103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5801

 

Introduced 4/2/2024, by Rep. Lindsey LaPointe

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 124/10

    Amends the Network Adequacy and Transparency Act. Provides that the Department of Insurance shall consider establishing ratios for providers of genetic medicine and genetic counseling.


LRB103 39930 RPS 70997 b

 

 

A BILL FOR

 

HB5801LRB103 39930 RPS 70997 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    An insurer shall not prohibit a preferred provider from
22discussing any specific or all treatment options with
23beneficiaries irrespective of the insurer's position on those

 

 

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1treatment options or from advocating on behalf of
2beneficiaries within the utilization review, grievance, or
3appeals processes established by the insurer in accordance
4with any rights or remedies available under applicable State
5or federal law.
6    (b) Insurers must file for review a description of the
7services to be offered through a network plan. The description
8shall include all of the following:
9        (1) A geographic map of the area proposed to be served
10    by the plan by county service area and zip code, including
11    marked locations for preferred providers.
12        (2) As deemed necessary by the Department, the names,
13    addresses, phone numbers, and specialties of the providers
14    who have entered into preferred provider agreements under
15    the network plan.
16        (3) The number of beneficiaries anticipated to be
17    covered by the network plan.
18        (4) An Internet website and toll-free telephone number
19    for beneficiaries and prospective beneficiaries to access
20    current and accurate lists of preferred providers,
21    additional information about the plan, as well as any
22    other information required by Department rule.
23        (5) A description of how health care services to be
24    rendered under the network plan are reasonably accessible
25    and available to beneficiaries. The description shall
26    address all of the following:

 

 

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1            (A) the type of health care services to be
2        provided by the network plan;
3            (B) the ratio of physicians and other providers to
4        beneficiaries, by specialty and including primary care
5        physicians and facility-based physicians when
6        applicable under the contract, necessary to meet the
7        health care needs and service demands of the currently
8        enrolled population;
9            (C) the travel and distance standards for plan
10        beneficiaries in county service areas; and
11            (D) a description of how the use of telemedicine,
12        telehealth, or mobile care services may be used to
13        partially meet the network adequacy standards, if
14        applicable.
15        (6) A provision ensuring that whenever a beneficiary
16    has made a good faith effort, as evidenced by accessing
17    the provider directory, calling the network plan, and
18    calling the provider, to utilize preferred providers for a
19    covered service and it is determined the insurer does not
20    have the appropriate preferred providers due to
21    insufficient number, type, unreasonable travel distance or
22    delay, or preferred providers refusing to provide a
23    covered service because it is contrary to the conscience
24    of the preferred providers, as protected by the Health
25    Care Right of Conscience Act, the insurer shall ensure,
26    directly or indirectly, by terms contained in the payer

 

 

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

 

 

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1    beneficiary than if the service had been provided by a
2    preferred provider. This provision shall be consistent
3    with Section 356z.3a of the Illinois Insurance Code.
4        (8) A limitation that, if the plan provides that the
5    beneficiary will incur a penalty for failing to
6    pre-certify inpatient hospital treatment, the penalty may
7    not exceed $1,000 per occurrence in addition to the plan
8    cost sharing provisions.
9    (c) The network plan shall demonstrate to the Director a
10minimum ratio of providers to plan beneficiaries as required
11by the Department.
12        (1) The ratio of physicians or other providers to plan
13    beneficiaries shall be established annually by the
14    Department in consultation with the Department of Public
15    Health based upon the guidance from the federal Centers
16    for Medicare and Medicaid Services. The Department shall
17    not establish ratios for vision or dental providers who
18    provide services under dental-specific or vision-specific
19    benefits. The Department shall consider establishing
20    ratios for the following physicians or other providers:
21            (A) Primary Care;
22            (B) Pediatrics;
23            (C) Cardiology;
24            (D) Gastroenterology;
25            (E) General Surgery;
26            (F) Neurology;

 

 

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1            (G) OB/GYN;
2            (H) Oncology/Radiation;
3            (I) Ophthalmology;
4            (J) Urology;
5            (K) Behavioral Health;
6            (L) Allergy/Immunology;
7            (M) Chiropractic;
8            (N) Dermatology;
9            (O) Endocrinology;
10            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
11            (Q) Infectious Disease;
12            (R) Nephrology;
13            (S) Neurosurgery;
14            (T) Orthopedic Surgery;
15            (U) Physiatry/Rehabilitative;
16            (V) Plastic Surgery;
17            (W) Pulmonary;
18            (X) Rheumatology;
19            (Y) Anesthesiology;
20            (Z) Pain Medicine;
21            (AA) Pediatric Specialty Services;
22            (BB) Outpatient Dialysis; and
23            (CC) HIV; and .
24            (DD) Genetic Medicine and Genetic Counseling.
25        (2) The Director shall establish a process for the
26    review of the adequacy of these standards, along with an

 

 

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

 

 

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

 

 

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

 

 

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1    mental, emotional, nervous, or substance use disorders or
2    conditions for outpatient treatment; however, subject to
3    the protections of paragraph (3) of this subsection, a
4    network plan shall not be held responsible if the
5    beneficiary or provider voluntarily chooses to schedule an
6    appointment outside of these required time frames.
7    (2) For beneficiaries residing in all Illinois counties,
8network adequacy standards for timely and proximate access to
9treatment for mental, emotional, nervous, or substance use
10disorders or conditions means a beneficiary shall not have to
11travel longer than 60 minutes or 60 miles from the
12beneficiary's residence to receive inpatient or residential
13treatment for mental, emotional, nervous, or substance use
14disorders or conditions.
15    (3) If there is no in-network facility or provider
16available for a beneficiary to receive timely and proximate
17access to treatment for mental, emotional, nervous, or
18substance use disorders or conditions in accordance with the
19network adequacy standards outlined in this subsection, the
20insurer shall provide necessary exceptions to its network to
21ensure admission and treatment with a provider or at a
22treatment facility in accordance with the network adequacy
23standards in this subsection.
24    (e) Except for network plans solely offered as a group
25health plan, these ratio and time and distance standards apply
26to the lowest cost-sharing tier of any tiered network.

 

 

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

 

 

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1    the physicians currently refer beneficiaries, or both; or
2        (3) other circumstances deemed appropriate by the
3    Department consistent with the requirements of this Act.
4    (h) Insurers are required to report to the Director any
5material change to an approved network plan within 15 days
6after the change occurs and any change that would result in
7failure to meet the requirements of this Act. Upon notice from
8the insurer, the Director shall reevaluate the network plan's
9compliance with the network adequacy and transparency
10standards of this Act.
11(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
12102-1117, eff. 1-13-23.)