conducting the audit.

9 (C) The general nature of the activities covered by

10 the insurance compliance audit.

11 (D) An identification of the portions of the insurance

12 compliance self-evaluative audit document for which the

13 privilege is being asserted.

14 (e) (1) A company asserting the insurance compliance

15 self-evaluative privilege set forth in subsection (b) of this

16 Section has the burden of demonstrating the applicability of

17 the privilege. Once a company has established the

18 applicability of the privilege, a party seeking disclosure

19 under subsections (c)(2)(A) or (C) of this Section has the

20 burden of proving that the privilege is asserted for a

21 fraudulent purpose or that the company failed to undertake

22 reasonable corrective action or eliminate the noncompliance

23 with a reasonable time. The Director, State's Attorney, or

24 Attorney General seeking disclosure under subsection (c)(3) of

25 this Section has the burden of proving the elements set forth

26 in subsection (c)(3) of this Section.

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1 (2) The parties may at any time stipulate in proceedings

2 under subsections (c) or (d) of this Section to entry of an

3 order directing that specific information contained in an

4 insurance compliance self-evaluative audit document is or is

5 not subject to the privilege provided under subsection (b) of

6 this Section.

7 (f) The privilege set forth in subsection (b) of this

8 Section shall not extend to any of the following:

9 (1) documents, communications, data, reports, or other

10 information required to be collected, developed,

11 maintained, reported, or otherwise made available to a

12 regulatory agency pursuant to this Code, or other federal

13 or State law, rule, or order;

14 (2) information obtained by observation or monitoring

15 by any regulatory agency; or

16 (3) information obtained from a source independent of

17 the insurance compliance audit.

18 (g) As used in this Section:

19 (1) "Insurance compliance audit" means a voluntary,

20 internal evaluation, review, assessment, or audit not

21 otherwise expressly required by law of a company or an

22 activity regulated under this Code, or other State or

23 federal law applicable to a company, or of management

24 systems related to the company or activity, that is

25 designed to identify and prevent noncompliance and to

26 improve compliance with those statutes, rules, or orders.

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1 An insurance compliance audit may be conducted by the

2 company, its employees, or by independent contractors.

3 (2) "Insurance compliance self-evaluative audit

4 document" means documents prepared as a result of or in

5 connection with and not prior to an insurance compliance

6 audit. An insurance compliance self-evaluation audit

7 document may include a written response to the findings of

8 an insurance compliance audit. An insurance compliance

9 self-evaluative audit document may include, but is not

10 limited to, as applicable, field notes and records of

11 observations, findings, opinions, suggestions,

12 conclusions, drafts, memoranda, drawings, photographs,

13 computer-generated or electronically recorded

14 information, phone records, maps, charts, graphs, and

15 surveys, provided this supporting information is collected

16 or developed for the primary purpose and in the course of

17 an insurance compliance audit. An insurance compliance

18 self-evaluative audit document may also include any of the

19 following:

20 (A) an insurance compliance audit report prepared

21 by an auditor, who may be an employee of the company or

22 an independent contractor, which may include the scope

23 of the audit, the information gained in the audit, and

24 conclusions and recommendations, with exhibits and

25 appendices;

26 (B) memoranda and documents analyzing portions or

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1 all of the insurance compliance audit report and

2 discussing potential implementation issues;

3 (C) an implementation plan that addresses

4 correcting past noncompliance, improving current

5 compliance, and preventing future noncompliance; or

6 (D) analytic data generated in the course of

7 conducting the insurance compliance audit.

8 (3) "Company" has the same meaning as provided in

9 Section 2 of this Code.

10 (h) Nothing in this Section shall limit, waive, or

11 abrogate the scope or nature of any statutory or common law

12 privilege including, but not limited to, the work product

13 doctrine, the attorney-client privilege, or the subsequent

14 remedial measures exclusion.

15 (Source: P.A. 90-499, eff. 8-19-97; 90-655, eff. 7-30-98.)

16 (215 ILCS 5/402) (from Ch. 73, par. 1014)

17 Sec. 402. Examinations, investigations and hearings. (1)

18 All examinations, investigations and hearings provided for by

19 this Code may be conducted either by the Director personally,

20 or by one or more of the actuaries, technical advisors,

21 deputies, supervisors or examiners employed or retained by the

22 Department and designated by the Director for such purpose.

23 When necessary to supplement its examination procedures, the

24 Department may retain independent actuaries deemed competent

25 by the Director, independent certified public accountants,

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1 attorneys,or qualified examiners of insurance companies

2 deemed competent by the Director, or any combination of the

3 foregoing, the cost of which shall be borne by the company or

4 person being examined. The Director may compensate independent

5 actuaries, certified public accountants and qualified

6 examiners retained for supplementing examination procedures in

7 amounts not to exceed the reasonable and customary charges for

8 such services. The Director may also accept as a part of the

9 Department's examination of any company or person (a) a report

10 by an independent actuary deemed competent by the Director or

11 (b) a report of an audit made by an independent certified

12 public accountant. Neither those persons so designated nor any

13 members of their immediate families shall be officers of,

14 connected with, or financially interested in any company other

15 than as policyholders, nor shall they be financially

16 interested in any other corporation or person affected by the

17 examination, investigation or hearing.

18 (2) All hearings provided for in this Code shall, unless

19 otherwise specially provided, be held at such time and place

20 as shall be designated in a notice which shall be given by the

21 Director in writing to the person or company whose interests

22 are affected, at least 10 days before the date designated

23 therein. The notice shall state the subject of inquiry and the

24 specific charges, if any. The hearings shall be held in the

25 City of Springfield, the City of Chicago, or in the county

26 where the principal business address of the person or company

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1 affected is located.

2 (Source: P.A. 87-757.)

3 (215 ILCS 5/408) (from Ch. 73, par. 1020)

4 Sec. 408. Fees and charges.

5 (1) The Director shall charge, collect and give proper

6 acquittances for the payment of the following fees and

7 charges:

8 (a) For filing all documents submitted for the

9 incorporation or organization or certification of a

10 domestic company, except for a fraternal benefit society,

11 $2,000.

12 (b) For filing all documents submitted for the

13 incorporation or organization of a fraternal benefit

14 society, $500.

15 (c) For filing amendments to articles of incorporation

16 and amendments to declaration of organization, except for

17 a fraternal benefit society, a mutual benefit association,

18 a burial society or a farm mutual, $200.

19 (d) For filing amendments to articles of incorporation

20 of a fraternal benefit society, a mutual benefit

21 association or a burial society, $100.

22 (e) For filing amendments to articles of incorporation

23 of a farm mutual, $50.

24 (f) For filing bylaws or amendments thereto, $50.

25 (g) For filing agreement of merger or consolidation:

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1 (i) for a domestic company, except for a fraternal

2 benefit society, a mutual benefit association, a

3 burial society, or a farm mutual, $2,000.

4 (ii) for a foreign or alien company, except for a

5 fraternal benefit society, $600.

6 (iii) for a fraternal benefit society, a mutual

7 benefit association, a burial society, or a farm

8 mutual, $200.

9 (h) For filing agreements of reinsurance by a domestic

10 company, $200.

11 (i) For filing all documents submitted by a foreign or

12 alien company to be admitted to transact business or

13 accredited as a reinsurer in this State, except for a

14 fraternal benefit society, $5,000.

15 (j) For filing all documents submitted by a foreign or

16 alien fraternal benefit society to be admitted to transact

17 business in this State, $500.

18 (k) For filing declaration of withdrawal of a foreign

19 or alien company, $50.

20 (l) For filing annual statement by a domestic company,

21 except a fraternal benefit society, a mutual benefit

22 association, a burial society, or a farm mutual, $200.

23 (m) For filing annual statement by a domestic

24 fraternal benefit society, $100.

25 (n) For filing annual statement by a farm mutual, a

26 mutual benefit association, or a burial society, $50.

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1 (o) For issuing a certificate of authority or renewal

2 thereof except to a foreign fraternal benefit society,

3 $400.

4 (p) For issuing a certificate of authority or renewal

5 thereof to a foreign fraternal benefit society, $200.

6 (q) For issuing an amended certificate of authority,

7 $50.

8 (r) For each certified copy of certificate of

9 authority, $20.

10 (s) For each certificate of deposit, or valuation, or

11 compliance or surety certificate, $20.

12 (t) For copies of papers or records per page, $1.

13 (u) For each certification to copies of papers or

14 records, $10.

15 (v) For multiple copies of documents or certificates

16 listed in subparagraphs (r), (s), and (u) of paragraph (1)

17 of this Section, $10 for the first copy of a certificate of

18 any type and $5 for each additional copy of the same

19 certificate requested at the same time, unless, pursuant

20 to paragraph (2) of this Section, the Director finds these

21 additional fees excessive.

22 (w) For issuing a permit to sell shares or increase

23 paid-up capital:

24 (i) in connection with a public stock offering,

25 $300;

26 (ii) in any other case, $100.

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1 (x) For issuing any other certificate required or

2 permissible under the law, $50.

3 (y) For filing a plan of exchange of the stock of a

4 domestic stock insurance company, a plan of

5 demutualization of a domestic mutual company, or a plan of

6 reorganization under Article XII, $2,000.

7 (z) For filing a statement of acquisition of a

8 domestic company as defined in Section 131.4 of this Code,

9 $2,000.

10 (aa) For filing an agreement to purchase the business

11 of an organization authorized under the Dental Service

12 Plan Act or the Voluntary Health Services Plans Act or of a

13 health maintenance organization or a limited health

14 service organization, $2,000.

15 (bb) For filing a statement of acquisition of a

16 foreign or alien insurance company as defined in Section

17 131.12a of this Code, $1,000.

18 (cc) For filing a registration statement as required

19 in Sections 131.13 and 131.14, the notification as

20 required by Sections 131.16, 131.20a, or 141.4, or an

21 agreement or transaction required by Sections 124.2(2),

22 141, 141a, or 141.1, $200.

23 (dd) For filing an application for licensing of:

24 (i) a religious or charitable risk pooling trust

25 or a workers' compensation pool, $1,000;

26 (ii) a workers' compensation service company,

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1 $500;

2 (iii) a self-insured automobile fleet, $200; or

3 (iv) a renewal of or amendment of any license

4 issued pursuant to (i), (ii), or (iii) above, $100.

5 (ee) For filing articles of incorporation for a

6 syndicate to engage in the business of insurance through

7 the Illinois Insurance Exchange, $2,000.

8 (ff) For filing amended articles of incorporation for

9 a syndicate engaged in the business of insurance through

10 the Illinois Insurance Exchange, $100.

11 (gg) For filing articles of incorporation for a

12 limited syndicate to join with other subscribers or

13 limited syndicates to do business through the Illinois

14 Insurance Exchange, $1,000.

15 (hh) For filing amended articles of incorporation for

16 a limited syndicate to do business through the Illinois

17 Insurance Exchange, $100.

18 (ii) For a permit to solicit subscriptions to a

19 syndicate or limited syndicate, $100.

20 (jj) For the filing of each form as required in

21 Section 143 of this Code, $50 per form. The fee for

22 advisory and rating organizations shall be $200 per form.

23 (i) For the purposes of the form filing fee,

24 filings made on insert page basis will be considered

25 one form at the time of its original submission.

26 Changes made to a form subsequent to its approval

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1 shall be considered a new filing.

2 (ii) Only one fee shall be charged for a form,

3 regardless of the number of other forms or policies

4 with which it will be used.

5 (iii) Fees charged for a policy filed as it will be

6 issued regardless of the number of forms comprising

7 that policy shall not exceed $1,500. For advisory or

8 rating organizations, fees charged for a policy filed

9 as it will be issued regardless of the number of forms

10 comprising that policy shall not exceed $2,500.

11 (iv) The Director may by rule exempt forms from

12 such fees.

13 (kk) For filing an application for licensing of a

14 reinsurance intermediary, $500.

15 (ll) For filing an application for renewal of a

16 license of a reinsurance intermediary, $200.

17 (mm) For a network adequacy filing required under the

18 Network Adequacy and Transparency Act, $500, except that

19 the fee for a filing required based on a material change is

20 $100.

21 (2) When printed copies or numerous copies of the same

22 paper or records are furnished or certified, the Director may

23 reduce such fees for copies if he finds them excessive. He may,

24 when he considers it in the public interest, furnish without

25 charge to state insurance departments and persons other than

26 companies, copies or certified copies of reports of

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1 examinations and of other papers and records.

2 (3) The expenses incurred in any performance examination

3 authorized by law shall be paid by the company or person being

4 examined. The charge shall be reasonably related to the cost

5 of the examination including but not limited to compensation

6 of examiners, electronic data processing costs, supervision

7 and preparation of an examination report and lodging and

8 travel expenses. All lodging and travel expenses shall be in

9 accord with the applicable travel regulations as published by

10 the Department of Central Management Services and approved by

11 the Governor's Travel Control Board, except that out-of-state

12 lodging and travel expenses related to examinations authorized

13 under Section 132 shall be in accordance with travel rates

14 prescribed under paragraph 301-7.2 of the Federal Travel

15 Regulations, 41 C.F.R. 301-7.2, for reimbursement of

16 subsistence expenses incurred during official travel. All

17 lodging and travel expenses may be reimbursed directly upon

18 authorization of the Director. With the exception of the

19 direct reimbursements authorized by the Director, all

20 performance examination charges collected by the Department

21 shall be paid to the Insurance Producer Administration Fund,

22 however, the electronic data processing costs incurred by the

23 Department in the performance of any examination shall be

24 billed directly to the company being examined for payment to

25 the Technology Management Revolving Fund.

26 (4) At the time of any service of process on the Director

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1 as attorney for such service, the Director shall charge and

2 collect the sum of $20, which may be recovered as taxable costs

3 by the party to the suit or action causing such service to be

4 made if he prevails in such suit or action.

5 (5) (a) The costs incurred by the Department of Insurance

6 in conducting any hearing authorized by law shall be assessed

7 against the parties to the hearing in such proportion as the

8 Director of Insurance may determine upon consideration of all

9 relevant circumstances including: (1) the nature of the

10 hearing; (2) whether the hearing was instigated by, or for the

11 benefit of a particular party or parties; (3) whether there is

12 a successful party on the merits of the proceeding; and (4) the

13 relative levels of participation by the parties.

14 (b) For purposes of this subsection (5) costs incurred

15 shall mean the hearing officer fees, court reporter fees, and

16 travel expenses of Department of Insurance officers and

17 employees; provided however, that costs incurred shall not

18 include hearing officer fees or court reporter fees unless the

19 Department has retained the services of independent

20 contractors or outside experts to perform such functions.

21 (c) The Director shall make the assessment of costs

22 incurred as part of the final order or decision arising out of

23 the proceeding; provided, however, that such order or decision

24 shall include findings and conclusions in support of the

25 assessment of costs. This subsection (5) shall not be

26 construed as permitting the payment of travel expenses unless

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1 calculated in accordance with the applicable travel

2 regulations of the Department of Central Management Services,

3 as approved by the Governor's Travel Control Board. The

4 Director as part of such order or decision shall require all

5 assessments for hearing officer fees and court reporter fees,

6 if any, to be paid directly to the hearing officer or court

7 reporter by the party(s) assessed for such costs. The

8 assessments for travel expenses of Department officers and

9 employees shall be reimbursable to the Director of Insurance

10 for deposit to the fund out of which those expenses had been

11 paid.

12 (d) The provisions of this subsection (5) shall apply in

13 the case of any hearing conducted by the Director of Insurance

14 not otherwise specifically provided for by law.

15 (6) The Director shall charge and collect an annual

16 financial regulation fee from every domestic company for

17 examination and analysis of its financial condition and to

18 fund the internal costs and expenses of the Interstate

19 Insurance Receivership Commission as may be allocated to the

20 State of Illinois and companies doing an insurance business in

21 this State pursuant to Article X of the Interstate Insurance

22 Receivership Compact. The fee shall be the greater fixed

23 amount based upon the combination of nationwide direct premium

24 income and nationwide reinsurance assumed premium income or

25 upon admitted assets calculated under this subsection as

26 follows:

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1 (a) Combination of nationwide direct premium income

2 and nationwide reinsurance assumed premium.

3 (i) $150, if the premium is less than $500,000 and

4 there is no reinsurance assumed premium;

5 (ii) $750, if the premium is $500,000 or more, but

6 less than $5,000,000 and there is no reinsurance

7 assumed premium; or if the premium is less than

8 $5,000,000 and the reinsurance assumed premium is less

9 than $10,000,000;

10 (iii) $3,750, if the premium is less than

11 $5,000,000 and the reinsurance assumed premium is

12 $10,000,000 or more;

13 (iv) $7,500, if the premium is $5,000,000 or more,

14 but less than $10,000,000;

15 (v) $18,000, if the premium is $10,000,000 or

16 more, but less than $25,000,000;

17 (vi) $22,500, if the premium is $25,000,000 or

18 more, but less than $50,000,000;

19 (vii) $30,000, if the premium is $50,000,000 or

20 more, but less than $100,000,000;

21 (viii) $37,500, if the premium is $100,000,000 or

22 more.

23 (b) Admitted assets.

24 (i) $150, if admitted assets are less than

25 $1,000,000;

26 (ii) $750, if admitted assets are $1,000,000 or

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1 more, but less than $5,000,000;

2 (iii) $3,750, if admitted assets are $5,000,000 or

3 more, but less than $25,000,000;

4 (iv) $7,500, if admitted assets are $25,000,000 or

5 more, but less than $50,000,000;

6 (v) $18,000, if admitted assets are $50,000,000 or

7 more, but less than $100,000,000;

8 (vi) $22,500, if admitted assets are $100,000,000

9 or more, but less than $500,000,000;

10 (vii) $30,000, if admitted assets are $500,000,000

11 or more, but less than $1,000,000,000;

12 (viii) $37,500, if admitted assets are

13 $1,000,000,000 or more.

14 (c) The sum of financial regulation fees charged to

15 the domestic companies of the same affiliated group shall

16 not exceed $250,000 in the aggregate in any single year

17 and shall be billed by the Director to the member company

18 designated by the group.

19 (7) The Director shall charge and collect an annual

20 financial regulation fee from every foreign or alien company,

21 except fraternal benefit societies, for the examination and

22 analysis of its financial condition and to fund the internal

23 costs and expenses of the Interstate Insurance Receivership

24 Commission as may be allocated to the State of Illinois and

25 companies doing an insurance business in this State pursuant

26 to Article X of the Interstate Insurance Receivership Compact.

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1 The fee shall be a fixed amount based upon Illinois direct

2 premium income and nationwide reinsurance assumed premium

3 income in accordance with the following schedule:

4 (a) $150, if the premium is less than $500,000 and

5 there is no reinsurance assumed premium;

6 (b) $750, if the premium is $500,000 or more, but less

7 than $5,000,000 and there is no reinsurance assumed

8 premium; or if the premium is less than $5,000,000 and the

9 reinsurance assumed premium is less than $10,000,000;

10 (c) $3,750, if the premium is less than $5,000,000 and

11 the reinsurance assumed premium is $10,000,000 or more;

12 (d) $7,500, if the premium is $5,000,000 or more, but

13 less than $10,000,000;

14 (e) $18,000, if the premium is $10,000,000 or more,

15 but less than $25,000,000;

16 (f) $22,500, if the premium is $25,000,000 or more,

17 but less than $50,000,000;

18 (g) $30,000, if the premium is $50,000,000 or more,

19 but less than $100,000,000;

20 (h) $37,500, if the premium is $100,000,000 or more.

21 The sum of financial regulation fees under this subsection

22 (7) charged to the foreign or alien companies within the same

23 affiliated group shall not exceed $250,000 in the aggregate in

24 any single year and shall be billed by the Director to the

25 member company designated by the group.

26 (8) Beginning January 1, 1992, the financial regulation

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1 fees imposed under subsections (6) and (7) of this Section

2 shall be paid by each company or domestic affiliated group

3 annually. After January 1, 1994, the fee shall be billed by

4 Department invoice based upon the company's premium income or

5 admitted assets as shown in its annual statement for the

6 preceding calendar year. The invoice is due upon receipt and

7 must be paid no later than June 30 of each calendar year. All

8 financial regulation fees collected by the Department shall be

9 paid to the Insurance Financial Regulation Fund. The

10 Department may not collect financial examiner per diem charges

11 from companies subject to subsections (6) and (7) of this

12 Section undergoing financial examination after June 30, 1992.

13 (9) In addition to the financial regulation fee required

14 by this Section, a company undergoing any financial

15 examination authorized by law shall pay the following costs

16 and expenses incurred by the Department: electronic data

17 processing costs, the expenses authorized under Section 131.21

18 and subsection (d) of Section 132.4 of this Code, and lodging

19 and travel expenses.

20 Electronic data processing costs incurred by the

21 Department in the performance of any examination shall be

22 billed directly to the company undergoing examination for

23 payment to the Technology Management Revolving Fund. Except

24 for direct reimbursements authorized by the Director or direct

25 payments made under Section 131.21 or subsection (d) of

26 Section 132.4 of this Code, all financial regulation fees and

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1 all financial examination charges collected by the Department

2 shall be paid to the Insurance Financial Regulation Fund.

3 All lodging and travel expenses shall be in accordance

4 with applicable travel regulations published by the Department

5 of Central Management Services and approved by the Governor's

6 Travel Control Board, except that out-of-state lodging and

7 travel expenses related to examinations authorized under

8 Sections 132.1 through 132.7 shall be in accordance with

9 travel rates prescribed under paragraph 301-7.2 of the Federal

10 Travel Regulations, 41 C.F.R. 301-7.2, for reimbursement of

11 subsistence expenses incurred during official travel. All

12 lodging and travel expenses may be reimbursed directly upon

13 the authorization of the Director.

14 In the case of an organization or person not subject to the

15 financial regulation fee, the expenses incurred in any

16 financial examination authorized by law shall be paid by the

17 organization or person being examined. The charge shall be

18 reasonably related to the cost of the examination including,

19 but not limited to, compensation of examiners and other costs

20 described in this subsection.

21 (10) Any company, person, or entity failing to make any

22 payment of $150 or more as required under this Section shall be

23 subject to the penalty and interest provisions provided for in

24 subsections (4) and (7) of Section 412.

25 (11) Unless otherwise specified, all of the fees collected

26 under this Section shall be paid into the Insurance Financial

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1 Regulation Fund.

2 (12) For purposes of this Section:

3 (a) "Domestic company" means a company as defined in

4 Section 2 of this Code which is incorporated or organized

5 under the laws of this State, and in addition includes a

6 not-for-profit corporation authorized under the Dental

7 Service Plan Act or the Voluntary Health Services Plans

8 Act, a health maintenance organization, and a limited

9 health service organization.

10 (b) "Foreign company" means a company as defined in

11 Section 2 of this Code which is incorporated or organized

12 under the laws of any state of the United States other than

13 this State and in addition includes a health maintenance

14 organization and a limited health service organization

15 which is incorporated or organized under the laws of any

16 state of the United States other than this State.

17 (c) "Alien company" means a company as defined in

18 Section 2 of this Code which is incorporated or organized

19 under the laws of any country other than the United

20 States.

21 (d) "Fraternal benefit society" means a corporation,

22 society, order, lodge or voluntary association as defined

23 in Section 282.1 of this Code.

24 (e) "Mutual benefit association" means a company,

25 association or corporation authorized by the Director to

26 do business in this State under the provisions of Article

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1 XVIII of this Code.

2 (f) "Burial society" means a person, firm,

3 corporation, society or association of individuals

4 authorized by the Director to do business in this State

5 under the provisions of Article XIX of this Code.

6 (g) "Farm mutual" means a district, county and

7 township mutual insurance company authorized by the

8 Director to do business in this State under the provisions

9 of the Farm Mutual Insurance Company Act of 1986.

10 (Source: P.A. 100-23, eff. 7-6-17.)

11 (215 ILCS 5/511.109) (from Ch. 73, par. 1065.58-109)

12 (Section scheduled to be repealed on January 1, 2027)

13 Sec. 511.109. Examination.

14 (a) The Director or the Director's ~~his~~ designee may

15 examine any applicant for or holder of an administrator's

16 license in accordance with Sections 132 through 132.7 of this

17 Code. If the Director or the examiners find that the

18 administrator has violated this Article or any other

19 insurance-related laws or rules under the Director's

20 jurisdiction because of the manner in which the administrator

21 has conducted business on behalf of an insurer or plan

22 sponsor, then, unless the insurer or plan sponsor is included

23 in the examination and has been afforded the same opportunity

24 to request or participate in a hearing on the examination

25 report, the examination report shall not allege a violation by

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1 the insurer or plan sponsor and the Director's order based on

2 the report shall not impose any requirements, prohibitions, or

3 penalties on the insurer or plan sponsor. Nothing in this

4 Section shall prevent the Director from using any information

5 obtained during the examination of an administrator to

6 examine, investigate, or take other appropriate regulatory or

7 legal action with respect to an insurer or plan sponsor.

8 (b) (Blank). ~~Any administrator being examined shall~~

9 ~~provide to the Director or his designee convenient and free~~

10 ~~access, at all reasonable hours at their offices, to all~~

11 ~~books, records, documents and other papers relating to such~~

12 ~~administrator's business affairs.~~

13 (c) (Blank). ~~The Director or his designee may administer~~

14 ~~oaths and thereafter examine any individual about the business~~

15 ~~of the administrator.~~

16 (d) (Blank). ~~The examiners designated by the Director~~

17 ~~pursuant to this Section may make reports to the Director. Any~~

18 ~~report alleging substantive violations of this Article, any~~

19 ~~applicable provisions of the Illinois Insurance Code, or any~~

20 ~~applicable Part of Title 50 of the Illinois Administrative~~

21 ~~Code shall be in writing and be based upon facts obtained by~~

22 ~~the examiners. The report shall be verified by the examiners.~~

23 (e) (Blank). ~~If a report is made, the Director shall~~

24 ~~either deliver a duplicate thereof to the administrator being~~

25 ~~examined or send such duplicate by certified or registered~~

26 ~~mail to the administrator's address specified in the records~~

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1 ~~of the Department. The Director shall afford the administrator~~

2 ~~an opportunity to request a hearing to object to the report.~~

3 ~~The administrator may request a hearing within 30 days after~~

4 ~~receipt of the duplicate of the examination report by giving~~

5 ~~the Director written notice of such request together with~~

6 ~~written objections to the report. Any hearing shall be~~

7 ~~conducted in accordance with Sections 402 and 403 of this~~

8 ~~Code. The right to hearing is waived if the delivery of the~~

9 ~~report is refused or the report is otherwise undeliverable or~~

10 ~~the administrator does not timely request a hearing. After the~~

11 ~~hearing or upon expiration of the time period during which an~~

12 ~~administrator may request a hearing, if the examination~~

13 ~~reveals that the administrator is operating in violation of~~

14 ~~any applicable provision of the Illinois Insurance Code, any~~

15 ~~applicable Part of Title 50 of the Illinois Administrative~~

16 ~~Code or prior order, the Director, in the written order, may~~

17 ~~require the administrator to take any action the Director~~

18 ~~considers necessary or appropriate in accordance with the~~

19 ~~report or examination hearing. If the Director issues an~~

20 ~~order, it shall be issued within 90 days after the report is~~

21 ~~filed, or if there is a hearing, within 90 days after the~~

22 ~~conclusion of the hearing. The order is subject to review~~

23 ~~under the Administrative Review Law.~~

24 (Source: P.A. 84-887.)

25 (215 ILCS 5/512-3) (from Ch. 73, par. 1065.59-3)

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1 Sec. 512-3. Definitions. For the purposes of this Article,

2 unless the context otherwise requires, the terms defined in

3 this Article have the meanings ascribed to them herein:

4 (a) "Third party prescription program" or "program" means

5 any system of providing for the reimbursement of

6 pharmaceutical services and prescription drug products offered

7 or operated in this State under a contractual arrangement or

8 agreement between a provider of such services and another

9 party who is not the consumer of those services and products.

10 Such programs may include, but need not be limited to,

11 employee benefit plans whereby a consumer receives

12 prescription drugs or other pharmaceutical services and those

13 services are paid for by an agent of the employer or others.

14 (b) "Third party program administrator" or "administrator"

15 means any person, partnership or corporation who issues or

16 causes to be issued any payment or reimbursement to a provider

17 for services rendered pursuant to a third party prescription

18 program, but does not include the Director of Healthcare and

19 Family Services or any agent authorized by the Director to

20 reimburse a provider of services rendered pursuant to a

21 program of which the Department of Healthcare and Family

22 Services is the third party.

23 (c) "Health care payer" means an insurance company, health

24 maintenance organization, limited health service organization,

25 health services plan corporation, or dental service plan

26 corporation authorized to do business in this State.

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1 (Source: P.A. 95-331, eff. 8-21-07.)

2 (215 ILCS 5/512-5) (from Ch. 73, par. 1065.59-5)

3 Sec. 512-5. Fiduciary and Bonding Requirements. A third

4 party prescription program administrator shall (1) establish

5 and maintain a fiduciary account, separate and apart from any

6 and all other accounts, for the receipt and disbursement of

7 funds for reimbursement of providers of services under the

8 program, or (2) post, or cause to be posted, a bond of

9 indemnity in an amount equal to not less than 10% of the total

10 estimated annual reimbursements under the program.

11 The establishment of such fiduciary accounts and bonds

12 shall be consistent with applicable State law. If a bond of

13 indemnity is posted, it shall be held by the Director of

14 Insurance for the benefit and indemnification of the providers

15 of services under the third party prescription program.

16 An administrator who operates more than one third party

17 prescription program may establish and maintain a separate

18 fiduciary account or bond of indemnity for each such program,

19 or may operate and maintain a consolidated fiduciary account

20 or bond of indemnity for all such programs.

21 The requirements of this Section do not apply to any third

22 party prescription program administered by or on behalf of any

23 health care payer ~~insurance company, Health Care Service Plan~~

24 ~~Corporation or Pharmaceutical Service Plan Corporation~~

25 ~~authorized to do business in the State of Illinois~~.

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1 (Source: P.A. 82-1005.)

2 (215 ILCS 5/512-11 new)

3 Sec. 512-11. Examination. The Director or the Director's

4 designee may examine any applicant for or holder of an

5 administrator's registration in accordance with Sections 132

6 through 132.7 of this Code. If the Director or the examiners

7 find that the administrator has violated this Article or any

8 other insurance-related laws or rules under the Director's

9 jurisdiction because of the manner in which the administrator

10 has conducted business on behalf of a separately incorporated

11 health care payer, then, unless the health care payer is

12 included in the examination and has been afforded the same

13 opportunity to request or participate in a hearing on the

14 examination report, the examination report shall not allege a

15 violation by the health care payer and the Director's order

16 based on the report shall not impose any requirements,

17 prohibitions, or penalties on the health care payer. Nothing

18 in this Section shall prevent the Director from using any

19 information obtained during the examination of an

20 administrator to examine, investigate, or take other

21 appropriate regulatory or legal action with respect to a

22 health care payer.

23 (215 ILCS 5/513b3)

24 Sec. 513b3. Examination.

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1 (a) The Director, or the Director's ~~his or her~~ designee,

2 may examine a registered pharmacy benefit manager in

3 accordance with Sections 132 through 132.7 of this Code. If

4 the Director or the examiners find that the pharmacy benefit

5 manager has violated this Article or any other

6 insurance-related laws or rules under the Director's

7 jurisdiction because of the manner in which the pharmacy

8 benefit manager has conducted business on behalf of a health

9 insurer or plan sponsor, then, unless the health insurer or

10 plan sponsor is included in the examination and has been

11 afforded the same opportunity to request or participate in a

12 hearing on the examination report, the examination report

13 shall not allege a violation by the health insurer or plan

14 sponsor and the Director's order based on the report shall not

15 impose any requirements, prohibitions, or penalties on the

16 health insurer or plan sponsor. Nothing in this Section shall

17 prevent the Director from using any information obtained

18 during the examination of an administrator to examine,

19 investigate, or take other appropriate regulatory or legal

20 action with respect to a health insurer or plan sponsor.

21 (b) (Blank). ~~Any pharmacy benefit manager being examined~~

22 ~~shall provide to the Director, or his or her designee,~~

23 ~~convenient and free access to all books, records, documents,~~

24 ~~and other papers relating to such pharmacy benefit manager's~~

25 ~~business affairs at all reasonable hours at its offices.~~

26 (c) (Blank). ~~The Director, or his or her designee, may~~

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1 ~~administer oaths and thereafter examine the pharmacy benefit~~

2 ~~manager's designee, representative, or any officer or senior~~

3 ~~manager as listed on the license or registration certificate~~

4 ~~about the business of the pharmacy benefit manager.~~

5 (d) (Blank). ~~The examiners designated by the Director~~

6 ~~under this Section may make reports to the Director. Any~~

7 ~~report alleging substantive violations of this Article, any~~

8 ~~applicable provisions of this Code, or any applicable Part of~~

9 ~~Title 50 of the Illinois Administrative Code shall be in~~

10 ~~writing and be based upon facts obtained by the examiners. The~~

11 ~~report shall be verified by the examiners.~~

12 (e) (Blank). ~~If a report is made, the Director shall~~

13 ~~either deliver a duplicate report to the pharmacy benefit~~

14 ~~manager being examined or send such duplicate by certified or~~

15 ~~registered mail to the pharmacy benefit manager's address~~

16 ~~specified in the records of the Department. The Director shall~~

17 ~~afford the pharmacy benefit manager an opportunity to request~~

18 ~~a hearing to object to the report. The pharmacy benefit~~

19 ~~manager may request a hearing within 30 days after receipt of~~

20 ~~the duplicate report by giving the Director written notice of~~

21 ~~such request together with written objections to the report.~~

22 ~~Any hearing shall be conducted in accordance with Sections 402~~

23 ~~and 403 of this Code. The right to a hearing is waived if the~~

24 ~~delivery of the report is refused or the report is otherwise~~

25 ~~undeliverable or the pharmacy benefit manager does not timely~~

26 ~~request a hearing. After the hearing or upon expiration of the~~

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1 ~~time period during which a pharmacy benefit manager may~~

2 ~~request a hearing, if the examination reveals that the~~

3 ~~pharmacy benefit manager is operating in violation of any~~

4 ~~applicable provision of this Code, any applicable Part of~~

5 ~~Title 50 of the Illinois Administrative Code, a provision of~~

6 ~~this Article, or prior order, the Director, in the written~~

7 ~~order, may require the pharmacy benefit manager to take any~~

8 ~~action the Director considers necessary or appropriate in~~

9 ~~accordance with the report or examination hearing. If the~~

10 ~~Director issues an order, it shall be issued within 90 days~~

11 ~~after the report is filed, or if there is a hearing, within 90~~

12 ~~days after the conclusion of the hearing. The order is subject~~

13 ~~to review under the Administrative Review Law.~~

14 (Source: P.A. 101-452, eff. 1-1-20.)

15 Section 15. The Network Adequacy and Transparency Act is

16 amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and

17 by adding Sections 35 and 40 as follows:

18 (215 ILCS 124/3)

19 Sec. 3. Applicability of Act. This Act applies to an

20 individual or group policy of ~~accident and~~ health insurance

21 coverage with a network plan amended, delivered, issued, or

22 renewed in this State on or after January 1, 2019. This Act

23 does not apply to an individual or group policy for excepted

24 benefits or short-term, limited-duration health insurance

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1 coverage ~~dental or vision insurance or a limited health~~

2 ~~service organization~~ with a network plan amended, delivered,

3 issued, or renewed in this State on or after January 1, 2019,

4 except to the extent that federal law establishes network

5 adequacy and transparency standards for stand-alone dental

6 plans, which the Department shall enforce.

7 (Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)

8 (215 ILCS 124/5)

9 Sec. 5. Definitions. In this Act:

10 "Authorized representative" means a person to whom a

11 beneficiary has given express written consent to represent the

12 beneficiary; a person authorized by law to provide substituted

13 consent for a beneficiary; or the beneficiary's treating

14 provider only when the beneficiary or his or her family member

15 is unable to provide consent.

16 "Beneficiary" means an individual, an enrollee, an

17 insured, a participant, or any other person entitled to

18 reimbursement for covered expenses of or the discounting of

19 provider fees for health care services under a program in

20 which the beneficiary has an incentive to utilize the services

21 of a provider that has entered into an agreement or

22 arrangement with an issuer ~~insurer~~.

23 "Department" means the Department of Insurance.

24 "Essential community provider" has the meaning ascribed to

25 that term in 45 CFR 156.235.

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1 "Excepted benefits" has the meaning ascribed to that term

2 in 42 U.S.C. 300gg-91(c).

3 "Director" means the Director of Insurance.

4 "Family caregiver" means a relative, partner, friend, or

5 neighbor who has a significant relationship with the patient

6 and administers or assists the patient with activities of

7 daily living, instrumental activities of daily living, or

8 other medical or nursing tasks for the quality and welfare of

9 that patient.

10 "Group health plan" has the meaning ascribed to that term

11 in Section 5 of the Illinois Health Insurance Portability and

12 Accountability Act.

13 "Health insurance coverage" has the meaning ascribed to

14 that term in Section 5 of the Illinois Health Insurance

15 Portability and Accountability Act. "Health insurance

16 coverage" does not include any coverage or benefits under

17 Medicare or under the medical assistance program established

18 under Article V of the Illinois Public Aid Code.

19 "Issuer" means a "health insurance issuer" as defined in

20 Section 5 of the Illinois Health Insurance Portability and

21 Accountability Act.

22 ~~"Insurer" means any entity that offers individual or group~~

23 ~~accident and health insurance, including, but not limited to,~~

24 ~~health maintenance organizations, preferred provider~~

25 ~~organizations, exclusive provider organizations, and other~~

26 ~~plan structures requiring network participation, excluding the~~

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1 ~~medical assistance program under the Illinois Public Aid Code,~~

2 ~~the State employees group health insurance program, workers~~

3 ~~compensation insurance, and pharmacy benefit managers.~~

4 "Material change" means a significant reduction in the

5 number of providers available in a network plan, including,

6 but not limited to, a reduction of 10% or more in a specific

7 type of providers within any county, the removal of a major

8 health system that causes a network to be significantly

9 different within any county from the network when the

10 beneficiary purchased the network plan, or any change that

11 would cause the network to no longer satisfy the requirements

12 of this Act or the Department's rules for network adequacy and

13 transparency.

14 "Network" means the group or groups of preferred providers

15 providing services to a network plan.

16 "Network plan" means an individual or group policy of

17 ~~accident and~~ health insurance coverage that either requires a

18 covered person to use or creates incentives, including

19 financial incentives, for a covered person to use providers

20 managed, owned, under contract with, or employed by the issuer

21 or by a third party contracted to arrange, contract for, or

22 administer such provider-related incentives for the issuer

23 ~~insurer~~.

24 "Ongoing course of treatment" means (1) treatment for a

25 life-threatening condition, which is a disease or condition

26 for which likelihood of death is probable unless the course of

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1 the disease or condition is interrupted; (2) treatment for a

2 serious acute condition, defined as a disease or condition

3 requiring complex ongoing care that the covered person is

4 currently receiving, such as chemotherapy, radiation therapy,

5 ~~or~~ post-operative visits, or a serious and complex condition

6 as defined under 42 U.S.C. 300gg-113(b)(2); (3) a course of

7 treatment for a health condition that a treating provider

8 attests that discontinuing care by that provider would worsen

9 the condition or interfere with anticipated outcomes; ~~or~~ (4)

10 the third trimester of pregnancy through the post-partum

11 period ; (5) undergoing a course of institutional or inpatient

12 care from the provider within the meaning of 42 U.S.C.

13 300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective

14 surgery from the provider, including receipt of postoperative

15 care from such provider with respect to such a surgery; or (7)

16 being determined to be terminally ill, as determined under 42

17 U.S.C. 1395x(dd)(3)(A), and receiving treatment for such

18 illness from such provider.

19 "Preferred provider" means any provider who has entered,

20 either directly or indirectly, into an agreement with an

21 employer or risk-bearing entity relating to health care

22 services that may be rendered to beneficiaries under a network

23 plan.

24 "Providers" means physicians licensed to practice medicine

25 in all its branches, other health care professionals,

26 hospitals, or other health care institutions or facilities

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1 that provide health care services.

2 "Short-term, limited-duration health insurance coverage"

3 has the meaning ascribed to that term in Section 5 of the

4 Short-Term, Limited-Duration Health Insurance Coverage Act.

5 "Stand-alone dental plan" has the meaning ascribed to that

6 term in 45 CFR 156.400.

7 "Telehealth" has the meaning given to that term in Section

8 356z.22 of the Illinois Insurance Code.

9 "Telemedicine" has the meaning given to that term in

10 Section 49.5 of the Medical Practice Act of 1987.

11 "Tiered network" means a network that identifies and

12 groups some or all types of provider and facilities into

13 specific groups to which different provider reimbursement,

14 covered person cost-sharing or provider access requirements,

15 or any combination thereof, apply for the same services.

16 "Woman's principal health care provider" means a physician

17 licensed to practice medicine in all of its branches

18 specializing in obstetrics, gynecology, or family practice.

19 (Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)

20 (215 ILCS 124/10)

21 Sec. 10. Network adequacy.

22 (a) Before issuing, delivering, or renewing a network

23 plan, an issuer ~~An insurer~~ providing a network plan shall file

24 a description of all of the following with the Director:

25 (1) The written policies and procedures for adding

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1 providers to meet patient needs based on increases in the

2 number of beneficiaries, changes in the

3 patient-to-provider ratio, changes in medical and health

4 care capabilities, and increased demand for services.

5 (2) The written policies and procedures for making

6 referrals within and outside the network.

7 (3) The written policies and procedures on how the

8 network plan will provide 24-hour, 7-day per week access

9 to network-affiliated primary care, emergency services,

10 and women's principal health care providers.

11 An issuer ~~insurer~~ shall not prohibit a preferred provider

12 from discussing any specific or all treatment options with

13 beneficiaries irrespective of the insurer's position on those

14 treatment options or from advocating on behalf of

15 beneficiaries within the utilization review, grievance, or

16 appeals processes established by the issuer ~~insurer~~ in

17 accordance with any rights or remedies available under

18 applicable State or federal law.

19 (b) Before issuing, delivering, or renewing a network

20 plan, an issuer ~~Insurers~~ must file for review a description of

21 the services to be offered through a network plan. The

22 description shall include all of the following:

23 (1) A geographic map of the area proposed to be served

24 by the plan by county service area and zip code, including

25 marked locations for preferred providers.

26 (2) As deemed necessary by the Department, the names,

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1 addresses, phone numbers, and specialties of the providers

2 who have entered into preferred provider agreements under

3 the network plan.

4 (3) The number of beneficiaries anticipated to be

5 covered by the network plan.

6 (4) An Internet website and toll-free telephone number

7 for beneficiaries and prospective beneficiaries to access

8 current and accurate lists of preferred providers,

9 additional information about the plan, as well as any

10 other information required by Department rule.

11 (5) A description of how health care services to be

12 rendered under the network plan are reasonably accessible

13 and available to beneficiaries. The description shall

14 address all of the following:

15 (A) the type of health care services to be

16 provided by the network plan;

17 (B) the ratio of physicians and other providers to

18 beneficiaries, by specialty and including primary care

19 physicians and facility-based physicians when

20 applicable under the contract, necessary to meet the

21 health care needs and service demands of the currently

22 enrolled population;

23 (C) the travel and distance standards for plan

24 beneficiaries in county service areas; and

25 (D) a description of how the use of telemedicine,

26 telehealth, or mobile care services may be used to

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1 partially meet the network adequacy standards, if

2 applicable.

3 (6) A provision ensuring that whenever a beneficiary

4 has made a good faith effort, as evidenced by accessing

5 the provider directory, calling the network plan, and

6 calling the provider, to utilize preferred providers for a

7 covered service and it is determined the insurer does not

8 have the appropriate preferred providers due to

9 insufficient number, type, unreasonable travel distance or

10 delay, or preferred providers refusing to provide a

11 covered service because it is contrary to the conscience

12 of the preferred providers, as protected by the Health

13 Care Right of Conscience Act, the issuer ~~insurer~~ shall

14 ensure, directly or indirectly, by terms contained in the

15 payer contract, that the beneficiary will be provided the

16 covered service at no greater cost to the beneficiary than

17 if the service had been provided by a preferred provider.

18 This paragraph (6) does not apply to: (A) a beneficiary

19 who willfully chooses to access a non-preferred provider

20 for health care services available through the panel of

21 preferred providers, or (B) a beneficiary enrolled in a

22 health maintenance organization. In these circumstances,

23 the contractual requirements for non-preferred provider

24 reimbursements shall apply unless Section 356z.3a of the

25 Illinois Insurance Code requires otherwise. In no event

26 shall a beneficiary who receives care at a participating

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1 health care facility be required to search for

2 participating providers under the circumstances described

3 in subsection (b) or (b-5) of Section 356z.3a of the

4 Illinois Insurance Code except under the circumstances

5 described in paragraph (2) of subsection (b-5).

6 (7) A provision that the beneficiary shall receive

7 emergency care coverage such that payment for this

8 coverage is not dependent upon whether the emergency

9 services are performed by a preferred or non-preferred

10 provider and the coverage shall be at the same benefit

11 level as if the service or treatment had been rendered by a

12 preferred provider. For purposes of this paragraph (7),

13 "the same benefit level" means that the beneficiary is

14 provided the covered service at no greater cost to the

15 beneficiary than if the service had been provided by a

16 preferred provider. This provision shall be consistent

17 with Section 356z.3a of the Illinois Insurance Code.

18 (8) A limitation that, if the plan provides that the

19 beneficiary will incur a penalty for failing to

20 pre-certify inpatient hospital treatment, the penalty may

21 not exceed $1,000 per occurrence in addition to the plan

22 cost sharing provisions.

23 (9) For a network plan in the individual or small group

24 market other than a grandfathered health plan, evidence that

25 the network plan:

26 (A) contracts with at least 35% of the essential

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1 community providers in the service area of the network

2 plan that are available to participate in the provider

3 network of the network plan, as calculated using the

4 methodology contained in the most recent Letter to Issuers

5 in the Federally-facilitated Marketplaces issued by the

6 federal Centers for Medicare and Medicaid Services. The

7 Director may specify a different percentage by rule.

8 (B) offers contracts in good faith to all available

9 Indian health care providers in the service area of the

10 network plan, including, without limitation, the Indian

11 Health Service, Indian tribes, tribal organizations, and

12 urban Indian organizations, as defined in 25 U.S.C. 1603,

13 which apply the special terms and conditions necessitated

14 by federal statutes and regulations as referenced in the

15 Model Qualified Health Plan Addendum for Indian Health

16 Care Providers issued by the federal Centers for Medicare

17 and Medicaid Services.

18 (C) offers contracts in good faith to at least one

19 essential community provider in each category of essential

20 community provider, as contained in the most recent Letter

21 to Issuers in the Federally-facilitated Marketplaces, in

22 each county in the service area of the network plan, where

23 an essential community provider in that category is

24 available and provides medical or dental services that are

25 covered by the network plan. To offer a contract in good

26 faith, a network plan must offer contract terms comparable

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1 to the terms that an issuer would offer to a similarly

2 situated provider that is not an essential community

3 provider, except for terms that would not be applicable to

4 an essential community provider, including, without

5 limitation, because of the type of services that an

6 essential community provider provides. A network plan must

7 be able to provide verification of such offers if the

8 Centers for Medicare and Medicaid Services of the United

9 States Department of Health and Human Services requests to

10 verify compliance with this policy.

11 (c) The issuer ~~network plan~~ shall demonstrate to the

12 Director a minimum ratio of providers to plan beneficiaries as

13 required by the Department for each network plan.

14 (1) The minimum ratio of physicians or other providers

15 to plan beneficiaries shall be established ~~annually~~ by the

16 Department in consultation with the Department of Public

17 Health based upon the guidance from the federal Centers

18 for Medicare and Medicaid Services. The Department shall

19 not establish ratios for vision or dental providers who

20 provide services under dental-specific or vision-specific

21 benefits, except to the extent provided under federal law

22 for stand-alone dental plans. The Department shall

23 consider establishing ratios for the following physicians

24 or other providers:

25 (A) Primary Care;

26 (B) Pediatrics;

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1 (C) Cardiology;

2 (D) Gastroenterology;

3 (E) General Surgery;

4 (F) Neurology;

5 (G) OB/GYN;

6 (H) Oncology/Radiation;

7 (I) Ophthalmology;

8 (J) Urology;

9 (K) Behavioral Health;

10 (L) Allergy/Immunology;

11 (M) Chiropractic;

12 (N) Dermatology;

13 (O) Endocrinology;

14 (P) Ears, Nose, and Throat (ENT)/Otolaryngology;

15 (Q) Infectious Disease;

16 (R) Nephrology;

17 (S) Neurosurgery;

18 (T) Orthopedic Surgery;

19 (U) Physiatry/Rehabilitative;

20 (V) Plastic Surgery;

21 (W) Pulmonary;

22 (X) Rheumatology;

23 (Y) Anesthesiology;

24 (Z) Pain Medicine;

25 (AA) Pediatric Specialty Services;

26 (BB) Outpatient Dialysis; and

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1 (CC) HIV.

2 (2) The Director shall establish a process for the

3 review of the adequacy of these standards, along with an

4 assessment of additional specialties to be included in the

5 list under this subsection (c).

6 (3) Notwithstanding any other law or rule, the minimum

7 ratio for each provider type shall be no less than any such

8 ratio established for qualified health plans in

9 Federally-Facilitated Exchanges by federal law or by the

10 federal Centers for Medicare and Medicaid Services, even

11 if the network plan is issued in the large group market or

12 is otherwise not issued through an exchange. Federal

13 standards for stand-alone dental plans shall only apply to

14 such network plans. In the absence of an applicable

15 Department rule, the federal standards shall apply for the

16 time period specified in the federal law, regulation, or

17 guidance. If the Centers for Medicare and Medicaid

18 Services establish standards that are more stringent than

19 the standards in effect under any Department rule, the

20 Department may amend its rules to conform to the more

21 stringent federal standards.

22 (4) Prior to the enactment of an applicable Department

23 rule or the promulgation of federal standards for

24 qualified health plans or stand-alone dental plans, the

25 minimum ratios for any network plan issued, delivered,

26 amended, or renewed during 2024 shall be the following,

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1 expressed in terms of providers to beneficiaries for

2 health care professionals and in terms of providers per

3 county for facilities:

4 (A) primary care physician, general practice,

5 family practice, internal medicine, pediatrician,

6 primary care physician assistant, or primary care

7 nurse practitioner - 1:500;

8 (B) allergy/immunology - 1:15,000;

9 (C) cardiology - 1:10,000;

10 (D) chiropractic - 1:10,000;

11 (E) dermatology - 1:10,000;

12 (F) endocrinology - 1:10,000;

13 (G) ENT/otolaryngology - 1:15,000;

14 (H) gastroenterology - 1:10,000;

15 (I) general surgery - 1:5,000;

16 (J) gynecology or OB/GYN - 1:2,500;

17 (K) infectious diseases - 1:15,000;

18 (L) nephrology - 1:10,000;

19 (M) neurology - 1:20,000;

20 (N) oncology/radiation - 1:15,000;

21 (O) ophthalmology - 1:10,000;

22 (P) orthopedic surgery - 1:10,000;

23 (Q) physiatry/rehabilitative medicine - 1:15,000;

24 (R) plastic surgery - 1:20,000;

25 (S) behavioral health - 1:5,000;

26 (T) pulmonology - 1:10,000;

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1 (U) rheumatology - 1:10,000;

2 (V) urology - 1:10,000;

3 (W) acute inpatient hospital with emergency

4 services available 24 hours a day, 7 days a week - one

5 per county; and

6 (X) inpatient or residential behavioral health

7 facility - one per county.

8 (d) The network plan shall demonstrate to the Director

9 maximum travel and distance standards and appointment wait

10 time standards for plan beneficiaries, which shall be

11 established ~~annually~~ by the Department in consultation with

12 the Department of Public Health based upon the guidance from

13 the federal Centers for Medicare and Medicaid Services. These

14 standards shall consist of the maximum minutes or miles to be

15 traveled by a plan beneficiary for each county type, such as

16 large counties, metro counties, or rural counties as defined

17 by Department rule.

18 The maximum travel time and distance standards must

19 include standards for each physician and other provider

20 category listed for which ratios have been established.

21 The Director shall establish a process for the review of

22 the adequacy of these standards along with an assessment of

23 additional specialties to be included in the list under this

24 subsection (d).

25 Notwithstanding any other law or Department rule, the

26 maximum travel and distance standards and appointment wait

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1 time standards shall be no greater than any such standards

2 established for qualified health plans in

3 Federally-Facilitated Exchanges by federal law or by the

4 federal Centers for Medicare and Medicaid Services, even if

5 the network plan is issued in the large group market or is

6 otherwise not issued through an exchange. Federal standards

7 for stand-alone dental plans shall only apply to such network

8 plans. In the absence of an applicable Department rule, the

9 federal standards shall apply for the time period specified in

10 the federal law, regulation, or guidance. If the Centers for

11 Medicare and Medicaid Services establish standards that are

12 more stringent than the standards in effect under any

13 Department rule, the Department may amend its rules to conform

14 to the more stringent federal standards.

15 If the federal area designations for the maximum time or

16 distance or appointment wait time standards required are

17 changed by the most recent Letter to Issuers in the

18 Federally-facilitated Marketplaces, the Department shall post

19 on its website notice of such changes and may amend its rules

20 to conform to those designations if the Director deems

21 appropriate.

22 (d-5)(1) Every issuer ~~insurer~~ shall ensure that

23 beneficiaries have timely and proximate access to treatment

24 for mental, emotional, nervous, or substance use disorders or

25 conditions in accordance with the provisions of paragraph (4)

26 of subsection (a) of Section 370c of the Illinois Insurance

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1 Code. Issuers ~~Insurers~~ shall use a comparable process,

2 strategy, evidentiary standard, and other factors in the

3 development and application of the network adequacy standards

4 for timely and proximate access to treatment for mental,

5 emotional, nervous, or substance use disorders or conditions

6 and those for the access to treatment for medical and surgical

7 conditions. As such, the network adequacy standards for timely

8 and proximate access shall equally be applied to treatment

9 facilities and providers for mental, emotional, nervous, or

10 substance use disorders or conditions and specialists

11 providing medical or surgical benefits pursuant to the parity

12 requirements of Section 370c.1 of the Illinois Insurance Code

13 and the federal Paul Wellstone and Pete Domenici Mental Health

14 Parity and Addiction Equity Act of 2008. Notwithstanding the

15 foregoing, the network adequacy standards for timely and

16 proximate access to treatment for mental, emotional, nervous,

17 or substance use disorders or conditions shall, at a minimum,

18 satisfy the following requirements:

19 (A) For beneficiaries residing in the metropolitan

20 counties of Cook, DuPage, Kane, Lake, McHenry, and Will,

21 network adequacy standards for timely and proximate access

22 to treatment for mental, emotional, nervous, or substance

23 use disorders or conditions means a beneficiary shall not

24 have to travel longer than 30 minutes or 30 miles from the

25 beneficiary's residence to receive outpatient treatment

26 for mental, emotional, nervous, or substance use disorders

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1 or conditions. Beneficiaries shall not be required to wait

2 longer than 10 business days between requesting an initial

3 appointment and being seen by the facility or provider of

4 mental, emotional, nervous, or substance use disorders or

5 conditions for outpatient treatment or to wait longer than

6 20 business days between requesting a repeat or follow-up

7 appointment and being seen by the facility or provider of

8 mental, emotional, nervous, or substance use disorders or

9 conditions for outpatient treatment; however, subject to

10 the protections of paragraph (3) of this subsection, a

11 network plan shall not be held responsible if the

12 beneficiary or provider voluntarily chooses to schedule an

13 appointment outside of these required time frames.

14 (B) For beneficiaries residing in Illinois counties

15 other than those counties listed in subparagraph (A) of

16 this paragraph, network adequacy standards for timely and

17 proximate access to treatment for mental, emotional,

18 nervous, or substance use disorders or conditions means a

19 beneficiary shall not have to travel longer than 60

20 minutes or 60 miles from the beneficiary's residence to

21 receive outpatient treatment for mental, emotional,

22 nervous, or substance use disorders or conditions.

23 Beneficiaries shall not be required to wait longer than 10

24 business days between requesting an initial appointment

25 and being seen by the facility or provider of mental,

26 emotional, nervous, or substance use disorders or

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1 conditions for outpatient treatment or to wait longer than

2 20 business days between requesting a repeat or follow-up

3 appointment and being seen by the facility or provider of

4 mental, emotional, nervous, or substance use disorders or

5 conditions for outpatient treatment; however, subject to

6 the protections of paragraph (3) of this subsection, a

7 network plan shall not be held responsible if the

8 beneficiary or provider voluntarily chooses to schedule an

9 appointment outside of these required time frames.

10 (2) For beneficiaries residing in all Illinois counties,

11 network adequacy standards for timely and proximate access to

12 treatment for mental, emotional, nervous, or substance use

13 disorders or conditions means a beneficiary shall not have to

14 travel longer than 60 minutes or 60 miles from the

15 beneficiary's residence to receive inpatient or residential

16 treatment for mental, emotional, nervous, or substance use

17 disorders or conditions.

18 (3) If there is no in-network facility or provider

19 available for a beneficiary to receive timely and proximate

20 access to treatment for mental, emotional, nervous, or

21 substance use disorders or conditions in accordance with the

22 network adequacy standards outlined in this subsection, the

23 issuer ~~insurer~~ shall provide necessary exceptions to its

24 network to ensure admission and treatment with a provider or

25 at a treatment facility in accordance with the network

26 adequacy standards in this subsection.

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1 (4) If the federal Centers for Medicare and Medicaid

2 Services establish or law requires more stringent standards

3 for qualified health plans in the Federally-Facilitated

4 Exchanges, the federal standards shall control for the time

5 period specified in the federal law, regulation, or guidance,

6 even if the network plan is issued in the large group market or

7 is otherwise not issued through an exchange.

8 (e) Except for network plans solely offered as a group

9 health plan, these ratio and time and distance standards apply

10 to the lowest cost-sharing tier of any tiered network.

11 (f) The network plan may consider use of other health care

12 service delivery options, such as telemedicine or telehealth,

13 mobile clinics, and centers of excellence, or other ways of

14 delivering care to partially meet the requirements set under

15 this Section.

16 (g) Except for the requirements set forth in subsection

17 (d-5), issuers ~~insurers~~ who are not able to comply with the

18 provider ratios and time and distance or appointment wait time

19 standards established under this Act ~~by the Department~~ may

20 request an exception to these requirements from the

21 Department. The Department may grant an exception in the

22 following circumstances:

23 (1) if no providers or facilities meet the specific

24 time and distance standard in a specific service area and

25 the issuer ~~insurer~~ (i) discloses information on the

26 distance and travel time points that beneficiaries would

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1 have to travel beyond the required criterion to reach the

2 next closest contracted provider outside of the service

3 area and (ii) provides contact information, including

4 names, addresses, and phone numbers for the next closest

5 contracted provider or facility;

6 (2) if patterns of care in the service area do not

7 support the need for the requested number of provider or

8 facility type and the issuer ~~insurer~~ provides data on

9 local patterns of care, such as claims data, referral

10 patterns, or local provider interviews, indicating where

11 the beneficiaries currently seek this type of care or

12 where the physicians currently refer beneficiaries, or

13 both; or

14 (3) other circumstances deemed appropriate by the

15 Department consistent with the requirements of this Act.

16 (h) Issuers ~~Insurers~~ are required to report to the

17 Director any material change to an approved network plan

18 within 15 days after the change occurs and any change that

19 would result in failure to meet the requirements of this Act.

20 The issuer shall submit a revised version of the complete

21 network adequacy filing based on the material change, and the

22 issuer shall attach versions with the changes indicated for

23 each document that was revised from the previous version of

24 the filing. Upon notice from the issuer ~~insurer~~, the Director

25 shall reevaluate the network plan's compliance with the

26 network adequacy and transparency standards of this Act. For

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1 every day past 15 days that the issuer fails to submit a

2 revised network adequacy filing to the Director, the Director

3 shall order a fine of $1,000 per day.

4 (i) If a network plan is inadequate under this Act with

5 respect to a provider type in a county, and if the network plan

6 does not have an approved exception for that provider type in

7 that county pursuant to subsection (g), an issuer shall

8 process out-of-network claims for covered health care services

9 received from that provider type within that county at the

10 in-network benefit level and shall retroactively adjudicate

11 and reimburse beneficiaries to achieve that objective if their

12 claims were processed at the out-of-network level contrary to

13 this subsection.

14 (j) If the Director determines that a network is

15 inadequate in any county and no exception has been granted

16 under subsection (g) and the issuer does not have a process in

17 place to comply with subsection (d-5), the Director may

18 prohibit the network plan from being issued or renewed within

19 that county until the Director determines that the network is

20 adequate apart from processes and exceptions described in

21 subsections (d-5) and (g). Nothing in this subsection shall be

22 construed to terminate any beneficiary's health insurance

23 coverage under a network plan before the expiration of the

24 beneficiary's policy period if the Director makes a

25 determination under this subsection after the issuance or

26 renewal of the beneficiary's policy or certificate because of

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1 a material change. Policies or certificates issued or renewed

2 in violation of this subsection shall subject the issuer to a

3 civil penalty of $1,000 per policy.

4 (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;

5 102-1117, eff. 1-13-23.)

6 (215 ILCS 124/15)

7 Sec. 15. Notice of nonrenewal or termination.

8 (a) A network plan must give at least 60 days' notice of

9 nonrenewal or termination of a provider to the provider and to

10 the beneficiaries served by the provider. The notice shall

11 include a name and address to which a beneficiary or provider

12 may direct comments and concerns regarding the nonrenewal or

13 termination and the telephone number maintained by the

14 Department for consumer complaints. Immediate written notice

15 may be provided without 60 days' notice when a provider's

16 license has been disciplined by a State licensing board or

17 when the network plan reasonably believes direct imminent

18 physical harm to patients under the provider's ~~providers~~ care

19 may occur. The notice to the beneficiary shall provide the

20 individual with an opportunity to notify the issuer of the

21 individual's need for transitional care.

22 (b) Primary care providers must notify active affected

23 patients of nonrenewal or termination of the provider from the

24 network plan, except in the case of incapacitation.

25 (Source: P.A. 100-502, eff. 9-15-17.)

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1 (215 ILCS 124/20)

2 Sec. 20. Transition of services.

3 (a) A network plan shall provide for continuity of care

4 for its beneficiaries as follows:

5 (1) If a beneficiary's ~~physician or hospital~~ provider

6 leaves the network plan's network of providers for reasons

7 other than termination of a contract in situations

8 involving imminent harm to a patient or a final

9 disciplinary action by a State licensing board and the

10 provider remains within the network plan's service area,

11 if benefits provided under such network plan with respect

12 to such provider or facility are terminated because of a

13 change in the terms of the participation of such provider

14 or facility in such plan, or if a contract between a group

15 health plan and a health insurance issuer offering a

16 network plan in connection with the group health plan is

17 terminated and results in a loss of benefits provided

18 under such plan with respect to such provider, then the

19 network plan shall permit the beneficiary to continue an

20 ongoing course of treatment with that provider during a

21 transitional period for the following duration:

22 (A) 90 days from the date of the notice to the

23 beneficiary of the provider's disaffiliation from the

24 network plan if the beneficiary has an ongoing course

25 of treatment; or

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1 (B) if the beneficiary has entered the third

2 trimester of pregnancy at the time of the provider's

3 disaffiliation, a period that includes the provision

4 of post-partum care directly related to the delivery.

5 (2) Notwithstanding the provisions of paragraph (1) of

6 this subsection (a), such care shall be authorized by the

7 network plan during the transitional period in accordance

8 with the following:

9 (A) the provider receives continued reimbursement

10 from the network plan at the rates and terms and

11 conditions applicable under the terminated contract

12 prior to the start of the transitional period;

13 (B) the provider adheres to the network plan's

14 quality assurance requirements, including provision to

15 the network plan of necessary medical information

16 related to such care; and

17 (C) the provider otherwise adheres to the network

18 plan's policies and procedures, including, but not

19 limited to, procedures regarding referrals and

20 obtaining preauthorizations for treatment.

21 (3) The provisions of this Section governing health

22 care provided during the transition period do not apply if

23 the beneficiary has successfully transitioned to another

24 provider participating in the network plan, if the

25 beneficiary has already met or exceeded the benefit

26 limitations of the plan, or if the care provided is not

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1 medically necessary.

2 (b) A network plan shall provide for continuity of care

3 for new beneficiaries as follows:

4 (1) If a new beneficiary whose provider is not a

5 member of the network plan's provider network, but is

6 within the network plan's service area, enrolls in the

7 network plan, the network plan shall permit the

8 beneficiary to continue an ongoing course of treatment

9 with the beneficiary's current physician during a

10 transitional period:

11 (A) of 90 days from the effective date of

12 enrollment if the beneficiary has an ongoing course of

13 treatment; or

14 (B) if the beneficiary has entered the third

15 trimester of pregnancy at the effective date of

16 enrollment, that includes the provision of post-partum

17 care directly related to the delivery.

18 (2) If a beneficiary, or a beneficiary's authorized

19 representative, elects in writing to continue to receive

20 care from such provider pursuant to paragraph (1) of this

21 subsection (b), such care shall be authorized by the

22 network plan for the transitional period in accordance

23 with the following:

24 (A) the provider receives reimbursement from the

25 network plan at rates established by the network plan;

26 (B) the provider adheres to the network plan's

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1 quality assurance requirements, including provision to

2 the network plan of necessary medical information

3 related to such care; and

4 (C) the provider otherwise adheres to the network

5 plan's policies and procedures, including, but not

6 limited to, procedures regarding referrals and

7 obtaining preauthorization for treatment.

8 (3) The provisions of this Section governing health

9 care provided during the transition period do not apply if

10 the beneficiary has successfully transitioned to another

11 provider participating in the network plan, if the

12 beneficiary has already met or exceeded the benefit

13 limitations of the plan, or if the care provided is not

14 medically necessary.

15 (c) In no event shall this Section be construed to require

16 a network plan to provide coverage for benefits not otherwise

17 covered or to diminish or impair preexisting condition

18 limitations contained in the beneficiary's contract.

19 (d) A provider shall comply with the requirements of 42

20 U.S.C. 300gg-138.

21 (Source: P.A. 100-502, eff. 9-15-17.)

22 (215 ILCS 124/25)

23 Sec. 25. Network transparency.

24 (a) A network plan shall post electronically an

25 up-to-date, accurate, and complete provider directory for each

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1 of its network plans, with the information and search

2 functions, as described in this Section.

3 (1) In making the directory available electronically,

4 the network plans shall ensure that the general public is

5 able to view all of the current providers for a plan

6 through a clearly identifiable link or tab and without

7 creating or accessing an account or entering a policy or

8 contract number.

9 (2) The network plan shall update the online provider

10 directory at least monthly. An issuer's failure to update

11 a network plan's directory shall subject the issuer to a

12 civil penalty of $5,000 per month. Providers shall notify

13 the network plan electronically or in writing of any

14 changes to their information as listed in the provider

15 directory, including the information required in

16 subparagraph (K) of paragraph (1) of subsection (b). If a

17 provider is no longer accepting new patients, the provider

18 must give notice to the issuer within 5 business days

19 after deciding to cease accepting new patients, or within

20 5 business days after the effective date of this

21 amendatory Act of the 103rd General Assembly, whichever is

22 later. The network plan shall update its online provider

23 directory in a manner consistent with the information

24 provided by the provider within 2 ~~10~~ business days after

25 being notified of the change by the provider. Nothing in

26 this paragraph (2) shall void any contractual relationship

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1 between the provider and the plan.

2 (3) At least once every 90 days, the ~~The~~ network plan

3 shall audit each ~~periodically at least 25%~~ of its print

4 and online provider directories for accuracy, make any

5 corrections necessary, and retain documentation of the

6 audit. The network plan shall submit the audit to the

7 Director upon request. As part of these audits, the

8 network plan shall contact any provider in its network

9 that has not submitted a claim to the plan or otherwise

10 communicated his or her intent to continue participation

11 in the plan's network. The audits shall comply with 42

12 U.S.C. 300gg-115(a)(2), except that "provider directory

13 information" shall include all information required to be

14 included in a provider directory pursuant to this Act.

15 (4) A network plan shall provide a print copy of a

16 current provider directory or a print copy of the

17 requested directory information upon request of a

18 beneficiary or a prospective beneficiary. Print copies

19 must be updated quarterly and an errata that reflects

20 changes in the provider network must be updated quarterly.

21 (5) For each network plan, a network plan shall

22 include, in plain language in both the electronic and

23 print directory, the following general information:

24 (A) in plain language, a description of the

25 criteria the plan has used to build its provider

26 network;

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1 (B) if applicable, in plain language, a

2 description of the criteria the issuer ~~insurer~~ or

3 network plan has used to create tiered networks;

4 (C) if applicable, in plain language, how the

5 network plan designates the different provider tiers

6 or levels in the network and identifies for each

7 specific provider, hospital, or other type of facility

8 in the network which tier each is placed, for example,

9 by name, symbols, or grouping, in order for a

10 beneficiary-covered person or a prospective

11 beneficiary-covered person to be able to identify the

12 provider tier; and

13 (D) if applicable, a notation that authorization

14 or referral may be required to access some providers.

15 (6) A network plan shall make it clear for both its

16 electronic and print directories what provider directory

17 applies to which network plan, such as including the

18 specific name of the network plan as marketed and issued

19 in this State. The network plan shall include in both its

20 electronic and print directories a customer service email

21 address and telephone number or electronic link that

22 beneficiaries or the general public may use to notify the

23 network plan of inaccurate provider directory information

24 and contact information for the Department's Office of

25 Consumer Health Insurance.

26 (7) A provider directory, whether in electronic or

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1 print format, shall accommodate the communication needs of

2 individuals with disabilities, and include a link to or

3 information regarding available assistance for persons

4 with limited English proficiency.

5 (b) For each network plan, a network plan shall make

6 available through an electronic provider directory the

7 following information in a searchable format:

8 (1) for health care professionals:

9 (A) name;

10 (B) gender;

11 (C) participating office locations;

12 (D) specialty, if applicable;

13 (E) medical group affiliations, if applicable;

14 (F) facility affiliations, if applicable;

15 (G) participating facility affiliations, if

16 applicable;

17 (H) languages spoken other than English, if

18 applicable;

19 (I) whether accepting new patients;

20 (J) board certifications, if applicable; and

21 (K) use of telehealth or telemedicine, including,

22 but not limited to:

23 (i) whether the provider offers the use of

24 telehealth or telemedicine to deliver services to

25 patients for whom it would be clinically

26 appropriate;

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1 (ii) what modalities are used and what types

2 of services may be provided via telehealth or

3 telemedicine; and

4 (iii) whether the provider has the ability and

5 willingness to include in a telehealth or

6 telemedicine encounter a family caregiver who is

7 in a separate location than the patient if the

8 patient wishes and provides his or her consent;

9 (2) for hospitals:

10 (A) hospital name;

11 (B) hospital type (such as acute, rehabilitation,

12 children's, or cancer);

13 (C) participating hospital location; and

14 (D) hospital accreditation status; and

15 (3) for facilities, other than hospitals, by type:

16 (A) facility name;

17 (B) facility type;

18 (C) types of services performed; and

19 (D) participating facility location or locations,

20 including for each location where the health care

21 professional is at the location at least 3 days per

22 week.

23 (c) For the electronic provider directories, for each

24 network plan, a network plan shall make available all of the

25 following information in addition to the searchable

26 information required in this Section:

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1 (1) for health care professionals:

2 (A) contact information, including both a

3 telephone number and digital contact information if

4 the provider has supplied digital contact information;

5 and

6 (B) languages spoken other than English by

7 clinical staff, if applicable;

8 (2) for hospitals, telephone number and digital

9 contact information; and

10 (3) for facilities other than hospitals, telephone

11 number.

12 (d) The issuer ~~insurer~~ or network plan shall make

13 available in print, upon request, the following provider

14 directory information for the applicable network plan:

15 (1) for health care professionals:

16 (A) name;

17 (B) contact information, including telephone

18 number and digital contact information if the provider

19 has supplied digital contact information;

20 (C) participating office location or locations,

21 including for each location where the health care

22 professional is at the location at least 3 days per

23 week;

24 (D) specialty, if applicable;

25 (E) languages spoken other than English, if

26 applicable;

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1 (F) whether accepting new patients; and

2 (G) use of telehealth or telemedicine, including,

3 but not limited to:

4 (i) whether the provider offers the use of

5 telehealth or telemedicine to deliver services to

6 patients for whom it would be clinically

7 appropriate;

8 (ii) what modalities are used and what types

9 of services may be provided via telehealth or

10 telemedicine; and

11 (iii) whether the provider has the ability and

12 willingness to include in a telehealth or

13 telemedicine encounter a family caregiver who is

14 in a separate location than the patient if the

15 patient wishes and provides his or her consent;

16 (2) for hospitals:

17 (A) hospital name;

18 (B) hospital type (such as acute, rehabilitation,

19 children's, or cancer); and

20 (C) participating hospital location, ~~and~~ telephone

21 number, and digital contact information; and

22 (3) for facilities, other than hospitals, by type:

23 (A) facility name;

24 (B) facility type;

25 (C) types of services performed; and

26 (D) participating facility location or locations,

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1 ~~and~~ telephone numbers, and digital contact information

2 for each location.

3 (e) The network plan shall include a disclosure in the

4 print format provider directory that the information included

5 in the directory is accurate as of the date of printing and

6 that beneficiaries or prospective beneficiaries should consult

7 the issuer's ~~insurer's~~ electronic provider directory on its

8 website and contact the provider. The network plan shall also

9 include a telephone number in the print format provider

10 directory for a customer service representative where the

11 beneficiary can obtain current provider directory information.

12 (f) The Director may conduct periodic audits of the

13 accuracy of provider directories. A network plan shall not be

14 subject to any fines or penalties for information required in

15 this Section that a provider submits that is inaccurate or

16 incomplete.

17 (g) To the extent not otherwise provided in this Act, an

18 issuer shall comply with the requirements of 42 U.S.C.

19 300gg-115, except that "provider directory information" shall

20 include all information required to be included in a provider

21 directory pursuant to this Section.

22 (Source: P.A. 102-92, eff. 7-9-21.)

23 (215 ILCS 124/30)

24 Sec. 30. Administration and enforcement.

25 (a) Issuers ~~Insurers~~, as defined in this Act, have a

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1 continuing obligation to comply with the requirements of this

2 Act. Other than the duties specifically created in this Act,

3 nothing in this Act is intended to preclude, prevent, or

4 require the adoption, modification, or termination of any

5 utilization management, quality management, or claims

6 processing methodologies of an issuer ~~insurer~~.

7 (b) Nothing in this Act precludes, prevents, or requires

8 the adoption, modification, or termination of any network plan

9 term, benefit, coverage or eligibility provision, or payment

10 methodology.

11 (c) The Director shall enforce the provisions of this Act

12 pursuant to the enforcement powers granted to it by law.

13 (d) The Department shall adopt rules to enforce compliance

14 with this Act to the extent necessary.

15 (e) In accordance with Section 5-45.21 of the Illinois

16 Administrative Procedure Act, the Department may adopt

17 emergency rules to implement federal standards for provider

18 ratios, travel time and distance, and appointment wait times

19 if such standards apply to health insurance coverage regulated

20 by the Department and are more stringent than the State

21 standards extant at the time the final federal standards are

22 published.

23 (Source: P.A. 100-502, eff. 9-15-17.)

24 (215 ILCS 124/35 new)

25 Sec. 35. Provider requirements. Providers shall comply

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1 with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations

2 promulgated thereunder, as well as Section 20 and paragraph

3 (2) of subsection (a) of Section 25 of this Act, except that

4 "provider directory information" includes all information

5 required to be included in a provider directory pursuant to

6 Section 25 of this Act. To the extent a provider is licensed by

7 the Department of Financial and Professional Regulation or by

8 the Department of Public Health, that agency shall have the

9 authority to investigate, examine, process complaints, issue

10 subpoenas, examine witnesses under oath, issue a fine, or take

11 disciplinary action against the provider's license for

12 violations of these requirements in accordance with the

13 provider's applicable licensing statute.

14 (215 ILCS 124/40 new)

15 Sec. 40. Confidentiality.

16 (a) All records in the custody or possession of the

17 Department are presumed to be open to public inspection or

18 copying unless exempt from disclosure by Section 7 or 7.5 of

19 the Freedom of Information Act. Except as otherwise provided

20 in this Section or other applicable law, the filings required

21 under this Act shall be open to public inspection or copying.

22 (b) The following information shall not be deemed

23 confidential:

24 (1) actual or projected ratios of providers to

25 beneficiaries;

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1 (2) actual or projected time and distance between

2 network providers and beneficiaries or actual or projected

3 waiting times for a beneficiary to see a network provider;

4 (3) geographic maps of network providers;

5 (4) requests for exceptions under subsection (g) of

6 Section 10, except with respect to any discussion of

7 ongoing or planned contractual negotiations with providers

8 that the issuer requests to be treated as confidential;

9 and

10 (5) provider directories.

11 (c) An issuer's work papers and reports on the results of a

12 self-audit of its provider directories shall remain

13 confidential unless expressly waived by the insurer or unless

14 deemed public information under federal law.

15 (d) The filings required under Section 10 of this Act

16 shall be confidential while they remain under the Department's

17 review but shall become open to public inspection and copying

18 upon completion of the review, except as provided in this

19 Section or under other applicable law.

20 (e) Nothing in this Section shall supersede the statutory

21 requirement that work papers obtained during a market conduct

22 examination be deemed confidential.

23 Section 20. The Managed Care Reform and Patient Rights Act

24 is amended by changing Sections 20 and 25 as follows:

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1 (215 ILCS 134/20)

2 Sec. 20. Notice of nonrenewal or termination. A health

3 care plan must give at least 60 days notice of nonrenewal or

4 termination of a health care provider to the health care

5 provider and to the enrollees served by the health care

6 provider. The notice shall include a name and address to which

7 an enrollee or health care provider may direct comments and

8 concerns regarding the nonrenewal or termination. Immediate

9 written notice may be provided without 60 days notice when a

10 health care provider's license has been disciplined by a State

11 licensing board. The notice to the enrollee shall provide the

12 individual with an opportunity to notify the health care plan

13 of the individual's need for transitional care.

14 (Source: P.A. 91-617, eff. 1-1-00.)

15 (215 ILCS 134/25)

16 Sec. 25. Transition of services.

17 (a) A health care plan shall provide for continuity of

18 care for its enrollees as follows:

19 (1) If an enrollee's health care provider ~~physician~~

20 leaves the health care plan's network of health care

21 providers for reasons other than termination of a contract

22 in situations involving imminent harm to a patient or a

23 final disciplinary action by a State licensing board and

24 the provider ~~physician~~remains within the health care

25 plan's service area, or if benefits provided under such

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1 health care plan with respect to such provider are

2 terminated because of a change in the terms of the

3 participation of such provider in such plan, or if a

4 contract between a group health plan, as defined in

5 Section 5 of the Illinois Health Insurance Portability and

6 Accountability Act, and a health care plan offered

7 connection with the group health plan is terminated and

8 results in a loss of benefits provided under such plan

9 with respect to such provider,the health care plan shall

10 permit the enrollee to continue an ongoing course of

11 treatment with that provider~~physician~~ during a

12 transitional period:

13 (A) of 90 days from the date of the notice of

14 provider's ~~physician's~~termination from the health

15 care plan to the enrollee of the provider's

16 ~~physician's~~disaffiliation from the health care plan

17 if the enrollee has an ongoing course of treatment; or

18 (B) if the enrollee has entered the third

19 trimester of pregnancy at the time of theprovider's

20 ~~physician's~~disaffiliation, that includes the

21 provision of post-partum care directly related to the

22 delivery.

23 (2) Notwithstanding the provisions in item (1) of this

24 subsection, such care shall be authorized by the health

25 care plan during the transitional period only if the

26 provider~~physician~~ agrees:

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1 (A) to continue to accept reimbursement from the

2 health care plan at the rates applicable prior to the

3 start of the transitional period;

4 (B) to adhere to the health care plan's quality

5 assurance requirements and to provide to the health

6 care plan necessary medical information related to

7 such care; and

8 (C) to otherwise adhere to the health care plan's

9 policies and procedures, including but not limited to

10 procedures regarding referrals and obtaining

11 preauthorizations for treatment.

12 (3) During an enrollee's plan year, a health care plan

13 shall not remove a drug from its formulary or negatively

14 change its preferred or cost-tier sharing unless, at least

15 60 days before making the formulary change, the health

16 care plan:

17 (A) provides general notification of the change in

18 its formulary to current and prospective enrollees;

19 (B) directly notifies enrollees currently

20 receiving coverage for the drug, including information

21 on the specific drugs involved and the steps they may

22 take to request coverage determinations and

23 exceptions, including a statement that a certification

24 of medical necessity by the enrollee's prescribing

25 provider will result in continuation of coverage at

26 the existing level; and

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1 (C) directly notifies by first class mail and

2 through an electronic transmission, if available, the

3 prescribing provider of all health care plan enrollees

4 currently prescribed the drug affected by the proposed

5 change; the notice shall include a one-page form by

6 which the prescribing provider can notify the health

7 care plan by first class mail that coverage of the drug

8 for the enrollee is medically necessary.

9 The notification in paragraph (C) may direct the

10 prescribing provider to an electronic portal through which

11 the prescribing provider may electronically file a

12 certification to the health care plan that coverage of the

13 drug for the enrollee is medically necessary. The

14 prescribing provider may make a secure electronic

15 signature beside the words "certification of medical

16 necessity", and this certification shall authorize

17 continuation of coverage for the drug.

18 If the prescribing provider certifies to the health

19 care plan either in writing or electronically that the

20 drug is medically necessary for the enrollee as provided

21 in paragraph (C), a health care plan shall authorize

22 coverage for the drug prescribed based solely on the

23 prescribing provider's assertion that coverage is

24 medically necessary, and the health care plan is

25 prohibited from making modifications to the coverage

26 related to the covered drug, including, but not limited

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1 to:

2 (i) increasing the out-of-pocket costs for the

3 covered drug;

4 (ii) moving the covered drug to a more restrictive

5 tier; or

6 (iii) denying an enrollee coverage of the drug for

7 which the enrollee has been previously approved for

8 coverage by the health care plan.

9 Nothing in this item (3) prevents a health care plan

10 from removing a drug from its formulary or denying an

11 enrollee coverage if the United States Food and Drug

12 Administration has issued a statement about the drug that

13 calls into question the clinical safety of the drug, the

14 drug manufacturer has notified the United States Food and

15 Drug Administration of a manufacturing discontinuance or

16 potential discontinuance of the drug as required by

17 Section 506C of the Federal Food, Drug, and Cosmetic Act,

18 as codified in 21 U.S.C. 356c, or the drug manufacturer

19 has removed the drug from the market.

20 Nothing in this item (3) prohibits a health care plan,

21 by contract, written policy or procedure, or any other

22 agreement or course of conduct, from requiring a

23 pharmacist to effect substitutions of prescription drugs

24 consistent with Section 19.5 of the Pharmacy Practice Act,

25 under which a pharmacist may substitute an interchangeable

26 biologic for a prescribed biologic product, and Section 25

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1 of the Pharmacy Practice Act, under which a pharmacist may

2 select a generic drug determined to be therapeutically

3 equivalent by the United States Food and Drug

4 Administration and in accordance with the Illinois Food,

5 Drug and Cosmetic Act.

6 This item (3) applies to a policy or contract that is

7 amended, delivered, issued, or renewed on or after January

8 1, 2019. This item (3) does not apply to a health plan as

9 defined in the State Employees Group Insurance Act of 1971

10 or medical assistance under Article V of the Illinois

11 Public Aid Code.

12 (b) A health care plan shall provide for continuity of

13 care for new enrollees as follows:

14 (1) If a new enrollee whose physician is not a member

15 of the health care plan's provider network, but is within

16 the health care plan's service area, enrolls in the health

17 care plan, the health care plan shall permit the enrollee

18 to continue an ongoing course of treatment with the

19 enrollee's current physician during a transitional period:

20 (A) of 90 days from the effective date of

21 enrollment if the enrollee has an ongoing course of

22 treatment; or

23 (B) if the enrollee has entered the third

24 trimester of pregnancy at the effective date of

25 enrollment, that includes the provision of post-partum

26 care directly related to the delivery.

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1 (2) If an enrollee elects to continue to receive care

2 from such physician pursuant to item (1) of this

3 subsection, such care shall be authorized by the health

4 care plan for the transitional period only if the

5 physician agrees:

6 (A) to accept reimbursement from the health care

7 plan at rates established by the health care plan;

8 such rates shall be the level of reimbursement

9 applicable to similar physicians within the health

10 care plan for such services;

11 (B) to adhere to the health care plan's quality

12 assurance requirements and to provide to the health

13 care plan necessary medical information related to

14 such care; and

15 (C) to otherwise adhere to the health care plan's

16 policies and procedures including, but not limited to

17 procedures regarding referrals and obtaining

18 preauthorization for treatment.

19 (c) In no event shall this Section be construed to require

20 a health care plan to provide coverage for benefits not

21 otherwise covered or to diminish or impair preexisting

22 condition limitations contained in the enrollee's contract. In

23 no event shall this Section be construed to prohibit the

24 addition of prescription drugs to a health care plan's list of

25 covered drugs during the coverage year.

26 (d) In this Section, "ongoing course of treatment" has the

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1 meaning ascribed to that term in Section 5 of the Network

2 Adequacy and Transparency Act.

3 (Source: P.A. 100-1052, eff. 8-24-18.)

4 Section 99. Effective date. This Act takes effect upon

5 becoming law.

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INDEX

Statutes amended in order of appearance