SB2641 EngrossedLRB103 35049 JAG 64994 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Network Adequacy and Transparency Act is
5amended by changing Section 10 as follows:
 
6    (215 ILCS 124/10)
7    Sec. 10. Network adequacy.
8    (a) An insurer providing a network plan shall file a
9description of all of the following with the Director:
10        (1) The written policies and procedures for adding
11    providers to meet patient needs based on increases in the
12    number of beneficiaries, changes in the
13    patient-to-provider ratio, changes in medical and health
14    care capabilities, and increased demand for services.
15        (2) The written policies and procedures for making
16    referrals within and outside the network.
17        (3) The written policies and procedures on how the
18    network plan will provide 24-hour, 7-day per week access
19    to network-affiliated primary care, emergency services,
20    and women's principal health care providers.
21        (4) The process for monitoring health plan
22    beneficiaries' timely in-network access to physician
23    specialist services.

 

 

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1    An insurer shall not prohibit a preferred provider from
2discussing any specific or all treatment options with
3beneficiaries irrespective of the insurer's position on those
4treatment options or from advocating on behalf of
5beneficiaries within the utilization review, grievance, or
6appeals processes established by the insurer in accordance
7with any rights or remedies available under applicable State
8or federal law.
9    (a-5) An insurer providing a network plan shall file an
10insurer's monitoring report for each network hospital and
11facility, which shall include, but is not limited to, the
12number and percentage of physician providers under contract in
13each of the specialties of emergency medicine, anesthesiology,
14radiology, and pathology practicing in the in-network hospital
15or facility when such providers are not employees of the
16hospital or facility. The insurer's monitoring report must be
17included in an effort to ensure that plan beneficiaries have
18reasonable and timely in-network access to physician
19specialist providers at in-network hospitals and facilities.
20    (b) Insurers must file for review a description of the
21services to be offered through a network plan. The description
22shall 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 insurer shall ensure,
14    directly or indirectly, by terms contained in the payer
15    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    (c) The network plan shall demonstrate to the Director a
24minimum ratio of providers to plan beneficiaries as required
25by the Department.
26        (1) The ratio of physicians or other providers to plan

 

 

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1    beneficiaries shall be established annually by the
2    Department in consultation with the Department of Public
3    Health based upon the guidance from the federal Centers
4    for Medicare and Medicaid Services. The Department shall
5    not establish ratios for vision or dental providers who
6    provide services under dental-specific or vision-specific
7    benefits. The Department shall consider establishing
8    ratios for the following physicians or other providers:
9            (A) Primary Care;
10            (B) Pediatrics;
11            (C) Cardiology;
12            (D) Gastroenterology;
13            (E) General Surgery;
14            (F) Neurology;
15            (G) OB/GYN;
16            (H) Oncology/Radiation;
17            (I) Ophthalmology;
18            (J) Urology;
19            (K) Behavioral Health;
20            (L) Allergy/Immunology;
21            (M) Chiropractic;
22            (N) Dermatology;
23            (O) Endocrinology;
24            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
25            (Q) Infectious Disease;
26            (R) Nephrology;

 

 

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1            (S) Neurosurgery;
2            (T) Orthopedic Surgery;
3            (U) Physiatry/Rehabilitative;
4            (V) Plastic Surgery;
5            (W) Pulmonary;
6            (X) Rheumatology;
7            (Y) Anesthesiology;
8            (Z) Pain Medicine;
9            (AA) Pediatric Specialty Services;
10            (BB) Outpatient Dialysis; and
11            (CC) HIV.
12        (2) The Director shall establish a process for the
13    review of the adequacy of these standards, along with an
14    assessment of additional specialties to be included in the
15    list under this subsection (c).
16    (d) The network plan shall demonstrate to the Director
17maximum travel and distance standards for plan beneficiaries,
18which shall be established annually by the Department in
19consultation with the Department of Public Health based upon
20the guidance from the federal Centers for Medicare and
21Medicaid Services. These standards shall consist of the
22maximum minutes or miles to be traveled by a plan beneficiary
23for each county type, such as large counties, metro counties,
24or rural counties as defined by Department rule.
25    The maximum travel time and distance standards must
26include standards for each physician and other provider

 

 

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1category listed for which ratios have been established.
2    The Director shall establish a process for the review of
3the adequacy of these standards along with an assessment of
4additional specialties to be included in the list under this
5subsection (d).
6    (d-5)(1) Every insurer shall ensure that beneficiaries
7have timely and proximate access to treatment for mental,
8emotional, nervous, or substance use disorders or conditions
9in accordance with the provisions of paragraph (4) of
10subsection (a) of Section 370c of the Illinois Insurance Code.
11Insurers shall use a comparable process, strategy, evidentiary
12standard, and other factors in the development and application
13of the network adequacy standards for timely and proximate
14access to treatment for mental, emotional, nervous, or
15substance use disorders or conditions and those for the access
16to treatment for medical and surgical conditions. As such, the
17network adequacy standards for timely and proximate access
18shall equally be applied to treatment facilities and providers
19for mental, emotional, nervous, or substance use disorders or
20conditions and specialists providing medical or surgical
21benefits pursuant to the parity requirements of Section 370c.1
22of the Illinois Insurance Code and the federal Paul Wellstone
23and Pete Domenici Mental Health Parity and Addiction Equity
24Act of 2008. Notwithstanding the foregoing, the network
25adequacy standards for timely and proximate access to
26treatment for mental, emotional, nervous, or substance use

 

 

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1disorders or conditions shall, at a minimum, satisfy the
2following requirements:
3        (A) For beneficiaries residing in the metropolitan
4    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
5    network adequacy standards for timely and proximate access
6    to treatment for mental, emotional, nervous, or substance
7    use disorders or conditions means a beneficiary shall not
8    have to travel longer than 30 minutes or 30 miles from the
9    beneficiary's residence to receive outpatient treatment
10    for mental, emotional, nervous, or substance use disorders
11    or conditions. Beneficiaries shall not be required to wait
12    longer than 10 business days between requesting an initial
13    appointment and being seen by the facility or provider of
14    mental, emotional, nervous, or substance use disorders or
15    conditions for outpatient treatment or to wait longer than
16    20 business days between requesting a repeat or follow-up
17    appointment and being seen by the facility or provider of
18    mental, emotional, nervous, or substance use disorders or
19    conditions for outpatient treatment; however, subject to
20    the protections of paragraph (3) of this subsection, a
21    network plan shall not be held responsible if the
22    beneficiary or provider voluntarily chooses to schedule an
23    appointment outside of these required time frames.
24        (B) For beneficiaries residing in Illinois counties
25    other than those counties listed in subparagraph (A) of
26    this paragraph, network adequacy standards for timely and

 

 

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1    proximate access to treatment for mental, emotional,
2    nervous, or substance use disorders or conditions means a
3    beneficiary shall not have to travel longer than 60
4    minutes or 60 miles from the beneficiary's residence to
5    receive outpatient treatment for mental, emotional,
6    nervous, or substance use disorders or conditions.
7    Beneficiaries shall not be required to wait longer than 10
8    business days between requesting an initial appointment
9    and being seen by the facility or provider of mental,
10    emotional, nervous, or substance use disorders or
11    conditions for outpatient treatment or to wait longer than
12    20 business days between requesting a repeat or follow-up
13    appointment and being seen by the facility or provider of
14    mental, emotional, nervous, or substance use disorders or
15    conditions for outpatient treatment; however, subject to
16    the protections of paragraph (3) of this subsection, a
17    network plan shall not be held responsible if the
18    beneficiary or provider voluntarily chooses to schedule an
19    appointment outside of these required time frames.
20    (1.5) Every insurer shall demonstrate to the Director that
21each in-network hospital and facility has a sufficient number
22of hospital-based medical specialists to ensure that covered
23persons have reasonable and timely access to such in-network
24physicians and the services they direct or supervise. As used
25in this subsection, "hospital-based medical specialists" means
26physicians working in specialties that are usually located at

 

 

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1in-network hospitals and facilities, including, but not
2limited to, radiologists, pathologists, anesthesiologists, and
3emergency room physicians.
4    (2) For beneficiaries residing in all Illinois counties,
5network adequacy standards for timely and proximate access to
6treatment for mental, emotional, nervous, or substance use
7disorders or conditions means a beneficiary shall not have to
8travel longer than 60 minutes or 60 miles from the
9beneficiary's residence to receive inpatient or residential
10treatment for mental, emotional, nervous, or substance use
11disorders or conditions.
12    (3) If there is no in-network facility or provider
13available for a beneficiary to receive timely and proximate
14access to treatment for mental, emotional, nervous, or
15substance use disorders or conditions in accordance with the
16network adequacy standards outlined in this subsection, the
17insurer shall provide necessary exceptions to its network to
18ensure admission and treatment with a provider or at a
19treatment facility in accordance with the network adequacy
20standards in this subsection.
21    (e) Except for network plans solely offered as a group
22health plan, these ratio and time and distance standards apply
23to the lowest cost-sharing tier of any tiered network.
24    (f) The network plan may consider use of other health care
25service delivery options, such as telemedicine or telehealth,
26mobile clinics, and centers of excellence, or other ways of

 

 

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1delivering care to partially meet the requirements set under
2this Section.
3    (g) Except for the requirements set forth in subsection
4(d-5), insurers who are not able to comply with the provider
5ratios and time and distance standards established by the
6Department may request an exception to these requirements from
7the Department. The Department may grant an exception in the
8following circumstances:
9        (1) if no providers or facilities meet the specific
10    time and distance standard in a specific service area and
11    the insurer (i) discloses information on the distance and
12    travel time points that beneficiaries would have to travel
13    beyond the required criterion to reach the next closest
14    contracted provider outside of the service area and (ii)
15    provides contact information, including names, addresses,
16    and phone numbers for the next closest contracted provider
17    or facility;
18        (2) if patterns of care in the service area do not
19    support the need for the requested number of provider or
20    facility type and the insurer provides data on local
21    patterns of care, such as claims data, referral patterns,
22    or local provider interviews, indicating where the
23    beneficiaries currently seek this type of care or where
24    the physicians currently refer beneficiaries, or both; or
25        (3) other circumstances deemed appropriate by the
26    Department consistent with the requirements of this Act.

 

 

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1    (h) Insurers are required to report to the Director any
2material change to an approved network plan within 15 days
3after the change occurs and any change that would result in
4failure to meet the requirements of this Act. Upon notice from
5the insurer, the Director shall reevaluate the network plan's
6compliance with the network adequacy and transparency
7standards of this Act.
8(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
9102-1117, eff. 1-13-23.)