Bill Text: IL SB0070 | 2017-2018 | 100th General Assembly | Introduced

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Bill Title: Creates the Network Adequacy and Transparency Act. Provides that administrators and insurers, prior to going to market, must file with the Department of Insurance for review and approval a description of the services to be offered through a network plan, with certain criteria included in the description. Provides that the network plan shall demonstrate to the Department, prior to approval, a minimum ratio of full-time equivalent providers to plan beneficiaries and maximum travel and distance standards for plan beneficiaries, which shall be established annually by the Department based upon specified sources. Provides that the Department shall conduct quarterly audits of network plans to verify compliance with network adequacy standards. Establishes certain notice requirements. Provides that a network plan shall provide for continuity of care for its beneficiaries under certain circumstances and according to certain requirements. Provides that a network plan shall post electronically a current and accurate provider directory and make available in print, upon request, a provider directory subject to certain specifications. Provides that the Department is granted specific authority to issue a cease and desist order against, fine, or otherwise penalize any insurer or administrator for violations of any provision of the Act. Makes other changes. Effective January 1, 2018.

Spectrum: Slight Partisan Bill (Democrat 6-3)

Status: (Failed) 2019-01-09 - Session Sine Die [SB0070 Detail]

Download: Illinois-2017-SB0070-Introduced.html

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100TH GENERAL ASSEMBLY State of Illinois 2017 and 2018 SB0070 Introduced 1/11/2017, by Sen. Linda Holmes SYNOPSIS AS INTRODUCED:
New Act
Creates the Network Adequacy and Transparency Act. Provides that administrators and insurers, prior to going to market, must file with the Department of Insurance for review and approval a description of the services to be offered through a network plan, with certain criteria included in the description. Provides that the network plan shall demonstrate to the Department, prior to approval, a minimum ratio of full-time equivalent providers to plan beneficiaries and maximum travel and distance standards for plan beneficiaries, which shall be established annually by the Department based upon specified sources. Provides that the Department shall conduct quarterly audits of network plans to verify compliance with network adequacy standards. Establishes certain notice requirements. Provides that a network plan shall provide for continuity of care for its beneficiaries under certain circumstances and according to certain requirements. Provides that a network plan shall post electronically a current and accurate provider directory and make available in print, upon request, a provider directory subject to certain specifications. Provides that the Department is granted specific authority to issue a cease and desist order against, fine, or otherwise penalize any insurer or administrator for violations of any provision of the Act. Makes other changes. Effective January 1, 2018.
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FISCAL NOTE ACT MAY APPLY
A BILL FOR
SB0070 LRB100 04184 RPS 14190 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. Short title. This Act may be cited as the
Network Adequacy and Transparency Act.
Section 5. Definitions. In this Act:
"Administrator" means any person, partnership, or
corporation, other than a risk-bearing entity, that arranges,
contracts with, or administers contracts with a provider under
which insureds or beneficiaries are provided an incentive to
use the services of the provider. "Administrator" also includes
(i) any person, partnership, or corporation, other than a
risk-bearing entity, that enters into a contract with another
administrator to enroll beneficiaries or insureds in a network
plan marketed as an independently identifiable program based on
marketing materials or member benefit identification cards and
(ii) an employer.
"Beneficiary" means an individual, an enrollee, an
insured, a participant, or any other person entitled to
reimbursement for covered expenses of or the discounting of
provider fees for health care services under a program in which
the beneficiary has an incentive to utilize the services of a
provider that has entered into an agreement or arrangement with

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an administrator, as defined in subsection (g) of Section 370g
of the Illinois Insurance Code.
"Department" means the Department of Insurance.
"Director" means the Director of Insurance.
"Insurer" means any entity that offers individual or group
accident and health insurance, including, but not limited to,
health maintenance organizations, preferred provider
organizations, exclusive provider organizations, and other
plan structures requiring network participation, excluding the
medical assistance program under the Illinois Public Aid Code
and the State employees group health insurance program.
"Material change" means a significant reduction in the
number of providers available in a network plan, including, but
not limited to, a reduction of 10% or more in a specific type
of providers, the removal of a major health system that causes
a network to be significantly different from the network when
the beneficiary purchased the network plan, or any change that
would cause the network to no longer satisfy the requirements
of this Act or the Department's rules for network adequacy and
transparency.
"Network" means the group or groups of preferred providers
providing services to a network plan.
"Network plan" means an individual or group policy of
accident and health insurance that either requires a covered
person to use or creates incentives, including financial
incentives, for a covered person to use providers managed,

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owned, under contract with, or employed by the insurer.
"Ongoing course of treatment" means (1) treatment for a
life-threatening condition, which is a disease or condition for
which likelihood of death is probable unless the course of the
disease or condition is interrupted; (2) treatment for a
serious acute condition, defined as a disease or condition
requiring complex ongoing care that the covered person is
currently receiving, such as chemotherapy, radiation therapy,
or post-operative visits; (3) a course of treatment for a
health condition that a treating provider attests that
discontinuing care by that provider would worsen the condition
or interfere with anticipated outcomes; or (4) the third
trimester of pregnancy through the post-partum period.
"Preferred provider" means any provider who has entered,
either directly or indirectly, into an agreement with an
administrator, employer, or risk-bearing entity relating to
health care services that may be rendered to beneficiaries
under a network plan.
"Providers" means physicians licensed to practice medicine
in all its branches, other health care professionals,
hospitals, or other health care institutions that provide
health care services.
"Tiered network" means a network that identifies and groups
some or all types of provider and facilities into specific
groups to which different provider reimbursement, covered
person cost-sharing or provider access requirements, or any

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combination thereof, apply for the same services.
"Woman's principal health care provider" means a physician
licensed to practice medicine in all of its branches
specializing in obstetrics, gynecology, or family practice.
Section 10. Network adequacy.
(a) An insurer or administrator providing a network plan
shall file all of the following with the Director:
(1) The method of marketing the network plan.
(2) Written policies and procedures for maintaining a
network that is sufficient in numbers and appropriate types
of providers, including those that serve predominantly
low-income, medically underserved individuals, to ensure
that all covered services to beneficiaries, including
adults and children, low-income persons, persons with
serious, chronic, or complex health conditions or physical
or mental disabilities, or persons with limited English
proficiency, will be accessible without unreasonable
travel or delay.
(3) Written policies and procedures for the selection
and tiering, if any, of providers, including each health
care professional specialty. Selection and tiering
standards shall not:
(A) allow an insurer or administrator to
discriminate against high-risk populations by
excluding and tiering providers because they are

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located in geographic areas that contain populations
or providers presenting a risk of higher than average
claims, losses, or health care services utilization;
(B) exclude providers because they treat or
specialize in treating populations presenting a risk
of higher than average claims, losses, or health care
services utilization; or
(C) discriminate, with respect to participation
under the health benefit plan, against any provider who
is acting within the scope of the provider's license or
certification under applicable State law or rules.
(i) The provisions of this subdivision (C) do
not require an insurer or administrator or the
networks with which it contracts to employ
specific providers acting within the scope of
their licenses or certifications under applicable
State law who may meet the selection criteria of
the insurers or administrators or the networks
with which they contract or to contract with or
retain more providers acting within the scope of
their license or certification under applicable
State law than are necessary to maintain a
sufficient provider network.
(ii) The provisions of this subdivision (C)
may not be construed to require an insurer or
administrator to contract with any provider

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willing to abide by the terms and conditions for
participation established by the carrier.
(iii) The provisions of this subdivision (C)
shall not be construed to prohibit an insurer or
administrator from declining to select a provider
who fails to meet the other legitimate selection
criteria developed in compliance with this Act.
(D) An insurer or administrator shall not offer an
inducement to a provider that would encourage or
otherwise incentivize the provider to deliver less
than medically necessary services to a covered person.
(E) An insurer or administrator shall not prohibit
a preferred provider from discussing any specific or
all treatment options with beneficiaries irrespective
of the insurer's position on those treatment options or
from advocating on behalf of beneficiaries within the
utilization review, grievance, or appeals processes
established by the administrator or insurer in
accordance with any rights or remedies available under
applicable State or federal law.
(4) The written policies and procedures for
determining when the plan is closed to new providers
desiring to enter into a network plan.
(5) The written policies and procedures for adding
providers to meet patient needs based on increases in the
number of beneficiaries, changes in the

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patient-to-provider ratio, changes in medical and health
care capabilities, and increased demand for services.
(6) The written policies and procedures for making
referrals within and outside the network.
(7) Written policies and procedures on how the network
plan will provide 24-hour, 7-day per week access to
network-affiliated primary care, emergency services, and
woman's principal health care providers.
(b) Prior to going to market, administrators and insurers
must file with the Director for review and approval a
description of the services to be offered through a network
plan. The description shall include all of the following:
(1) A geographic map of the area proposed to be served
by the plan by county service area and zip code, including
marked locations for preferred providers.
(2) The names, addresses, phone numbers, and
specialties of the providers who have entered into
preferred provider agreements under the network plan.
(3) The number of beneficiaries anticipated to be
covered by the network plan.
(4) An Internet website and toll-free telephone number
for beneficiaries and prospective beneficiaries to access
current and accurate lists of preferred providers,
additional information about the plan, as well as any other
information required by Department rule.
(5) A description of how health care services to be

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rendered under the network plan are reasonably accessible
and available to beneficiaries. The description shall
address all of the following:
(A) the type of health care services to be provided
by the network plan;
(B) the ratio of full-time equivalent physicians
and other providers to beneficiaries, by specialty and
including primary care physicians and facility-based
physicians when applicable under the contract,
necessary to meet the health care needs and service
demands of the currently enrolled population;
(C) the travel and distance standards for plan
beneficiaries in county service areas; and
(D) a description for each network hospital of the
percentage of physicians in each of these specialties,
(i) emergency medicine, (ii) anesthesiology, (iii)
pathology, (iv) radiology, (v) neonatology, and (vi)
hospitalists, who practice in the hospital are in the
insurer's or administrator's network.
(6) A provision ensuring that whenever a beneficiary
has made a good faith effort, as evidenced by accessing the
provider directory and calling the provider when possible,
to utilize preferred providers for a covered service and it
is determined the administrator or insurer does not have
the appropriate preferred providers due to insufficient
number, type, or unreasonable travel distance or delay, the

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administrator or insurer shall ensure, directly or
indirectly, by terms contained in the payer contract, that
the beneficiary will be provided the covered service at no
greater cost to the beneficiary than if the service had
been provided by a preferred provider. This paragraph (6)
does not apply to a beneficiary who willfully chooses to
access a non-preferred provider for health care services
available through the administrator's panel of preferred
providers. In these circumstances, the contractual
requirements for non-preferred provider reimbursements
shall apply.
(7) The procedures for paying benefits when particular
physician specialties are not available within the
provider network.
(8) A provision that the beneficiary shall receive
emergency care coverage such that payment for this coverage
is not dependent upon whether the emergency services are
performed by a preferred or non-preferred provider and the
coverage shall be at the same benefit level as if the
service or treatment had been rendered by a preferred
provider. For purposes of this paragraph (8), "the same
benefit level" means that the beneficiary is provided the
covered service at no greater cost to the beneficiary than
if the service had been provided by a preferred provider.
(9) A limitation that, if the plan provides that the
beneficiary will incur a penalty for failing to pre-certify

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inpatient hospital treatment, the penalty may not exceed
$1,000 per occurrence in addition to the plan cost sharing
provisions.
(c) The network plan shall demonstrate to the Director,
prior to approval, a minimum ratio of full-time equivalent
providers to plan beneficiaries as required by the Department.
(1) The ratio of full-time equivalent physician or
other providers to plan beneficiaries shall be established
annually by the Department based upon the guidance from the
federal Centers for Medicare and Medicaid Services
concerning exchange plans or Medicare Advantage Plans.
These ratios at a minimum must include physicians or other
providers as follows:
(A) Primary Care;
(B) Pediatrics;
(C) Cardiology;
(D) Gastroenterology;
(E) General Surgery;
(F) Neurology;
(G) OB/GYN;
(H) Oncology/Radiation;
(I) Ophthalmology;
(J) Urology;
(K) Behavioral Health;
(L) Allergy/Immunology;
(M) Chiropractic;

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(N) Dermatology;
(O) Endocrinology;
(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
(Q) Infectious Disease;
(R) Nephrology;
(S) Neurosurgery;
(T) Orthopedic Surgery;
(U) Physiatry/Rehabilitative;
(V) Plastic Surgery;
(W) Pulmonary;
(X) Rheumatology;
(Y) Anesthesiology;
(Z) Pain Medicine;
(AA) Pediatric Specialty Services;
(BB) Outpatient Dialysis; and
(CC) HIV.
(2) The Director shall establish a process for the
annual review of the adequacy of these standards, along
with an assessment of additional specialties to be included
in the list under this subsection (c).
(d) The network plan shall demonstrate to the Director,
prior to approval, maximum travel and distance standards for
plan beneficiaries, which shall be established annually by the
Department based upon the guidance from the federal Centers for
Medicare and Medicaid Services concerning exchange plans or
Medicare Advantage Plans. These standards shall consist of the

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maximum minutes or miles to be traveled by a plan beneficiary
for each county type, such as large counties, metro counties,
or rural counties as defined by Department rule.
(1) The maximum travel time and distance standards must
include standards for each physician and other provider
category listed in paragraph (1) of subsection (c).
(2) The network plan must demonstrate, prior to
approval, that it has contracted with physicians who
specialize in emergency medicine, anesthesiology,
pathology, and radiology and hospitalists, in sufficient
numbers at any in-network facility or in-network hospital
included in such plan so that patients enrolled in the plan
have reasonable access to these in-network physician
specialists.
(3) The network plan must demonstrate, prior to
approval, that it has contracted with physicians who
specialize in pediatric hospital-based services, including
emergency medicine, anesthesiology, pathology, radiology,
and hospitalists, in sufficient numbers at any in-network
facility or in-network hospital included in such plan so
that pediatric patients enrolled in the plan have
reasonable access to these in-network physician
specialists.
(4) The Director shall establish a process for the
annual review of the adequacy of these standards along with
an assessment of additional specialties to be included in

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the list under this subsection (d).
(e) These ratio and time and distance standards apply to
the lowest cost-sharing tier of any tiered network.
(f) Insurers and administrators who are not able to comply
with the provider ratios and time and distance standards
established by the Department may request an exception to these
requirements from the Department. The Department may grant an
exception in the following circumstances:
(1) if no providers or facilities meet the specific
time and distance standard in a specific service area and
the insurer or administrator (i) discloses information on
the distance and travel time points that beneficiaries
would have to travel beyond the required criterion to reach
the next closest contracted provider outside of the service
area and (ii) provides contact information, including
names, addresses, and phone numbers for the next closest
contracted provider or facility; or
(2) if patterns of care in the service area do not
support the need for the requested number of provider or
facility type and the insurer or administrator provides
data on local patterns of care, such as claims data,
referral patterns, or local provider interviews,
indicating where the beneficiaries currently seek this
type of care, where the physicians currently refer
beneficiaries, or both.
(g) Insurers and administrators are required to report to

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the Director any material change to an approved network plan
within 15 days after the change occurs and any change that
would result in failure to meet the requirements of this Act.
Upon notice from the insurer or administrator, the Director
shall reevaluate the network plan's compliance with the network
adequacy and transparency standards of this Act.
(h) The Director shall conduct quarterly audits of all
network plans to verify compliance with network adequacy
standards. These audits shall include surveys to be sent to
plan beneficiaries and providers for the purpose of assessing
network plan compliance with the provisions of this Section.
Section 15. Notice of nonrenewal or termination. A network
plan must give at least 60 days' notice of nonrenewal or
termination of a provider to the provider and to the
beneficiaries served by the provider. The notice shall include
a name and address to which a beneficiary or provider may
direct comments and concerns regarding the nonrenewal or
termination and the telephone number maintained by the
Department for consumer complaints. Immediate written notice
may be provided without 60 days' notice when a provider's
license has been disciplined by a State licensing board or when
the network plan reasonably believes direct imminent physical
harm to patients under the providers care may occur.
Section 20. Transition of services.

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(a) A network plan shall provide for continuity of care for
its beneficiaries as follows:
(1) If a beneficiary's physician or hospital provider
leaves the network plan's network of providers for reasons
other than termination of a contract in situations
involving imminent harm to a patient or a final
disciplinary action by a State licensing board and the
provider remains within the network plan's service area,
the network plan shall permit the beneficiary to continue
an ongoing course of treatment with that provider during a
transitional period for the following duration:
(A) 90 days from the date of the notice to the
beneficiary of the provider's disaffiliation from the
network plan if the beneficiary has an ongoing course
of treatment; or
(B) if the beneficiary has entered the third
trimester of pregnancy at the time of the provider's
disaffiliation, a period that includes the provision
of post-partum care directly related to the delivery.
(2) Notwithstanding the provisions of paragraph (1) of
this subsection (a), such care shall be authorized by the
network plan during the transitional period in accordance
with the following:
(A) the provider receives continued reimbursement
from the network plan at the rates and terms and
conditions applicable prior to the start of the

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transitional period;
(B) the provider adheres to the network plan's
quality assurance requirements, including provision to
the network plan of necessary medical information
related to such care; and
(C) the provider otherwise adheres to the network
plan's policies and procedures, including, but not
limited to, procedures regarding referrals and
obtaining preauthorizations for treatment.
(3) The provisions of this Section governing health
care provided during the transition period do not apply if
the beneficiary has successfully transitioned to another
provider participating in the network plan, if the
beneficiary has already met or exceeded the benefit
limitations of the plan, or if the care provided is not
medically necessary.
(b) The termination or departure of a beneficiary's
physician or hospital provider from a network plan shall
constitute a qualifying event, allowing beneficiaries to
select a new network plan outside of a standard open enrollment
period within 60 days of notice of termination or departure.
(c) A network plan shall provide for continuity of care for
new beneficiaries as follows:
(1) If a new beneficiary whose provider is not a member
of the network plan's provider network, but is within the
network plan's service area, enrolls in the network plan,

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the network plan shall permit the beneficiary to continue
an ongoing course of treatment with the beneficiary's
current physician during a transitional period:
(A) of 90 days from the effective date of
enrollment if the beneficiary has an ongoing course of
treatment; or
(B) if the beneficiary has entered the third
trimester of pregnancy at the effective date of
enrollment, that includes the provision of post-partum
care directly related to the delivery.
(2) If a beneficiary elects to continue to receive care
from such provider pursuant to paragraph (1) of this
subsection (c), such care shall be authorized by the
network plan for the transitional period in accordance with
the following:
(A) the provider receives reimbursement from the
network plan at rates established by the network plan;
(B) the provider adheres to the network plan's
quality assurance requirements, including provision to
the network plan of necessary medical information
related to such care; and
(C) the provider otherwise adheres to the network
plan's policies and procedures, including, but not
limited to, procedures regarding referrals and
obtaining preauthorization for treatment.
(3) The provisions of this Section governing health

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care provided during the transition period do not apply if
the beneficiary has successfully transitioned to another
provider participating in the network plan, if the
beneficiary has already met or exceeded the benefit
limitations of the plan, or if the care provided is not
medically necessary.
(d) In no event shall this Section be construed to require
a network plan to provide coverage for benefits not otherwise
covered or to diminish or impair preexisting condition
limitations contained in the beneficiary's contract.
Section 25. Network transparency.
(a) A network plan shall post electronically an up-to-date,
accurate, and complete provider directory for each of its
network plans, with the information and search functions, as
described in this Section.
(1) In making the directory available electronically,
the network plans shall ensure that the general public is
able to view all of the current providers for a plan
through a clearly identifiable link or tab and without
creating or accessing an account or entering a policy or
contract number.
(2) The network plan shall provide updates to the
online provider directory within 10 business days after
knowing a change is necessary.
(3) The network plan shall audit monthly at least 25%

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of its provider directories for accuracy, make any
corrections necessary, and retain documentation of the
audit. The network plan shall submit the audit annually to
the Director. As part of these audits, the network plan
shall contact any provider in its network that has not
submitted a claim to the plan or otherwise communicated his
or her intent to continue participation in the plan's
network within a 6-month period.
(4) A network plan shall provide a print copy of a
current provider directory or a print copy of the requested
directory information upon request of a beneficiary or a
prospective beneficiary. Print copies must be updated
monthly or provide an errata that reflects changes in the
provider network, to be updated monthly.
(5) For each network plan, a network plan shall
include, in plain language in both the electronic and print
directory, the following general information:
(A) in plain language, a description of the
criteria the plan has used to build its provider
network;
(B) if applicable, in plain language, a
description of the criteria the administrator,
insurer, or network plan has used to create tiered
networks;
(C) if applicable, in plain language, how the
network plan designates the different provider tiers

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or levels in the network and identifies for each
specific provider, hospital, or other type of facility
in the network which tier each is placed, for example,
by name, symbols, or grouping, in order for a
beneficiary-covered person or a prospective
beneficiary-covered person to be able to identify the
provider tier; and
(D) if applicable, a notation that authorization
or referral may be required to access some providers.
(6) A network plan shall make it clear for both its
electronic and print directories what provider directory
applies to which network plan, such as including the
specific name of the network plan as marketed and issued in
this State. The network plan shall include in both its
electronic and print directories a customer service email
address and telephone number or electronic link that
beneficiaries or the general public may use to notify the
network plan of inaccurate provider directory information
and contact information for the Department's Office of
Consumer Health Insurance.
(7) A provider directory, whether in electronic or
print format, shall accommodate the communication needs of
individuals with disabilities, and include a link to or
information regarding available assistance for persons
with limited English proficiency.
(b) For each network plan, a network plan shall make

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available through an electronic provider directory the
following information in a searchable format:
(1) for health care professionals:
(A) name;
(B) gender;
(C) participating office locations;
(D) specialty, if applicable;
(E) medical group affiliations, if applicable;
(F) facility affiliations, if applicable;
(G) participating facility affiliations, if
applicable;
(H) languages spoken other than English, if
applicable;
(I) whether accepting new patients; and
(J) board certifications, if applicable.
(2) for hospitals:
(A) hospital name;
(B) hospital type (such as acute, rehabilitation,
children's, or cancer);
(C) participating hospital location; and
(D) hospital accreditation status; and
(3) for facilities, other than hospitals, by type:
(A) facility name;
(B) facility type;
(C) types of services performed; and
(D) participating facility location or locations.

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(c) For the electronic provider directories, for each
network plan, a network plan shall make available all of the
following information in addition to the searchable
information required in this Section:
(1) for health care professionals:
(A) contact information; and
(B) languages spoken other than English by
clinical staff, if applicable;
(2) for hospitals, telephone number; and
(3) for facilities other than hospitals, telephone
number.
(d) The administrator, insurer, or network plan shall make
available in print, upon request, the following provider
directory information for the applicable network plan:
(1) for health care professionals:
(A) name;
(B) contact information;
(C) participating office location or locations;
(D) specialty, if applicable;
(E) languages spoken other than English, if
applicable; and
(F) whether accepting new patients.
(2) for hospitals:
(A) hospital name;
(B) hospital type (such as acute, rehabilitation,
children's, or cancer); and

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(C) participating hospital location and telephone
number; and
(3) for facilities, other than hospitals, by type:
(A) facility name;
(B) facility type;
(C) types of services performed; and
(D) participating facility location or locations
and telephone numbers.
(e) The network plan shall include a disclosure in the
print format provider directory that the information included
in the directory is accurate as of the date of printing and
that beneficiaries or prospective beneficiaries should consult
the insurer's or administrator's electronic provider directory
on its website and contact the provider. The network plan shall
also include a telephone number in the print format provider
directory for a customer service representative where the
beneficiary can obtain current provider directory information.
(f) The Director shall conduct semi-annual audits of the
accuracy of provider directories to ensure plan compliance.
Section 30. Administration and enforcement.
(a) Insurers and administrators, as defined in this Act,
have a continuing obligation to comply with the requirements of
this Act. Other than the duties specifically created in this
Act, nothing in this Act is intended to preclude, prevent, or
require the adoption, modification, or termination of any

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utilization management, quality management, or claims
processing methodologies of an insurer or administrator.
(b) Nothing in this Act precludes, prevents, or requires
the adoption, modification, or termination of any network plan
term, benefit, coverage or eligibility provision, or payment
methodology.
(c) The Director shall enforce the provisions of this Act
pursuant to the enforcement powers granted to it by law.
(d) The Director is hereby granted specific authority to
issue a cease and desist order against, fine, or otherwise
penalize any insurer or administrator for violations of any
provision of this Act.
(e) The Department shall adopt rules to enforce compliance
with this Act to the extent necessary.
Section 99. Effective date. This Act takes effect January
1, 2018.