Bill Text: IL SB0241 | 2023-2024 | 103rd General Assembly | Introduced

---

Bill Title: Amends the Illinois Insurance Code. Makes a change in provisions concerning disclosure of nonparticipating provider limited benefits. Adds reproductive health care to the definition of "ancillary services". Amends the Network Adequacy and Transparency Act. Provides that an insurer providing a network plan shall file a description with the Director of Insurance of written policies and procedures on how the network plan will provide 24-hour, 7-day per week access to reproductive health care. Provides that the Department of Insurance shall consider establishing ratios for reproductive health care physicians or other providers. Effective July 1, 2024, except that certain changes take effect January 1, 2025.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2023-01-31 - Referred to Assignments [SB0241 Detail]

Download: Illinois-2023-SB0241-Introduced.html

---

103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB0241 Introduced 1/31/2023, by Sen. Laura Ellman SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.3
215 ILCS 5/356z.3a
215 ILCS 124/10
Amends the Illinois Insurance Code. Makes a change in provisions concerning disclosure of nonparticipating provider limited benefits. Adds reproductive health care to the definition of "ancillary services". Amends the Network Adequacy and Transparency Act. Provides that an insurer providing a network plan shall file a description with the Director of Insurance of written policies and procedures on how the network plan will provide 24-hour, 7-day per week access to reproductive health care. Provides that the Department of Insurance shall consider establishing ratios for reproductive health care physicians or other providers. Effective July 1, 2024, except that certain changes take effect January 1, 2025.
LRB103 27273 BMS 53644 b
A BILL FOR
SB0241 LRB103 27273 BMS 53644 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
changing Sections 356z.3 and 356z.3a as follows:
(215 ILCS 5/356z.3)
Sec. 356z.3. Disclosure of limited benefit. An insurer
that issues, delivers, amends, or renews an individual or
group policy of accident and health insurance in this State
after the effective date of this amendatory Act of the 92nd
General Assembly and arranges, contracts with, or administers
contracts with a provider whereby beneficiaries are provided
an incentive to use the services of such provider must include
the following disclosure on its contracts and evidences of
coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that
when you elect to utilize the services of a non-participating
provider for a covered service in non-emergency situations,
benefit payments to such non-participating provider are not
based upon the amount billed. The basis of your benefit
payment will be determined according to your policy's fee
schedule, usual and customary charge (which is determined by
comparing charges for similar services adjusted to the

SB0241 - 2 - LRB103 27273 BMS 53644 b
geographical area where the services are performed), or other
method as defined by the policy. YOU CAN EXPECT TO PAY MORE
THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE
PLAN HAS PAID ITS REQUIRED PORTION. Non-participating
providers may bill members for any amount up to the billed
charge after the plan has paid its portion of the bill, except
as provided in Section 356z.3a of the Illinois Insurance Code
for covered services received at a participating health care
facility from a nonparticipating provider that are: (a)
ancillary services, (b) items or services furnished as a
result of unforeseen, urgent medical needs that arise at the
time the item or service is furnished, or (c) items or services
received when the facility or the non-participating provider
fails to satisfy the notice and consent criteria specified
under Section 356z.3a, or (d) reproductive health care, as
defined in Section 1-10 of the Reproductive Health Act.
Participating providers have agreed to accept discounted
payments for services with no additional billing to the member
other than co-insurance and deductible amounts. You may obtain
further information about the participating status of
professional providers and information on out-of-pocket
expenses by calling the toll free telephone number on your
identification card.".
(Source: P.A. 102-901, eff. 1-1-23.)
(215 ILCS 5/356z.3a)

SB0241 - 3 - LRB103 27273 BMS 53644 b
Sec. 356z.3a. Billing; emergency services;
nonparticipating providers.
(a) As used in this Section:
"Ancillary services" means:
(1) items and services related to emergency medicine,
anesthesiology, pathology, radiology, and neonatology that
are provided by any health care provider;
(2) items and services provided by assistant surgeons,
hospitalists, and intensivists;
(3) diagnostic services, including radiology and
laboratory services, except for advanced diagnostic
laboratory tests identified on the most current list
published by the United States Secretary of Health and
Human Services under 42 U.S.C. 300gg-132(b)(3);
(4) items and services provided by other specialty
practitioners as the United States Secretary of Health and
Human Services specifies through rulemaking under 42
U.S.C. 300gg-132(b)(3);
(5) items and services provided by a nonparticipating
provider if there is no participating provider who can
furnish the item or service at the facility; and
(6) items and services provided by a nonparticipating
provider if there is no participating provider who will
furnish the item or service because a participating
provider has asserted the participating provider's rights
under the Health Care Right of Conscience Act; and .

SB0241 - 4 - LRB103 27273 BMS 53644 b
(7) reproductive health care, as defined in Section
1-10 of the Reproductive Health Act.
"Cost sharing" means the amount an insured, beneficiary,
or enrollee is responsible for paying for a covered item or
service under the terms of the policy or certificate. "Cost
sharing" includes copayments, coinsurance, and amounts paid
toward deductibles, but does not include amounts paid towards
premiums, balance billing by out-of-network providers, or the
cost of items or services that are not covered under the policy
or certificate.
"Emergency department of a hospital" means any hospital
department that provides emergency services, including a
hospital outpatient department.
"Emergency medical condition" has the meaning ascribed to
that term in Section 10 of the Managed Care Reform and Patient
Rights Act.
"Emergency medical screening examination" has the meaning
ascribed to that term in Section 10 of the Managed Care Reform
and Patient Rights Act.
"Emergency services" means, with respect to an emergency
medical condition:
(1) in general, an emergency medical screening
examination, including ancillary services routinely
available to the emergency department to evaluate such
emergency medical condition, and such further medical
examination and treatment as would be required to

SB0241 - 5 - LRB103 27273 BMS 53644 b
stabilize the patient regardless of the department of the
hospital or other facility in which such further
examination or treatment is furnished; or
(2) additional items and services for which benefits
are provided or covered under the coverage and that are
furnished by a nonparticipating provider or
nonparticipating emergency facility regardless of the
department of the hospital or other facility in which such
items are furnished after the insured, beneficiary, or
enrollee is stabilized and as part of outpatient
observation or an inpatient or outpatient stay with
respect to the visit in which the services described in
paragraph (1) are furnished. Services after stabilization
cease to be emergency services only when all the
conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
regulations thereunder are met.
"Freestanding Emergency Center" means a facility licensed
under Section 32.5 of the Emergency Medical Services (EMS)
Systems Act.
"Health care facility" means, in the context of
non-emergency services, any of the following:
(1) a hospital as defined in 42 U.S.C. 1395x(e);
(2) a hospital outpatient department;
(3) a critical access hospital certified under 42
U.S.C. 1395i-4(e);
(4) an ambulatory surgical treatment center as defined

SB0241 - 6 - LRB103 27273 BMS 53644 b
in the Ambulatory Surgical Treatment Center Act; or
(5) any recipient of a license under the Hospital
Licensing Act that is not otherwise described in this
definition.
"Health care provider" means a provider as defined in
subsection (d) of Section 370g. "Health care provider" does
not include a provider of air ambulance or ground ambulance
services.
"Health care services" has the meaning ascribed to that
term in subsection (a) of Section 370g.
"Health insurance issuer" has the meaning ascribed to that
term in Section 5 of the Illinois Health Insurance Portability
and Accountability Act.
"Nonparticipating emergency facility" means, with respect
to the furnishing of an item or service under a policy of group
or individual health insurance coverage, any of the following
facilities that does not have a contractual relationship
directly or indirectly with a health insurance issuer in
relation to the coverage:
(1) an emergency department of a hospital;
(2) a Freestanding Emergency Center;
(3) an ambulatory surgical treatment center as defined
in the Ambulatory Surgical Treatment Center Act; or
(4) with respect to emergency services described in
paragraph (2) of the definition of "emergency services", a
hospital.

SB0241 - 7 - LRB103 27273 BMS 53644 b
"Nonparticipating provider" means, with respect to the
furnishing of an item or service under a policy of group or
individual health insurance coverage, any health care provider
who does not have a contractual relationship directly or
indirectly with a health insurance issuer in relation to the
coverage.
"Participating emergency facility" means any of the
following facilities that has a contractual relationship
directly or indirectly with a health insurance issuer offering
group or individual health insurance coverage setting forth
the terms and conditions on which a relevant health care
service is provided to an insured, beneficiary, or enrollee
under the coverage:
(1) an emergency department of a hospital;
(2) a Freestanding Emergency Center;
(3) an ambulatory surgical treatment center as defined
in the Ambulatory Surgical Treatment Center Act; or
(4) with respect to emergency services described in
paragraph (2) of the definition of "emergency services", a
hospital.
For purposes of this definition, a single case agreement
between an emergency facility and an issuer that is used to
address unique situations in which an insured, beneficiary, or
enrollee requires services that typically occur out-of-network
constitutes a contractual relationship and is limited to the
parties to the agreement.

SB0241 - 8 - LRB103 27273 BMS 53644 b
"Participating health care facility" means any health care
facility that has a contractual relationship directly or
indirectly with a health insurance issuer offering group or
individual health insurance coverage setting forth the terms
and conditions on which a relevant health care service is
provided to an insured, beneficiary, or enrollee under the
coverage. A single case agreement between an emergency
facility and an issuer that is used to address unique
situations in which an insured, beneficiary, or enrollee
requires services that typically occur out-of-network
constitutes a contractual relationship for purposes of this
definition and is limited to the parties to the agreement.
"Participating provider" means any health care provider
that has a contractual relationship directly or indirectly
with a health insurance issuer offering group or individual
health insurance coverage setting forth the terms and
conditions on which a relevant health care service is provided
to an insured, beneficiary, or enrollee under the coverage.
"Qualifying payment amount" has the meaning given to that
term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
promulgated thereunder.
"Recognized amount" means the lesser of the amount
initially billed by the provider or the qualifying payment
amount.
"Stabilize" means "stabilization" as defined in Section 10
of the Managed Care Reform and Patient Rights Act.

SB0241 - 9 - LRB103 27273 BMS 53644 b
"Treating provider" means a health care provider who has
evaluated the individual.
"Visit" means, with respect to health care services
furnished to an individual at a health care facility, health
care services furnished by a provider at the facility, as well
as equipment, devices, telehealth services, imaging services,
laboratory services, and preoperative and postoperative
services regardless of whether the provider furnishing such
services is at the facility.
(b) Emergency services. When a beneficiary, insured, or
enrollee receives emergency services from a nonparticipating
provider or a nonparticipating emergency facility, the health
insurance issuer shall ensure that the beneficiary, insured,
or enrollee shall incur no greater out-of-pocket costs than
the beneficiary, insured, or enrollee would have incurred with
a participating provider or a participating emergency
facility. Any cost-sharing requirements shall be applied as
though the emergency services had been received from a
participating provider or a participating facility. Cost
sharing shall be calculated based on the recognized amount for
the emergency services. If the cost sharing for the same item
or service furnished by a participating provider would have
been a flat-dollar copayment, that amount shall be the
cost-sharing amount unless the provider has billed a lesser
total amount. In no event shall the beneficiary, insured,
enrollee, or any group policyholder or plan sponsor be liable

SB0241 - 10 - LRB103 27273 BMS 53644 b
to or billed by the health insurance issuer, the
nonparticipating provider, or the nonparticipating emergency
facility for any amount beyond the cost sharing calculated in
accordance with this subsection with respect to the emergency
services delivered. Administrative requirements or limitations
shall be no greater than those applicable to emergency
services received from a participating provider or a
participating emergency facility.
(b-5) Non-emergency services at participating health care
facilities.
(1) When a beneficiary, insured, or enrollee utilizes
a participating health care facility and, due to any
reason, covered ancillary services are provided by a
nonparticipating provider during or resulting from the
visit, the health insurance issuer shall ensure that the
beneficiary, insured, or enrollee shall incur no greater
out-of-pocket costs than the beneficiary, insured, or
enrollee would have incurred with a participating provider
for the ancillary services. Any cost-sharing requirements
shall be applied as though the ancillary services had been
received from a participating provider. Cost sharing shall
be calculated based on the recognized amount for the
ancillary services. If the cost sharing for the same item
or service furnished by a participating provider would
have been a flat-dollar copayment, that amount shall be
the cost-sharing amount unless the provider has billed a

SB0241 - 11 - LRB103 27273 BMS 53644 b
lesser total amount. In no event shall the beneficiary,
insured, enrollee, or any group policyholder or plan
sponsor be liable to or billed by the health insurance
issuer, the nonparticipating provider, or the
participating health care facility for any amount beyond
the cost sharing calculated in accordance with this
subsection with respect to the ancillary services
delivered. In addition to ancillary services, the
requirements of this paragraph shall also apply with
respect to covered items or services furnished as a result
of unforeseen, urgent medical needs that arise at the time
an item or service is furnished, regardless of whether the
nonparticipating provider satisfied the notice and consent
criteria under paragraph (2) of this subsection.
(2) When a beneficiary, insured, or enrollee utilizes
a participating health care facility and receives
non-emergency covered health care services other than
those described in paragraph (1) of this subsection from a
nonparticipating provider during or resulting from the
visit, the health insurance issuer shall ensure that the
beneficiary, insured, or enrollee incurs no greater
out-of-pocket costs than the beneficiary, insured, or
enrollee would have incurred with a participating provider
unless the nonparticipating provider or the participating
health care facility on behalf of the nonparticipating
provider satisfies the notice and consent criteria

SB0241 - 12 - LRB103 27273 BMS 53644 b
provided in 42 U.S.C. 300gg-132 and regulations
promulgated thereunder. If the notice and consent criteria
are not satisfied, then:
(A) any cost-sharing requirements shall be applied
as though the health care services had been received
from a participating provider;
(B) cost sharing shall be calculated based on the
recognized amount for the health care services; and
(C) in no event shall the beneficiary, insured,
enrollee, or any group policyholder or plan sponsor be
liable to or billed by the health insurance issuer,
the nonparticipating provider, or the participating
health care facility for any amount beyond the cost
sharing calculated in accordance with this subsection
with respect to the health care services delivered.
(c) Notwithstanding any other provision of this Code,
except when the notice and consent criteria are satisfied for
the situation in paragraph (2) of subsection (b-5), any
benefits a beneficiary, insured, or enrollee receives for
services under the situations in subsection (b) or (b-5) are
assigned to the nonparticipating providers or the facility
acting on their behalf. Upon receipt of the provider's bill or
facility's bill, the health insurance issuer shall provide the
nonparticipating provider or the facility with a written
explanation of benefits that specifies the proposed
reimbursement and the applicable deductible, copayment, or

SB0241 - 13 - LRB103 27273 BMS 53644 b
coinsurance amounts owed by the insured, beneficiary, or
enrollee. The health insurance issuer shall pay any
reimbursement subject to this Section directly to the
nonparticipating provider or the facility.
(d) For bills assigned under subsection (c), the
nonparticipating provider or the facility may bill the health
insurance issuer for the services rendered, and the health
insurance issuer may pay the billed amount or attempt to
negotiate reimbursement with the nonparticipating provider or
the facility. Within 30 calendar days after the provider or
facility transmits the bill to the health insurance issuer,
the issuer shall send an initial payment or notice of denial of
payment with the written explanation of benefits to the
provider or facility. If attempts to negotiate reimbursement
for services provided by a nonparticipating provider do not
result in a resolution of the payment dispute within 30 days
after receipt of written explanation of benefits by the health
insurance issuer, then the health insurance issuer or
nonparticipating provider or the facility may initiate binding
arbitration to determine payment for services provided on a
per-bill basis. The party requesting arbitration shall notify
the other party arbitration has been initiated and state its
final offer before arbitration. In response to this notice,
the nonrequesting party shall inform the requesting party of
its final offer before the arbitration occurs. Arbitration
shall be initiated by filing a request with the Department of

SB0241 - 14 - LRB103 27273 BMS 53644 b
Insurance.
(e) The Department of Insurance shall publish a list of
approved arbitrators or entities that shall provide binding
arbitration. These arbitrators shall be American Arbitration
Association or American Health Lawyers Association trained
arbitrators. Both parties must agree on an arbitrator from the
Department of Insurance's or its approved entity's list of
arbitrators. If no agreement can be reached, then a list of 5
arbitrators shall be provided by the Department of Insurance
or the approved entity. From the list of 5 arbitrators, the
health insurance issuer can veto 2 arbitrators and the
provider or facility can veto 2 arbitrators. The remaining
arbitrator shall be the chosen arbitrator. This arbitration
shall consist of a review of the written submissions by both
parties. The arbitrator shall not establish a rebuttable
presumption that the qualifying payment amount should be the
total amount owed to the provider or facility by the
combination of the issuer and the insured, beneficiary, or
enrollee. Binding arbitration shall provide for a written
decision within 45 days after the request is filed with the
Department of Insurance. Both parties shall be bound by the
arbitrator's decision. The arbitrator's expenses and fees,
together with other expenses, not including attorney's fees,
incurred in the conduct of the arbitration, shall be paid as
provided in the decision.
(f) (Blank).

SB0241 - 15 - LRB103 27273 BMS 53644 b
(g) Section 368a of this Act shall not apply during the
pendency of a decision under subsection (d). Upon the issuance
of the arbitrator's decision, Section 368a applies with
respect to the amount, if any, by which the arbitrator's
determination exceeds the issuer's initial payment under
subsection (c), or the entire amount of the arbitrator's
determination if initial payment was denied. Any interest
required to be paid to a provider under Section 368a shall not
accrue until after 30 days of an arbitrator's decision as
provided in subsection (d), but in no circumstances longer
than 150 days from the date the nonparticipating
facility-based provider billed for services rendered.
(h) Nothing in this Section shall be interpreted to change
the prudent layperson provisions with respect to emergency
services under the Managed Care Reform and Patient Rights Act.
(i) Nothing in this Section shall preclude a health care
provider from billing a beneficiary, insured, or enrollee for
reasonable administrative fees, such as service fees for
checks returned for nonsufficient funds and missed
appointments.
(j) Nothing in this Section shall preclude a beneficiary,
insured, or enrollee from assigning benefits to a
nonparticipating provider when the notice and consent criteria
are satisfied under paragraph (2) of subsection (b-5) or in
any other situation not described in subsection (b) or (b-5).
(k) Except when the notice and consent criteria are

SB0241 - 16 - LRB103 27273 BMS 53644 b
satisfied under paragraph (2) of subsection (b-5), if an
individual receives health care services under the situations
described in subsection (b) or (b-5), no referral requirement
or any other provision contained in the policy or certificate
of coverage shall deny coverage, reduce benefits, or otherwise
defeat the requirements of this Section for services that
would have been covered with a participating provider.
However, this subsection shall not be construed to preclude a
provider contract with a health insurance issuer, or with an
administrator or similar entity acting on the issuer's behalf,
from imposing requirements on the participating provider,
participating emergency facility, or participating health care
facility relating to the referral of covered individuals to
nonparticipating providers.
(l) Except if the notice and consent criteria are
satisfied under paragraph (2) of subsection (b-5),
cost-sharing amounts calculated in conformity with this
Section shall count toward any deductible or out-of-pocket
maximum applicable to in-network coverage.
(m) The Department has the authority to enforce the
requirements of this Section in the situations described in
subsections (b) and (b-5), and in any other situation for
which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
regulations promulgated thereunder would prohibit an
individual from being billed or liable for emergency services
furnished by a nonparticipating provider or nonparticipating

SB0241 - 17 - LRB103 27273 BMS 53644 b
emergency facility or for non-emergency health care services
furnished by a nonparticipating provider at a participating
health care facility.
(n) This Section does not apply with respect to air
ambulance or ground ambulance services. This Section does not
apply to any policy of excepted benefits or to short-term,
limited-duration health insurance coverage.
(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
Section 10. The Network Adequacy and Transparency Act is
amended by changing Section 10 as follows:
(215 ILCS 124/10)
Sec. 10. Network adequacy.
(a) An insurer providing a network plan shall file a
description of all of the following with the Director:
(1) The written policies and procedures for adding
providers to meet patient needs based on increases in the
number of beneficiaries, changes in the
patient-to-provider ratio, changes in medical and health
care capabilities, and increased demand for services.
(2) The written policies and procedures for making
referrals within and outside the network.
(3) The written policies and procedures on how the
network plan will provide 24-hour, 7-day per week access
to network-affiliated primary care, emergency services,

SB0241 - 18 - LRB103 27273 BMS 53644 b
reproductive health care, and women's principal health
care providers.
An insurer shall not prohibit a preferred provider from
discussing any specific or all treatment options with
beneficiaries irrespective of the insurer's position on those
treatment options or from advocating on behalf of
beneficiaries within the utilization review, grievance, or
appeals processes established by the insurer in accordance
with any rights or remedies available under applicable State
or federal law.
(b) Insurers must file for review a description of the
services to be offered through a network plan. The description
shall include all of the following:
(1) A geographic map of the area proposed to be served
by the plan by county service area and zip code, including
marked locations for preferred providers.
(2) As deemed necessary by the Department, the names,
addresses, phone numbers, and specialties of the providers
who have entered into preferred provider agreements under
the network plan.
(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

SB0241 - 19 - LRB103 27273 BMS 53644 b
other information required by Department rule.
(5) A description of how health care services to be
rendered under the network plan are reasonably accessible
and available to beneficiaries. The description shall
address all of the following:
(A) the type of health care services to be
provided by the network plan;
(B) the ratio of physicians and other providers to
beneficiaries, by specialty and including primary care
physicians and facility-based physicians when
applicable under the contract, necessary to meet the
health care needs and service demands of the currently
enrolled population;
(C) the travel and distance standards for plan
beneficiaries in county service areas; and
(D) a description of how the use of telemedicine,
telehealth, or mobile care services may be used to
partially meet the network adequacy standards, if
applicable.
(6) A provision ensuring that whenever a beneficiary
has made a good faith effort, as evidenced by accessing
the provider directory, calling the network plan, and
calling the provider, to utilize preferred providers for a
covered service and it is determined the insurer does not
have the appropriate preferred providers due to
insufficient number, type, unreasonable travel distance or

SB0241 - 20 - LRB103 27273 BMS 53644 b
delay, or preferred providers refusing to provide a
covered service because it is contrary to the conscience
of the preferred providers, as protected by the Health
Care Right of Conscience Act, the insurer shall ensure,
directly or indirectly, by terms contained in the payer
contract, that the beneficiary will be provided the
covered service at no greater cost to the beneficiary than
if the service had been provided by a preferred provider.
This paragraph (6) does not apply to: (A) a beneficiary
who willfully chooses to access a non-preferred provider
for health care services available through the panel of
preferred providers, or (B) a beneficiary enrolled in a
health maintenance organization. In these circumstances,
the contractual requirements for non-preferred provider
reimbursements shall apply unless Section 356z.3a of the
Illinois Insurance Code requires otherwise. In no event
shall a beneficiary who receives care at a participating
health care facility be required to search for
participating providers under the circumstances described
in subsection (b) or (b-5) of Section 356z.3a of the
Illinois Insurance Code except under the circumstances
described in paragraph (2) of subsection (b-5).
(7) A provision that the beneficiary shall receive
emergency care coverage such that payment for this
coverage is not dependent upon whether the emergency
services are performed by a preferred or non-preferred

SB0241 - 21 - LRB103 27273 BMS 53644 b
provider and the coverage shall be at the same benefit
level as if the service or treatment had been rendered by a
preferred provider. For purposes of this paragraph (7),
"the same benefit level" means that the beneficiary is
provided the covered service at no greater cost to the
beneficiary than if the service had been provided by a
preferred provider. This provision shall be consistent
with Section 356z.3a of the Illinois Insurance Code.
(8) A limitation that, if the plan provides that the
beneficiary will incur a penalty for failing to
pre-certify inpatient hospital treatment, the penalty may
not exceed $1,000 per occurrence in addition to the plan
cost sharing provisions.
(c) The network plan shall demonstrate to the Director a
minimum ratio of providers to plan beneficiaries as required
by the Department.
(1) The ratio of physicians or other providers to plan
beneficiaries shall be established annually by the
Department in consultation with the Department of Public
Health based upon the guidance from the federal Centers
for Medicare and Medicaid Services. The Department shall
not establish ratios for vision or dental providers who
provide services under dental-specific or vision-specific
benefits. The Department shall consider establishing
ratios for the following physicians or other providers:
(A) Primary Care;

SB0241 - 22 - LRB103 27273 BMS 53644 b
(B) Pediatrics;
(C) Cardiology;
(D) Gastroenterology;
(E) General Surgery;
(F) Neurology;
(G) OB/GYN;
(H) Oncology/Radiation;
(I) Ophthalmology;
(J) Urology;
(K) Behavioral Health;
(L) Allergy/Immunology;
(M) Chiropractic;
(N) Dermatology;
(O) Endocrinology;
(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
(Q) Infectious Disease;
(R) Nephrology;
(S) Neurosurgery;
(T) Orthopedic Surgery;
(U) Physiatry/Rehabilitative;
(V) Plastic Surgery;
(W) Pulmonary;
(X) Rheumatology;
(Y) Anesthesiology;
(Z) Pain Medicine;
(AA) Pediatric Specialty Services;

SB0241 - 23 - LRB103 27273 BMS 53644 b
(BB) Outpatient Dialysis; and
(CC) HIV; and .
(DD) Reproductive Health Care.
(2) The Director shall establish a process for the
review of the adequacy of these standards, along with an
assessment of additional specialties to be included in the
list under this subsection (c).
(d) The network plan shall demonstrate to the Director
maximum travel and distance standards for plan beneficiaries,
which shall be established annually by the Department in
consultation with the Department of Public Health based upon
the guidance from the federal Centers for Medicare and
Medicaid Services. These standards shall consist of the
maximum minutes or miles to be traveled by a plan beneficiary
for each county type, such as large counties, metro counties,
or rural counties as defined by Department rule.
The maximum travel time and distance standards must
include standards for each physician and other provider
category listed for which ratios have been established.
The Director shall establish a process for the review of
the adequacy of these standards along with an assessment of
additional specialties to be included in the list under this
subsection (d).
(d-5)(1) Every insurer shall ensure that beneficiaries
have timely and proximate access to treatment for mental,
emotional, nervous, or substance use disorders or conditions

SB0241 - 24 - LRB103 27273 BMS 53644 b
in accordance with the provisions of paragraph (4) of
subsection (a) of Section 370c of the Illinois Insurance Code.
Insurers shall use a comparable process, strategy, evidentiary
standard, and other factors in the development and application
of the network adequacy standards for timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions and those for the access
to treatment for medical and surgical conditions. As such, the
network adequacy standards for timely and proximate access
shall equally be applied to treatment facilities and providers
for mental, emotional, nervous, or substance use disorders or
conditions and specialists providing medical or surgical
benefits pursuant to the parity requirements of Section 370c.1
of the Illinois Insurance Code and the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008. Notwithstanding the foregoing, the network
adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions shall, at a minimum, satisfy the
following requirements:
(A) For beneficiaries residing in the metropolitan
counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
network adequacy standards for timely and proximate access
to treatment for mental, emotional, nervous, or substance
use disorders or conditions means a beneficiary shall not
have to travel longer than 30 minutes or 30 miles from the

SB0241 - 25 - LRB103 27273 BMS 53644 b
beneficiary's residence to receive outpatient treatment
for mental, emotional, nervous, or substance use disorders
or conditions. Beneficiaries shall not be required to wait
longer than 10 business days between requesting an initial
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(B) For beneficiaries residing in Illinois counties
other than those counties listed in subparagraph (A) of
this paragraph, network adequacy standards for timely and
proximate access to treatment for mental, emotional,
nervous, or substance use disorders or conditions means a
beneficiary shall not have to travel longer than 60
minutes or 60 miles from the beneficiary's residence to
receive outpatient treatment for mental, emotional,
nervous, or substance use disorders or conditions.
Beneficiaries shall not be required to wait longer than 10
business days between requesting an initial appointment

SB0241 - 26 - LRB103 27273 BMS 53644 b
and being seen by the facility or provider of mental,
emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(2) For beneficiaries residing in all Illinois counties,
network adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions means a beneficiary shall not have to
travel longer than 60 minutes or 60 miles from the
beneficiary's residence to receive inpatient or residential
treatment for mental, emotional, nervous, or substance use
disorders or conditions.
(3) If there is no in-network facility or provider
available for a beneficiary to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with the
network adequacy standards outlined in this subsection, the
insurer shall provide necessary exceptions to its network to
ensure admission and treatment with a provider or at a

SB0241 - 27 - LRB103 27273 BMS 53644 b
treatment facility in accordance with the network adequacy
standards in this subsection.
(e) Except for network plans solely offered as a group
health plan, these ratio and time and distance standards apply
to the lowest cost-sharing tier of any tiered network.
(f) The network plan may consider use of other health care
service delivery options, such as telemedicine or telehealth,
mobile clinics, and centers of excellence, or other ways of
delivering care to partially meet the requirements set under
this Section.
(g) Except for the requirements set forth in subsection
(d-5), insurers who are not able to comply with the provider
ratios and time and distance standards established by the
Department may request an exception to these requirements from
the Department. The Department may grant an exception in the
following circumstances:
(1) if no providers or facilities meet the specific
time and distance standard in a specific service area and
the insurer (i) discloses information on the distance and
travel time points that beneficiaries would have to travel
beyond the required criterion to reach the next closest
contracted provider outside of the service area and (ii)
provides contact information, including names, addresses,
and phone numbers for the next closest contracted provider
or facility;
(2) if patterns of care in the service area do not

SB0241 - 28 - LRB103 27273 BMS 53644 b
support the need for the requested number of provider or
facility type and the insurer provides data on local
patterns of care, such as claims data, referral patterns,
or local provider interviews, indicating where the
beneficiaries currently seek this type of care or where
the physicians currently refer beneficiaries, or both; or
(3) other circumstances deemed appropriate by the
Department consistent with the requirements of this Act.
(h) Insurers are required to report to the Director any
material change to an approved network plan within 15 days
after the change occurs and any change that would result in
failure to meet the requirements of this Act. Upon notice from
the insurer, the Director shall reevaluate the network plan's
compliance with the network adequacy and transparency
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
102-1117, eff. 1-13-23.)
Section 99. Effective date. This Act takes effect July 1,
2024, except that the changes to Section 356z.3 of the
Illinois Insurance Code take effect January 1, 2025.