Sen. Linda Holmes

Filed: 4/4/2024

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 2641

2    AMENDMENT NO. ______. Amend Senate Bill 2641 by replacing
3everything after the enacting clause with the following:
 
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.

 

 

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1        (3) The written policies and procedures on how the
2    network plan will provide 24-hour, 7-day per week access
3    to network-affiliated primary care, emergency services,
4    and women's principal health care providers.
5        (4) The process for monitoring health plan
6    beneficiaries' timely in-network access to physician
7    specialist services.
8    An insurer shall not prohibit a preferred provider from
9discussing any specific or all treatment options with
10beneficiaries irrespective of the insurer's position on those
11treatment options or from advocating on behalf of
12beneficiaries within the utilization review, grievance, or
13appeals processes established by the insurer in accordance
14with any rights or remedies available under applicable State
15or federal law.
16    (a-5) An insurer providing a network plan shall file an
17insurer's monitoring report for each network hospital and
18facility, which shall include, but is not limited to, the
19number and percentage of physician providers under contract in
20each of the specialties of emergency medicine, anesthesiology,
21radiology, and pathology practicing in the in-network hospital
22or facility when such providers are not employees of the
23hospital or facility. The insurer's monitoring report must be
24included in an effort to ensure that plan beneficiaries have
25reasonable and timely in-network access to physician
26specialist providers at in-network hospitals and facilities.

 

 

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1    (b) Insurers must file for review a description of the
2services to be offered through a network plan. The description
3shall include all of the following:
4        (1) A geographic map of the area proposed to be served
5    by the plan by county service area and zip code, including
6    marked locations for preferred providers.
7        (2) As deemed necessary by the Department, the names,
8    addresses, phone numbers, and specialties of the providers
9    who have entered into preferred provider agreements under
10    the network plan.
11        (3) The number of beneficiaries anticipated to be
12    covered by the network plan.
13        (4) An Internet website and toll-free telephone number
14    for beneficiaries and prospective beneficiaries to access
15    current and accurate lists of preferred providers,
16    additional information about the plan, as well as any
17    other information required by Department rule.
18        (5) A description of how health care services to be
19    rendered under the network plan are reasonably accessible
20    and available to beneficiaries. The description shall
21    address all of the following:
22            (A) the type of health care services to be
23        provided by the network plan;
24            (B) the ratio of physicians and other providers to
25        beneficiaries, by specialty and including primary care
26        physicians and facility-based physicians when

 

 

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1        applicable under the contract, necessary to meet the
2        health care needs and service demands of the currently
3        enrolled population;
4            (C) the travel and distance standards for plan
5        beneficiaries in county service areas; and
6            (D) a description of how the use of telemedicine,
7        telehealth, or mobile care services may be used to
8        partially meet the network adequacy standards, if
9        applicable.
10        (6) A provision ensuring that whenever a beneficiary
11    has made a good faith effort, as evidenced by accessing
12    the provider directory, calling the network plan, and
13    calling the provider, to utilize preferred providers for a
14    covered service and it is determined the insurer does not
15    have the appropriate preferred providers due to
16    insufficient number, type, unreasonable travel distance or
17    delay, or preferred providers refusing to provide a
18    covered service because it is contrary to the conscience
19    of the preferred providers, as protected by the Health
20    Care Right of Conscience Act, the insurer shall ensure,
21    directly or indirectly, by terms contained in the payer
22    contract, that the beneficiary will be provided the
23    covered service at no greater cost to the beneficiary than
24    if the service had been provided by a preferred provider.
25    This paragraph (6) does not apply to: (A) a beneficiary
26    who willfully chooses to access a non-preferred provider

 

 

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1    for health care services available through the panel of
2    preferred providers, or (B) a beneficiary enrolled in a
3    health maintenance organization. In these circumstances,
4    the contractual requirements for non-preferred provider
5    reimbursements shall apply unless Section 356z.3a of the
6    Illinois Insurance Code requires otherwise. In no event
7    shall a beneficiary who receives care at a participating
8    health care facility be required to search for
9    participating providers under the circumstances described
10    in subsection (b) or (b-5) of Section 356z.3a of the
11    Illinois Insurance Code except under the circumstances
12    described in paragraph (2) of subsection (b-5).
13        (7) A provision that the beneficiary shall receive
14    emergency care coverage such that payment for this
15    coverage is not dependent upon whether the emergency
16    services are performed by a preferred or non-preferred
17    provider and the coverage shall be at the same benefit
18    level as if the service or treatment had been rendered by a
19    preferred provider. For purposes of this paragraph (7),
20    "the same benefit level" means that the beneficiary is
21    provided the covered service at no greater cost to the
22    beneficiary than if the service had been provided by a
23    preferred provider. This provision shall be consistent
24    with Section 356z.3a of the Illinois Insurance Code.
25        (8) A limitation that, if the plan provides that the
26    beneficiary will incur a penalty for failing to

 

 

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1    pre-certify inpatient hospital treatment, the penalty may
2    not exceed $1,000 per occurrence in addition to the plan
3    cost sharing provisions.
4    (c) The network plan shall demonstrate to the Director a
5minimum ratio of providers to plan beneficiaries as required
6by the Department.
7        (1) The ratio of physicians or other providers to plan
8    beneficiaries shall be established annually by the
9    Department in consultation with the Department of Public
10    Health based upon the guidance from the federal Centers
11    for Medicare and Medicaid Services. The Department shall
12    not establish ratios for vision or dental providers who
13    provide services under dental-specific or vision-specific
14    benefits. The Department shall consider establishing
15    ratios for the following physicians or other providers:
16            (A) Primary Care;
17            (B) Pediatrics;
18            (C) Cardiology;
19            (D) Gastroenterology;
20            (E) General Surgery;
21            (F) Neurology;
22            (G) OB/GYN;
23            (H) Oncology/Radiation;
24            (I) Ophthalmology;
25            (J) Urology;
26            (K) Behavioral Health;

 

 

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1            (L) Allergy/Immunology;
2            (M) Chiropractic;
3            (N) Dermatology;
4            (O) Endocrinology;
5            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
6            (Q) Infectious Disease;
7            (R) Nephrology;
8            (S) Neurosurgery;
9            (T) Orthopedic Surgery;
10            (U) Physiatry/Rehabilitative;
11            (V) Plastic Surgery;
12            (W) Pulmonary;
13            (X) Rheumatology;
14            (Y) Anesthesiology;
15            (Z) Pain Medicine;
16            (AA) Pediatric Specialty Services;
17            (BB) Outpatient Dialysis; and
18            (CC) HIV.
19        (2) The Director shall establish a process for the
20    review of the adequacy of these standards, along with an
21    assessment of additional specialties to be included in the
22    list under this subsection (c).
23    (d) The network plan shall demonstrate to the Director
24maximum travel and distance standards for plan beneficiaries,
25which shall be established annually by the Department in
26consultation with the Department of Public Health based upon

 

 

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1the guidance from the federal Centers for Medicare and
2Medicaid Services. These standards shall consist of the
3maximum minutes or miles to be traveled by a plan beneficiary
4for each county type, such as large counties, metro counties,
5or rural counties as defined by Department rule.
6    The maximum travel time and distance standards must
7include standards for each physician and other provider
8category listed for which ratios have been established.
9    The Director shall establish a process for the review of
10the adequacy of these standards along with an assessment of
11additional specialties to be included in the list under this
12subsection (d).
13    (d-5)(1) Every insurer shall ensure that beneficiaries
14have timely and proximate access to treatment for mental,
15emotional, nervous, or substance use disorders or conditions
16in accordance with the provisions of paragraph (4) of
17subsection (a) of Section 370c of the Illinois Insurance Code.
18Insurers shall use a comparable process, strategy, evidentiary
19standard, and other factors in the development and application
20of the network adequacy standards for timely and proximate
21access to treatment for mental, emotional, nervous, or
22substance use disorders or conditions and those for the access
23to treatment for medical and surgical conditions. As such, the
24network adequacy standards for timely and proximate access
25shall equally be applied to treatment facilities and providers
26for mental, emotional, nervous, or substance use disorders or

 

 

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1conditions and specialists providing medical or surgical
2benefits pursuant to the parity requirements of Section 370c.1
3of the Illinois Insurance Code and the federal Paul Wellstone
4and Pete Domenici Mental Health Parity and Addiction Equity
5Act of 2008. Notwithstanding the foregoing, the network
6adequacy standards for timely and proximate access to
7treatment for mental, emotional, nervous, or substance use
8disorders or conditions shall, at a minimum, satisfy the
9following requirements:
10        (A) For beneficiaries residing in the metropolitan
11    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
12    network adequacy standards for timely and proximate access
13    to treatment for mental, emotional, nervous, or substance
14    use disorders or conditions means a beneficiary shall not
15    have to travel longer than 30 minutes or 30 miles from the
16    beneficiary's residence to receive outpatient treatment
17    for mental, emotional, nervous, or substance use disorders
18    or conditions. Beneficiaries shall not be required to wait
19    longer than 10 business days between requesting an initial
20    appointment and being seen by the facility or provider of
21    mental, emotional, nervous, or substance use disorders or
22    conditions for outpatient treatment or to wait longer than
23    20 business days between requesting a repeat or follow-up
24    appointment and being seen by the facility or provider of
25    mental, emotional, nervous, or substance use disorders or
26    conditions for outpatient treatment; however, subject to

 

 

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1    the protections of paragraph (3) of this subsection, a
2    network plan shall not be held responsible if the
3    beneficiary or provider voluntarily chooses to schedule an
4    appointment outside of these required time frames.
5        (B) For beneficiaries residing in Illinois counties
6    other than those counties listed in subparagraph (A) of
7    this paragraph, network adequacy standards for timely and
8    proximate access to treatment for mental, emotional,
9    nervous, or substance use disorders or conditions means a
10    beneficiary shall not have to travel longer than 60
11    minutes or 60 miles from the beneficiary's residence to
12    receive outpatient treatment for mental, emotional,
13    nervous, or substance use disorders or conditions.
14    Beneficiaries shall not be required to wait longer than 10
15    business days between requesting an initial appointment
16    and being seen by the facility or provider of mental,
17    emotional, nervous, or substance use disorders or
18    conditions for outpatient treatment or to wait longer than
19    20 business days between requesting a repeat or follow-up
20    appointment and being seen by the facility or provider of
21    mental, emotional, nervous, or substance use disorders or
22    conditions for outpatient treatment; however, subject to
23    the protections of paragraph (3) of this subsection, a
24    network plan shall not be held responsible if the
25    beneficiary or provider voluntarily chooses to schedule an
26    appointment outside of these required time frames.

 

 

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1    (1.5) Every insurer shall demonstrate to the Director that
2each in-network hospital and facility has a sufficient number
3of hospital-based medical specialists to ensure that covered
4persons have reasonable and timely access to such in-network
5physicians and the services they direct or supervise. As used
6in this subsection, "hospital-based medical specialists" means
7physicians working in specialties that are usually located at
8in-network hospitals and facilities, including, but not
9limited to, radiologists, pathologists, anesthesiologists, and
10emergency room physicians.
11    (2) For beneficiaries residing in all Illinois counties,
12network adequacy standards for timely and proximate access to
13treatment for mental, emotional, nervous, or substance use
14disorders or conditions means a beneficiary shall not have to
15travel longer than 60 minutes or 60 miles from the
16beneficiary's residence to receive inpatient or residential
17treatment for mental, emotional, nervous, or substance use
18disorders or conditions.
19    (3) If there is no in-network facility or provider
20available for a beneficiary to receive timely and proximate
21access to treatment for mental, emotional, nervous, or
22substance use disorders or conditions in accordance with the
23network adequacy standards outlined in this subsection, the
24insurer shall provide necessary exceptions to its network to
25ensure admission and treatment with a provider or at a
26treatment facility in accordance with the network adequacy

 

 

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1standards in this subsection.
2    (e) Except for network plans solely offered as a group
3health plan, these ratio and time and distance standards apply
4to the lowest cost-sharing tier of any tiered network.
5    (f) The network plan may consider use of other health care
6service delivery options, such as telemedicine or telehealth,
7mobile clinics, and centers of excellence, or other ways of
8delivering care to partially meet the requirements set under
9this Section.
10    (g) Except for the requirements set forth in subsection
11(d-5), insurers who are not able to comply with the provider
12ratios and time and distance standards established by the
13Department may request an exception to these requirements from
14the Department. The Department may grant an exception in the
15following circumstances:
16        (1) if no providers or facilities meet the specific
17    time and distance standard in a specific service area and
18    the insurer (i) discloses information on the distance and
19    travel time points that beneficiaries would have to travel
20    beyond the required criterion to reach the next closest
21    contracted provider outside of the service area and (ii)
22    provides contact information, including names, addresses,
23    and phone numbers for the next closest contracted provider
24    or facility;
25        (2) if patterns of care in the service area do not
26    support the need for the requested number of provider or

 

 

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1    facility type and the insurer provides data on local
2    patterns of care, such as claims data, referral patterns,
3    or local provider interviews, indicating where the
4    beneficiaries currently seek this type of care or where
5    the physicians currently refer beneficiaries, or both; or
6        (3) other circumstances deemed appropriate by the
7    Department consistent with the requirements of this Act.
8    (h) Insurers are required to report to the Director any
9material change to an approved network plan within 15 days
10after the change occurs and any change that would result in
11failure to meet the requirements of this Act. Upon notice from
12the insurer, the Director shall reevaluate the network plan's
13compliance with the network adequacy and transparency
14standards of this Act.
15(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
16102-1117, eff. 1-13-23.)".