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| Public Act 102-0092
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| SB0332 Enrolled | LRB102 13548 BMS 18895 b |
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Network Adequacy and Transparency Act is |
amended by changing Sections 5 and 25 as follows:
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(215 ILCS 124/5)
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Sec. 5. Definitions. In this Act: |
"Authorized representative" means a person to whom a |
beneficiary has given express written consent to represent the |
beneficiary; a person authorized by law to provide substituted |
consent for a beneficiary; or the beneficiary's treating |
provider only when the beneficiary or his or her family member |
is unable to provide consent. |
"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 an insurer. |
"Department" means the Department of Insurance. |
"Director" means the Director of Insurance. |
"Family caregiver" means a relative, partner, friend, or |
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neighbor who has a significant relationship with the patient |
and administers or assists them with activities of daily |
living, instrumental activities of daily living, or other |
medical or nursing tasks for the quality and welfare of that |
patient. |
"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, |
the State employees group health insurance program, workers |
compensation insurance, and pharmacy benefit managers. |
"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 |
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person to use or creates incentives, including financial |
incentives, for a covered person to use providers managed, |
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 |
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. |
"Telehealth" has the meaning given to that term in Section |
356z.22 of the Illinois Insurance Code. |
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"Telemedicine" has the meaning given to that term in |
Section 49.5 of the Medical Practice Act of 1987. |
"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 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.
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(Source: P.A. 100-502, eff. 9-15-17.)
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(215 ILCS 124/25)
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Sec. 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 update the online provider |
directory at least monthly. Providers shall notify the |
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network plan electronically or in writing of any changes |
to their information as listed in the provider directory, |
including the information required in subparagraph (K) of |
paragraph (1) of subsection (b). The network plan shall |
update its online provider directory in a manner |
consistent with the information provided by the provider |
within 10 business days after being notified of the change |
by the provider. Nothing in this paragraph (2) shall void |
any contractual relationship between the provider and the |
plan. |
(3) The network plan shall audit periodically at least |
25% of its provider directories for accuracy, make any |
corrections necessary, and retain documentation of the |
audit. The network plan shall submit the audit to the |
Director upon request. 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. |
(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 quarterly and an errata that reflects |
changes in the provider network must be updated quarterly. |
(5) For each network plan, a network plan shall |
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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 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 |
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 |
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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 |
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; and . |
(K) use of telehealth or telemedicine, including, |
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but not limited to: |
(i) whether the provider offers the use of |
telehealth or telemedicine to deliver services to |
patients for whom it would be clinically |
appropriate; |
(ii) what modalities are used and what types |
of services may be provided via telehealth or |
telemedicine; and |
(iii) whether the provider has the ability and |
willingness to include in a telehealth or |
telemedicine encounter a family caregiver who is |
in a separate location than the patient if the |
patient wishes and provides his or her consent; |
(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. |
(c) For the electronic provider directories, for each |
network plan, a network plan shall make available all of the |
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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 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; and . |
(G) use of telehealth or telemedicine, including, |
but not limited to: |
(i) whether the provider offers the use of |
telehealth or telemedicine to deliver services to |
patients for whom it would be clinically |
appropriate; |
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(ii) what modalities are used and what types |
of services may be provided via telehealth or |
telemedicine; and |
(iii) whether the provider has the ability and |
willingness to include in a telehealth or |
telemedicine encounter a family caregiver who is |
in a separate location than the patient if the |
patient wishes and provides his or her consent; |
(2) for hospitals: |
(A) hospital name; |
(B) hospital type (such as acute, rehabilitation, |
children's, or cancer); and |
(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 electronic provider directory on its website and |
contact the provider. The network plan shall also include a |
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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 may conduct periodic audits of the |
accuracy of provider directories. A network plan shall not be |
subject to any fines or penalties for information required in |
this Section that a provider submits that is inaccurate or |
incomplete.
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(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
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Section 99. Effective date. This Act takes effect upon |
becoming law.
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