SB3130 EngrossedLRB103 38249 RPS 68384 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 Department of Insurance Law of the Civil
5Administrative Code of Illinois is amended by changing Section
61405-50 as follows:
 
7    (20 ILCS 1405/1405-50)
8    Sec. 1405-50. Marketplace Director of the Illinois Health
9Benefits Exchange. The Governor shall appoint, with the advice
10and consent of the Senate, a person within the Department of
11Insurance to serve as the Marketplace Director of the Illinois
12Health Benefits Exchange. The Marketplace Director shall serve
13for a term of 2 years, and until a successor is appointed and
14qualified; except that the term of the first Marketplace
15Director appointed under this Law shall expire on the third
16Monday in January 2027. The Marketplace Director may serve for
17more than one term. The Governor may make a temporary
18appointment until the next meeting of the Senate. This person
19may be an existing employee with other duties. The Marketplace
20Director shall receive an annual salary as set by the Governor
21and shall be paid out of the appropriations to the Department.
22The Marketplace Director shall not be subject to the Personnel
23Code. The Marketplace Director, under the direction of the

 

 

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1Director, shall manage the operations and staff of the
2Illinois Health Benefits Exchange to ensure optimal exchange
3performance.
4(Source: P.A. 103-103, eff. 6-27-23.)
 
5    Section 10. The Illinois Insurance Code is amended by
6adding Section 356z.40a as follows:
 
7    (215 ILCS 5/356z.40a new)
8    Sec. 356z.40a. Pregnancy as a qualifying life event for
9qualified health plans. Beginning with the operation of a
10State-based exchange in plan year 2026, a pregnant individual
11has the right to enroll in a qualified health plan through a
12special enrollment period within 60 days after any qualified
13health care professional, including a licensed certified
14professional midwife, licensed or certified under the laws of
15this State or any other state to provide pregnancy-related
16health care services certifies that the individual is
17pregnant. Upon enrollment, coverage shall be effective on and
18after the first day of the month in which the qualified health
19care professional certifies that the individual is pregnant,
20unless the individual elects to have coverage effective on the
21first day of the month following the date that the individual
22received certification of the pregnancy.
 
23    Section 15. The Illinois Health Insurance Portability and

 

 

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1Accountability Act is amended by changing Sections 30, 50, and
260 as follows:
 
3    (215 ILCS 97/30)
4    Sec. 30. Guaranteed renewability of coverage for employers
5in the group market.
6    (A) In general. Except as provided in this Section, if a
7health insurance issuer offers health insurance coverage in
8the small or large group market in connection with a group
9health plan, the issuer must renew or continue in force such
10coverage at the option of the plan sponsor of the plan.
11    (B) General exceptions. A health insurance issuer may
12nonrenew or discontinue health insurance coverage offered in
13connection with a group health plan in the small or large group
14market based only on one or more of the following:
15        (1) Nonpayment of premiums. The plan sponsor has
16    failed to pay premiums or contributions in accordance with
17    the terms of the health insurance coverage or the issuer
18    has not received timely premium payments.
19        (2) Fraud. The plan sponsor has performed an act or
20    practice that constitutes fraud or made an intentional
21    misrepresentation of material fact under the terms of the
22    coverage.
23        (3) Violation of participation or contribution rules.
24    The plan sponsor has failed to comply with a material plan
25    provision relating to employer contribution or group

 

 

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1    participation rules, as permitted under Section 40(D) in
2    the case of the small group market or pursuant to
3    applicable State law in the case of the large group
4    market.
5        (4) Termination of coverage. The issuer is ceasing to
6    offer coverage in such market in accordance with
7    subsection (C) and applicable State law.
8        (5) Movement outside service area. In the case of a
9    health insurance issuer that offers health insurance
10    coverage in the market through a network plan, there is no
11    longer any enrollee in connection with such plan who
12    lives, resides, or works in the service area of the issuer
13    (or in the area for which the issuer is authorized to do
14    business) and, in the case of the small group market, the
15    issuer would deny enrollment with respect to such plan
16    under Section 40(C)(1)(a).
17        (6) Association membership ceases. In the case of
18    health insurance coverage that is made available in the
19    small or large group market (as the case may be) only
20    through one or more bona fide association, the membership
21    of an employer in the association (on the basis of which
22    the coverage is provided) ceases but only if such coverage
23    is terminated under this paragraph uniformly without
24    regard to any health status-related factor relating to any
25    covered individual.
26    (C) Requirements for uniform termination of coverage.

 

 

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1        (1) Particular type of coverage not offered. In any
2    case in which an issuer decides to discontinue offering a
3    particular type of group health insurance coverage offered
4    in the small or large group market, coverage of such type
5    may be discontinued by the issuer in accordance with
6    applicable State law in such market only if:
7            (a) the issuer provides notice to each plan
8        sponsor provided coverage of this type in such market
9        (and participants and beneficiaries covered under such
10        coverage) of such discontinuation at least 90 days
11        prior to the date of the discontinuation of such
12        coverage;
13            (b) the issuer offers to each plan sponsor
14        provided coverage of this type in such market, the
15        option to purchase all (or, in the case of the large
16        group market, any) other health insurance coverage
17        currently being offered by the issuer to a group
18        health plan in such market; and
19            (c) in exercising the option to discontinue
20        coverage of this type and in offering the option of
21        coverage under subparagraph (b), the issuer acts
22        uniformly without regard to the claims experience of
23        those sponsors or any health status-related factor
24        relating to any participants or beneficiaries who may
25        become eligible for such coverage.
26        (2) Discontinuance of all coverage.

 

 

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1            (a) In general. In any case in which a health
2        insurance issuer elects to discontinue offering all
3        health insurance coverage in the small group market or
4        the large group market, or both markets, in Illinois,
5        health insurance coverage may be discontinued by the
6        issuer only in accordance with Illinois law and if:
7                (i) the issuer provides notice to the
8            Department and to each plan sponsor (and
9            participants and beneficiaries covered under such
10            coverage) of such discontinuation at least 180
11            days prior to the date of the discontinuation of
12            such coverage and to the Department as provided in
13            Section 60 of this Act; and
14                (ii) all health insurance issued or delivered
15            for issuance in Illinois in such market (or
16            markets) are discontinued and coverage under such
17            health insurance coverage in such market (or
18            markets) is not renewed.
19            (b) Prohibition on market reentry. In the case of
20        a discontinuation under subparagraph (a) in a market,
21        the issuer may not provide for the issuance of any
22        health insurance coverage in the Illinois market
23        involved during the 5-year period beginning on the
24        date of the discontinuation of the last health
25        insurance coverage not so renewed.
26    (D) Exception for uniform modification of coverage. At the

 

 

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1time of coverage renewal, a health insurance issuer may modify
2the health insurance coverage for a product offered to a group
3health plan:
4        (1) in the large group market; or
5        (2) in the small group market if, for coverage that is
6    available in such market other than only through one or
7    more bona fide associations, such modification is
8    consistent with State law and effective on a uniform basis
9    among group health plans with that product.
10    (E) Application to coverage offered only through
11associations. In applying this Section in the case of health
12insurance coverage that is made available by a health
13insurance issuer in the small or large group market to
14employers only through one or more associations, a reference
15to "plan sponsor" is deemed, with respect to coverage provided
16to an employer member of the association, to include a
17reference to such employer.
18(Source: P.A. 90-30, eff. 7-1-97.)
 
19    (215 ILCS 97/50)
20    Sec. 50. Guaranteed renewability of individual health
21insurance coverage.
22    (A) In general. Except as provided in this Section, a
23health insurance issuer that provides individual health
24insurance coverage to an individual shall renew or continue in
25force such coverage at the option of the individual.

 

 

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1    (B) General exceptions. A health insurance issuer may
2nonrenew or discontinue health insurance coverage of an
3individual in the individual market based only on one or more
4of the following:
5        (1) Nonpayment of premiums. The individual has failed
6    to pay premiums or contributions in accordance with the
7    terms of the health insurance coverage or the issuer has
8    not received timely premium payments.
9        (2)  Fraud. The individual has performed an act or
10    practice that constitutes fraud or made an intentional
11    misrepresentation of material fact under the terms of the
12    coverage.
13        (3) Termination of plan. The issuer is ceasing to
14    offer coverage in the individual market in accordance with
15    subsection (C) of this Section and applicable Illinois
16    law.
17        (4) Movement outside the service area. In the case of
18    a health insurance issuer that offers health insurance
19    coverage in the market through a network plan, the
20    individual no longer resides, lives, or works in the
21    service area (or in an area for which the issuer is
22    authorized to do business), but only if such coverage is
23    terminated under this paragraph uniformly without regard
24    to any health status-related factor of covered
25    individuals.
26        (5) Association membership ceases. In the case of

 

 

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1    health insurance coverage that is made available in the
2    individual market only through one or more bona fide
3    associations, the membership of the individual in the
4    association (on the basis of which the coverage is
5    provided) ceases, but only if such coverage is terminated
6    under this paragraph uniformly without regard to any
7    health status-related factor of covered individuals.
8    (C) Requirements for uniform termination of coverage.
9        (1) Particular type of coverage not offered. In any
10    case in which an issuer decides to discontinue offering a
11    particular type of health insurance coverage offered in
12    the individual market, coverage of such type may be
13    discontinued by the issuer only if:
14            (a) the issuer provides notice to each covered
15        individual provided coverage of this type in such
16        market of such discontinuation at least 90 days prior
17        to the date of the discontinuation of such coverage;
18            (b) the issuer offers, to each individual in the
19        individual market provided coverage of this type, the
20        option to purchase any other individual health
21        insurance coverage currently being offered by the
22        issuer for individuals in such market; and
23            (c) in exercising the option to discontinue
24        coverage of that type and in offering the option of
25        coverage under subparagraph (b), the issuer acts
26        uniformly without regard to any health status-related

 

 

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1        factor of enrolled individuals or individuals who may
2        become eligible for such coverage.
3        (2) Discontinuance of all coverage.
4            (a) In general. Subject to subparagraph (c), in
5        any case in which a health insurance issuer elects to
6        discontinue offering all health insurance coverage in
7        the individual market in Illinois, health insurance
8        coverage may be discontinued by the issuer only if:
9                (i) the issuer provides notice to the Director
10            and to each individual of the discontinuation at
11            least 180 days prior to the date of the expiration
12            of such coverage and to the Director as provided
13            in Section 60 of this Act;
14                (ii) all health insurance issued or delivered
15            for issuance in Illinois in such market is
16            discontinued and coverage under such health
17            insurance coverage in such market is not renewed;
18            and
19                (iii) in the case where the issuer has
20            affiliates in the individual market, the issuer
21            gives notice to each affected individual at least
22            180 days prior to the date of the expiration of the
23            coverage of the individual's option to purchase
24            all other individual health benefit plans
25            currently offered by any affiliate of the carrier.
26            (b) Prohibition on market reentry. In the case of

 

 

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1        a discontinuation under subparagraph (a) in the
2        individual market, the issuer may not provide for the
3        issuance of any health insurance coverage in Illinois
4        involved during the 5-year period beginning on the
5        date of the discontinuation of the last health
6        insurance coverage not so renewed.
7            (c) If an issuer elects to discontinue offering
8        all health insurance coverage in the individual market
9        under subparagraph (a), its affiliates that offer
10        health insurance coverage in the individual market in
11        Illinois shall offer individual health insurance
12        coverage to all individuals who were covered by the
13        discontinued health insurance coverage on the date of
14        the notice provided to affected individuals under
15        subdivision (iii) of subparagraph (a) of this item (2)
16        if the individual applies for coverage no later than
17        63 days after the discontinuation of coverage.
18            (d) Subject to subparagraph (e) of this item (2),
19        an affiliate that issues coverage under subparagraph
20        (c) shall waive the preexisting condition exclusion
21        period to the extent that the individual has satisfied
22        the preexisting condition exclusion period under the
23        individual's prior contract or policy.
24            (e) An affiliate that issues coverage under
25        subparagraph (c) may require the individual to satisfy
26        the remaining part of the preexisting condition

 

 

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1        exclusion period, if any, under the individual's prior
2        contract or policy that has not been satisfied, unless
3        the coverage has a shorter preexisting condition
4        exclusion period, and may include in any coverage
5        issued under subparagraph (c) any waivers or
6        limitations of coverage that were included in the
7        individual's prior contract or policy.
8    (D) Exception for uniform modification of coverage. At the
9time of coverage renewal, a health insurance issuer may modify
10the health insurance coverage for a policy form offered to
11individuals in the individual market so long as the
12modification is consistent with Illinois law and effective on
13a uniform basis among all individuals with that policy form.
14    (E) Application to coverage offered only through
15associations. In applying this Section in the case of health
16insurance coverage that is made available by a health
17insurance issuer in the individual market to individuals only
18through one or more associations, a reference to an
19"individual" is deemed to include a reference to such an
20association (of which the individual is a member).
21    The changes to this Section made by this amendatory Act of
22the 94th General Assembly apply only to discontinuances of
23coverage occurring on or after the effective date of this
24amendatory Act of the 94th General Assembly.
25(Source: P.A. 94-502, eff. 8-8-05.)
 

 

 

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1    (215 ILCS 97/60)
2    Sec. 60. Notice requirement. In any case where a health
3insurance issuer elects to uniformly modify coverage,
4uniformly terminate coverage, or discontinue coverage in a
5marketplace in accordance with Sections 30 and 50 of this Act,
6the issuer shall provide notice to the Department prior to
7notifying the plan sponsors, participants, beneficiaries, and
8covered individuals. The notice shall be sent by certified
9mail to the Department 45 90 days in advance of any
10notification of the company's actions sent to plan sponsors,
11participants, beneficiaries, and covered individuals. The
12notice shall include: (i) a complete description of the action
13to be taken, (ii) a specific description of the type of
14coverage affected, (iii) the total number of covered lives
15affected, (iv) a sample draft of all letters being sent to the
16plan sponsors, participants, beneficiaries, or covered
17individuals, (v) time frames for the actions being taken, (vi)
18options the plans sponsors, participants, beneficiaries, or
19covered individuals may have available to them under this Act,
20and (vii) any other information as required by the Department.
21The Department may designate an email address or online
22platform to receive electronic notification in lieu of
23certified mail.
24    This Section applies only to discontinuances of coverage
25occurring on or after the effective date of this amendatory
26Act of the 94th General Assembly.

 

 

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1(Source: P.A. 94-502, eff. 8-8-05.)
 
2    Section 20. The Network Adequacy and Transparency Act is
3amended by changing Sections 3, 5, 10, and 25 as follows:
 
4    (215 ILCS 124/3)
5    Sec. 3. Applicability of Act. This Act applies to an
6individual or group policy of accident and health insurance
7with a network plan amended, delivered, issued, or renewed in
8this State on or after January 1, 2019. This Act does not apply
9to an individual or group policy for excepted benefits or
10short-term, limited-duration health insurance coverage dental
11or vision insurance or a limited health service organization
12with a network plan amended, delivered, issued, or renewed in
13this State on or after January 1, 2019 , except to the extent
14that federal law establishes network adequacy and transparency
15standards for stand-alone dental plans, which the Department
16shall enforce.
17(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
 
18    (215 ILCS 124/5)
19    Sec. 5. Definitions. In this Act:
20    "Authorized representative" means a person to whom a
21beneficiary has given express written consent to represent the
22beneficiary; a person authorized by law to provide substituted
23consent for a beneficiary; or the beneficiary's treating

 

 

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1provider only when the beneficiary or his or her family member
2is unable to provide consent.
3    "Beneficiary" means an individual, an enrollee, an
4insured, a participant, or any other person entitled to
5reimbursement for covered expenses of or the discounting of
6provider fees for health care services under a program in
7which the beneficiary has an incentive to utilize the services
8of a provider that has entered into an agreement or
9arrangement with an insurer.
10    "Department" means the Department of Insurance.
11    "Director" means the Director of Insurance.
12    "Excepted benefits" has the meaning given to that term in
1342 U.S.C. 300gg-91(c).
14    "Family caregiver" means a relative, partner, friend, or
15neighbor who has a significant relationship with the patient
16and administers or assists the patient with activities of
17daily living, instrumental activities of daily living, or
18other medical or nursing tasks for the quality and welfare of
19that patient.
20    "Insurer" means any entity that offers individual or group
21accident and health insurance, including, but not limited to,
22health maintenance organizations, preferred provider
23organizations, exclusive provider organizations, and other
24plan structures requiring network participation, excluding the
25medical assistance program under the Illinois Public Aid Code,
26the State employees group health insurance program, workers

 

 

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1compensation insurance, and pharmacy benefit managers.
2    "Material change" means a significant reduction in the
3number of providers available in a network plan, including,
4but not limited to, a reduction of 10% or more in a specific
5type of providers, the removal of a major health system that
6causes a network to be significantly different from the
7network when the beneficiary purchased the network plan, or
8any change that would cause the network to no longer satisfy
9the requirements of this Act or the Department's rules for
10network adequacy and transparency.
11    "Network" means the group or groups of preferred providers
12providing services to a network plan.
13    "Network plan" means an individual or group policy of
14accident and health insurance that either requires a covered
15person to use or creates incentives, including financial
16incentives, for a covered person to use providers managed,
17owned, under contract with, or employed by the insurer.
18    "Ongoing course of treatment" means (1) treatment for a
19life-threatening condition, which is a disease or condition
20for which likelihood of death is probable unless the course of
21the disease or condition is interrupted; (2) treatment for a
22serious acute condition, defined as a disease or condition
23requiring complex ongoing care that the covered person is
24currently receiving, such as chemotherapy, radiation therapy,
25or post-operative visits; (3) a course of treatment for a
26health condition that a treating provider attests that

 

 

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1discontinuing care by that provider would worsen the condition
2or interfere with anticipated outcomes; or (4) the third
3trimester of pregnancy through the post-partum period.
4    "Preferred provider" means any provider who has entered,
5either directly or indirectly, into an agreement with an
6employer or risk-bearing entity relating to health care
7services that may be rendered to beneficiaries under a network
8plan.
9    "Providers" means physicians licensed to practice medicine
10in all its branches, other health care professionals,
11hospitals, or other health care institutions that provide
12health care services.
13    "Short-term, limited-duration health insurance coverage
14has the meaning given to that term in Section 5 of the
15Short-Term, Limited-Duration Health Insurance Coverage Act.
16    "Stand-alone dental plan" has the meaning given to that
17term in 45 CFR 156.400.
18    "Telehealth" has the meaning given to that term in Section
19356z.22 of the Illinois Insurance Code.
20    "Telemedicine" has the meaning given to that term in
21Section 49.5 of the Medical Practice Act of 1987.
22    "Tiered network" means a network that identifies and
23groups some or all types of provider and facilities into
24specific groups to which different provider reimbursement,
25covered person cost-sharing or provider access requirements,
26or any combination thereof, apply for the same services.

 

 

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1    "Woman's principal health care provider" means a physician
2licensed to practice medicine in all of its branches
3specializing in obstetrics, gynecology, or family practice.
4(Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)
 
5    (215 ILCS 124/10)
6    Sec. 10. Network adequacy.
7    (a) An insurer providing a network plan shall file a
8description of all of the following with the Director:
9        (1) The written policies and procedures for adding
10    providers to meet patient needs based on increases in the
11    number of beneficiaries, changes in the
12    patient-to-provider ratio, changes in medical and health
13    care capabilities, and increased demand for services.
14        (2) The written policies and procedures for making
15    referrals within and outside the network.
16        (3) The written policies and procedures on how the
17    network plan will provide 24-hour, 7-day per week access
18    to network-affiliated primary care, emergency services,
19    and women's principal health care providers.
20    An insurer shall not prohibit a preferred provider from
21discussing any specific or all treatment options with
22beneficiaries irrespective of the insurer's position on those
23treatment options or from advocating on behalf of
24beneficiaries within the utilization review, grievance, or
25appeals processes established by the insurer in accordance

 

 

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

 

 

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

 

 

SB3130 Engrossed- 21 -LRB103 38249 RPS 68384 b

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

 

 

SB3130 Engrossed- 22 -LRB103 38249 RPS 68384 b

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

 

 

SB3130 Engrossed- 23 -LRB103 38249 RPS 68384 b

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

 

 

SB3130 Engrossed- 24 -LRB103 38249 RPS 68384 b

1        (3) If the federal Centers for Medicare and Medicaid
2    Services establishes minimum provider ratios for
3    stand-alone dental plans in the type of exchange in use in
4    this State for a given plan year, the Department shall
5    enforce those standards for stand-alone dental plans for
6    that plan year.
7    (d) The network plan shall demonstrate to the Director
8maximum travel and distance standards for plan beneficiaries,
9which shall be established annually by the Department in
10consultation with the Department of Public Health based upon
11the guidance from the federal Centers for Medicare and
12Medicaid Services. These standards shall consist of the
13maximum minutes or miles to be traveled by a plan beneficiary
14for each county type, such as large counties, metro counties,
15or rural counties as defined by Department rule.
16    The maximum travel time and distance standards must
17include standards for each physician and other provider
18category listed for which ratios have been established.
19    The Director shall establish a process for the review of
20the adequacy of these standards along with an assessment of
21additional specialties to be included in the list under this
22subsection (d).
23    If the federal Centers for Medicare and Medicaid Services
24establishes appointment wait-time standards for qualified
25health plans, including stand-alone dental plans, in the type
26of exchange in use in this State for a given plan year, the

 

 

SB3130 Engrossed- 25 -LRB103 38249 RPS 68384 b

1Department shall enforce those standards for the same types of
2qualified health plans for that plan year. If the federal
3Centers for Medicare and Medicaid Services establishes time
4and distance standards for stand-alone dental plans in the
5type of exchange in use in this State for a given plan year,
6the Department shall enforce those standards for stand-alone
7dental plans for that plan year.
8    (d-5)(1) Every insurer shall ensure that beneficiaries
9have timely and proximate access to treatment for mental,
10emotional, nervous, or substance use disorders or conditions
11in accordance with the provisions of paragraph (4) of
12subsection (a) of Section 370c of the Illinois Insurance Code.
13Insurers shall use a comparable process, strategy, evidentiary
14standard, and other factors in the development and application
15of the network adequacy standards for timely and proximate
16access to treatment for mental, emotional, nervous, or
17substance use disorders or conditions and those for the access
18to treatment for medical and surgical conditions. As such, the
19network adequacy standards for timely and proximate access
20shall equally be applied to treatment facilities and providers
21for mental, emotional, nervous, or substance use disorders or
22conditions and specialists providing medical or surgical
23benefits pursuant to the parity requirements of Section 370c.1
24of the Illinois Insurance Code and the federal Paul Wellstone
25and Pete Domenici Mental Health Parity and Addiction Equity
26Act of 2008. Notwithstanding the foregoing, the network

 

 

SB3130 Engrossed- 26 -LRB103 38249 RPS 68384 b

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

 

 

SB3130 Engrossed- 27 -LRB103 38249 RPS 68384 b

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

 

 

SB3130 Engrossed- 28 -LRB103 38249 RPS 68384 b

1beneficiary's residence to receive inpatient or residential
2treatment for mental, emotional, nervous, or substance use
3disorders or conditions.
4    (3) If there is no in-network facility or provider
5available for a beneficiary to receive timely and proximate
6access to treatment for mental, emotional, nervous, or
7substance use disorders or conditions in accordance with the
8network adequacy standards outlined in this subsection, the
9insurer shall provide necessary exceptions to its network to
10ensure admission and treatment with a provider or at a
11treatment facility in accordance with the network adequacy
12standards in this subsection.
13    (4) If the federal Centers for Medicare and Medicaid
14Services establishes a more stringent standard in any county
15than specified in paragraph (1) or (2) of this subsection
16(d-5) for qualified health plans in the type of exchange in use
17in this State for a given plan year, the federal standard shall
18apply in lieu of the standard in paragraph (1) or (2) of this
19subsection (d-5) for qualified health plans for that plan
20year.
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

 

 

SB3130 Engrossed- 29 -LRB103 38249 RPS 68384 b

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

 

 

SB3130 Engrossed- 30 -LRB103 38249 RPS 68384 b

1    Department consistent with the requirements of this Act.
2    (h) Insurers are required to report to the Director any
3material change to an approved network plan within 15 days
4after the change occurs and any change that would result in
5failure to meet the requirements of this Act. Upon notice from
6the insurer, the Director shall reevaluate the network plan's
7compliance with the network adequacy and transparency
8standards of this Act.
9(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
10102-1117, eff. 1-13-23.)
 
11    (215 ILCS 124/25)
12    Sec. 25. Network transparency.
13    (a) A network plan shall post electronically an
14up-to-date, accurate, and complete provider directory for each
15of its network plans, with the information and search
16functions, as described in this Section.
17        (1) In making the directory available electronically,
18    the network plans shall ensure that the general public is
19    able to view all of the current providers for a plan
20    through a clearly identifiable link or tab and without
21    creating or accessing an account or entering a policy or
22    contract number.
23        (2) The network plan shall update the online provider
24    directory at least monthly. Providers shall notify the
25    network plan electronically or in writing of any changes

 

 

SB3130 Engrossed- 31 -LRB103 38249 RPS 68384 b

1    to their information as listed in the provider directory,
2    including the information required in subparagraph (K) of
3    paragraph (1) of subsection (b). The network plan shall
4    update its online provider directory in a manner
5    consistent with the information provided by the provider
6    within 10 business days after being notified of the change
7    by the provider. Nothing in this paragraph (2) shall void
8    any contractual relationship between the provider and the
9    plan.
10        (3) The network plan shall audit periodically at least
11    25% of its provider directories for accuracy, make any
12    corrections necessary, and retain documentation of the
13    audit. The network plan shall submit the audit to the
14    Director upon request. As part of these audits, the
15    network plan shall contact any provider in its network
16    that has not submitted a claim to the plan or otherwise
17    communicated his or her intent to continue participation
18    in the plan's network.
19        (4) A network plan shall provide a printed print copy
20    of a current provider directory or a printed print copy of
21    the requested directory information upon request of a
22    beneficiary or a prospective beneficiary. Printed Print
23    copies must be updated quarterly and an errata that
24    reflects changes in the provider network must be updated
25    quarterly.
26        (5) For each network plan, a network plan shall

 

 

SB3130 Engrossed- 32 -LRB103 38249 RPS 68384 b

1    include, in plain language in both the electronic and
2    print directory, the following general information:
3            (A) in plain language, a description of the
4        criteria the plan has used to build its provider
5        network;
6            (B) if applicable, in plain language, a
7        description of the criteria the insurer or network
8        plan has used to create tiered networks;
9            (C) if applicable, in plain language, how the
10        network plan designates the different provider tiers
11        or levels in the network and identifies for each
12        specific provider, hospital, or other type of facility
13        in the network which tier each is placed, for example,
14        by name, symbols, or grouping, in order for a
15        beneficiary-covered person or a prospective
16        beneficiary-covered person to be able to identify the
17        provider tier; and
18            (D) if applicable, a notation that authorization
19        or referral may be required to access some providers.
20        (6) A network plan shall make it clear for both its
21    electronic and print directories what provider directory
22    applies to which network plan, such as including the
23    specific name of the network plan as marketed and issued
24    in this State. The network plan shall include in both its
25    electronic and print directories a customer service email
26    address and telephone number or electronic link that

 

 

SB3130 Engrossed- 33 -LRB103 38249 RPS 68384 b

1    beneficiaries or the general public may use to notify the
2    network plan of inaccurate provider directory information
3    and contact information for the Department's Office of
4    Consumer Health Insurance.
5        (7) A provider directory, whether in electronic or
6    print format, shall accommodate the communication needs of
7    individuals with disabilities, and include a link to or
8    information regarding available assistance for persons
9    with limited English proficiency.
10    (b) For each network plan, a network plan shall make
11available through an electronic provider directory the
12following information in a searchable format:
13        (1) for health care professionals:
14            (A) name;
15            (B) gender;
16            (C) participating office locations;
17            (D) specialty, if applicable;
18            (E) medical group affiliations, if applicable;
19            (F) facility affiliations, if applicable;
20            (G) participating facility affiliations, if
21        applicable;
22            (H) languages spoken other than English, if
23        applicable;
24            (I) whether accepting new patients;
25            (J) board certifications, if applicable; and
26            (K) use of telehealth or telemedicine, including,

 

 

SB3130 Engrossed- 34 -LRB103 38249 RPS 68384 b

1        but not limited to:
2                (i) whether the provider offers the use of
3            telehealth or telemedicine to deliver services to
4            patients for whom it would be clinically
5            appropriate;
6                (ii) what modalities are used and what types
7            of services may be provided via telehealth or
8            telemedicine; and
9                (iii) whether the provider has the ability and
10            willingness to include in a telehealth or
11            telemedicine encounter a family caregiver who is
12            in a separate location than the patient if the
13            patient wishes and provides his or her consent;
14        (2) for hospitals:
15            (A) hospital name;
16            (B) hospital type (such as acute, rehabilitation,
17        children's, or cancer);
18            (C) participating hospital location; and
19            (D) hospital accreditation status; and
20        (3) for facilities, other than hospitals, by type:
21            (A) facility name;
22            (B) facility type;
23            (C) types of services performed; and
24            (D) participating facility location or locations.
25    (c) For the electronic provider directories, for each
26network plan, a network plan shall make available all of the

 

 

SB3130 Engrossed- 35 -LRB103 38249 RPS 68384 b

1following information in addition to the searchable
2information required in this Section:
3        (1) for health care professionals:
4            (A) contact information; and
5            (B) languages spoken other than English by
6        clinical staff, if applicable;
7        (2) for hospitals, telephone number; and
8        (3) for facilities other than hospitals, telephone
9    number.
10    (d) The insurer or network plan shall make available in
11print, upon request, the following provider directory
12information for the applicable network plan:
13        (1) for health care professionals:
14            (A) name;
15            (B) contact information;
16            (C) participating office location or locations;
17            (D) specialty, if applicable;
18            (E) languages spoken other than English, if
19        applicable;
20            (F) whether accepting new patients; and
21            (G) use of telehealth or telemedicine, including,
22        but not limited to:
23                (i) whether the provider offers the use of
24            telehealth or telemedicine to deliver services to
25            patients for whom it would be clinically
26            appropriate;

 

 

SB3130 Engrossed- 36 -LRB103 38249 RPS 68384 b

1                (ii) what modalities are used and what types
2            of services may be provided via telehealth or
3            telemedicine; and
4                (iii) whether the provider has the ability and
5            willingness to include in a telehealth or
6            telemedicine encounter a family caregiver who is
7            in a separate location than the patient if the
8            patient wishes and provides his or her consent;
9        (2) for hospitals:
10            (A) hospital name;
11            (B) hospital type (such as acute, rehabilitation,
12        children's, or cancer); and
13            (C) participating hospital location and telephone
14        number; and
15        (3) for facilities, other than hospitals, by type:
16            (A) facility name;
17            (B) facility type;
18            (C) types of services performed; and
19            (D) participating facility location or locations
20        and telephone numbers.
21    (e) The network plan shall include a disclosure in the
22print format provider directory that the information included
23in the directory is accurate as of the date of printing and
24that beneficiaries or prospective beneficiaries should consult
25the insurer's electronic provider directory on its website and
26contact the provider. The network plan shall also include a

 

 

SB3130 Engrossed- 37 -LRB103 38249 RPS 68384 b

1telephone number in the print format provider directory for a
2customer service representative where the beneficiary can
3obtain current provider directory information.
4    (f) The Director may conduct periodic audits of the
5accuracy of provider directories. A network plan shall not be
6subject to any fines or penalties for information required in
7this Section that a provider submits that is inaccurate or
8incomplete.
9    (g) This Section applies to network plans that are not
10otherwise exempt under Section 3, including stand-alone dental
11plans that are subject to provider directory requirements
12under federal law.
13(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
 
14    Section 25. The Health Maintenance Organization Act is
15amended by changing Section 5-3 as follows:
 
16    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
17    Sec. 5-3. Insurance Code provisions.
18    (a) Health Maintenance Organizations shall be subject to
19the provisions of Sections 133, 134, 136, 137, 139, 140,
20141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
21154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
22355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v,
23356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
24356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,

 

 

SB3130 Engrossed- 38 -LRB103 38249 RPS 68384 b

1356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22,
2356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30,
3356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35,
4356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.40a,
5356z.41, 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49,
6356z.50, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57,
7356z.58, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65,
8356z.67, 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i,
9368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402,
10403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c)
11of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
12XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
13Illinois Insurance Code.
14    (b) For purposes of the Illinois Insurance Code, except
15for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
16Health Maintenance Organizations in the following categories
17are deemed to be "domestic companies":
18        (1) a corporation authorized under the Dental Service
19    Plan Act or the Voluntary Health Services Plans Act;
20        (2) a corporation organized under the laws of this
21    State; or
22        (3) a corporation organized under the laws of another
23    state, 30% or more of the enrollees of which are residents
24    of this State, except a corporation subject to
25    substantially the same requirements in its state of
26    organization as is a "domestic company" under Article VIII

 

 

SB3130 Engrossed- 39 -LRB103 38249 RPS 68384 b

1    1/2 of the Illinois Insurance Code.
2    (c) In considering the merger, consolidation, or other
3acquisition of control of a Health Maintenance Organization
4pursuant to Article VIII 1/2 of the Illinois Insurance Code,
5        (1) the Director shall give primary consideration to
6    the continuation of benefits to enrollees and the
7    financial conditions of the acquired Health Maintenance
8    Organization after the merger, consolidation, or other
9    acquisition of control takes effect;
10        (2)(i) the criteria specified in subsection (1)(b) of
11    Section 131.8 of the Illinois Insurance Code shall not
12    apply and (ii) the Director, in making his determination
13    with respect to the merger, consolidation, or other
14    acquisition of control, need not take into account the
15    effect on competition of the merger, consolidation, or
16    other acquisition of control;
17        (3) the Director shall have the power to require the
18    following information:
19            (A) certification by an independent actuary of the
20        adequacy of the reserves of the Health Maintenance
21        Organization sought to be acquired;
22            (B) pro forma financial statements reflecting the
23        combined balance sheets of the acquiring company and
24        the Health Maintenance Organization sought to be
25        acquired as of the end of the preceding year and as of
26        a date 90 days prior to the acquisition, as well as pro

 

 

SB3130 Engrossed- 40 -LRB103 38249 RPS 68384 b

1        forma financial statements reflecting projected
2        combined operation for a period of 2 years;
3            (C) a pro forma business plan detailing an
4        acquiring party's plans with respect to the operation
5        of the Health Maintenance Organization sought to be
6        acquired for a period of not less than 3 years; and
7            (D) such other information as the Director shall
8        require.
9    (d) The provisions of Article VIII 1/2 of the Illinois
10Insurance Code and this Section 5-3 shall apply to the sale by
11any health maintenance organization of greater than 10% of its
12enrollee population (including, without limitation, the health
13maintenance organization's right, title, and interest in and
14to its health care certificates).
15    (e) In considering any management contract or service
16agreement subject to Section 141.1 of the Illinois Insurance
17Code, the Director (i) shall, in addition to the criteria
18specified in Section 141.2 of the Illinois Insurance Code,
19take into account the effect of the management contract or
20service agreement on the continuation of benefits to enrollees
21and the financial condition of the health maintenance
22organization to be managed or serviced, and (ii) need not take
23into account the effect of the management contract or service
24agreement on competition.
25    (f) Except for small employer groups as defined in the
26Small Employer Rating, Renewability and Portability Health

 

 

SB3130 Engrossed- 41 -LRB103 38249 RPS 68384 b

1Insurance Act and except for medicare supplement policies as
2defined in Section 363 of the Illinois Insurance Code, a
3Health Maintenance Organization may by contract agree with a
4group or other enrollment unit to effect refunds or charge
5additional premiums under the following terms and conditions:
6        (i) the amount of, and other terms and conditions with
7    respect to, the refund or additional premium are set forth
8    in the group or enrollment unit contract agreed in advance
9    of the period for which a refund is to be paid or
10    additional premium is to be charged (which period shall
11    not be less than one year); and
12        (ii) the amount of the refund or additional premium
13    shall not exceed 20% of the Health Maintenance
14    Organization's profitable or unprofitable experience with
15    respect to the group or other enrollment unit for the
16    period (and, for purposes of a refund or additional
17    premium, the profitable or unprofitable experience shall
18    be calculated taking into account a pro rata share of the
19    Health Maintenance Organization's administrative and
20    marketing expenses, but shall not include any refund to be
21    made or additional premium to be paid pursuant to this
22    subsection (f)). The Health Maintenance Organization and
23    the group or enrollment unit may agree that the profitable
24    or unprofitable experience may be calculated taking into
25    account the refund period and the immediately preceding 2
26    plan years.

 

 

SB3130 Engrossed- 42 -LRB103 38249 RPS 68384 b

1    The Health Maintenance Organization shall include a
2statement in the evidence of coverage issued to each enrollee
3describing the possibility of a refund or additional premium,
4and upon request of any group or enrollment unit, provide to
5the group or enrollment unit a description of the method used
6to calculate (1) the Health Maintenance Organization's
7profitable experience with respect to the group or enrollment
8unit and the resulting refund to the group or enrollment unit
9or (2) the Health Maintenance Organization's unprofitable
10experience with respect to the group or enrollment unit and
11the resulting additional premium to be paid by the group or
12enrollment unit.
13    In no event shall the Illinois Health Maintenance
14Organization Guaranty Association be liable to pay any
15contractual obligation of an insolvent organization to pay any
16refund authorized under this Section.
17    (g) Rulemaking authority to implement Public Act 95-1045,
18if any, is conditioned on the rules being adopted in
19accordance with all provisions of the Illinois Administrative
20Procedure Act and all rules and procedures of the Joint
21Committee on Administrative Rules; any purported rule not so
22adopted, for whatever reason, is unauthorized.
23(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
24102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
251-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
26eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;

 

 

SB3130 Engrossed- 43 -LRB103 38249 RPS 68384 b

1102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
21-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
3eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
4103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
56-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
6eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
7    Section 30. The Managed Care Reform and Patient Rights Act
8is amended by changing Section 45.3 as follows:
 
9    (215 ILCS 134/45.3)
10    Sec. 45.3. Prescription drug benefits; plan choice.
11    (a) Notwithstanding any other provision of law, beginning
12January 1, 2023, every health insurance carrier that offers an
13individual health plan that provides coverage for prescription
14drugs shall ensure that at least 10% of individual health care
15plans offered in each applicable service area and at each
16level of coverage as defined in 42 U.S.C. 18022(d) apply a
17flat-dollar copayment structure to the entire drug benefit.
18Beginning January 1, 2024, every health insurance carrier that
19offers an individual health plan that provides coverage for
20prescription drugs shall ensure that at least 25% of
21individual health care plans offered in each applicable
22service area and at each level of coverage as defined in 42
23U.S.C. 18022(d) apply a flat-dollar copayment structure to the
24entire drug benefit. If a health insurance carrier offers

 

 

SB3130 Engrossed- 44 -LRB103 38249 RPS 68384 b

1fewer than 4 plans in a service area, then the health insurance
2carrier shall ensure that one plan applies a flat-dollar
3copayment structure to the entire drug benefit.
4    (b) Beginning January 1, 2023, every health insurance
5carrier that offers a group health plan that provides coverage
6for prescription drugs shall offer at least one group health
7plan in each applicable service area and at each level of
8coverage as defined in 42 U.S.C. 18022 that applies a
9flat-dollar copayment structure to the entire drug benefit.
10Every Beginning January 1, 2024, every health insurance
11carrier that offers a small group health plan that provides
12coverage for prescription drugs shall offer at least 2 small
13group health plans in each applicable service area and at each
14level of coverage as defined in 42 U.S.C. 18022(d) that apply a
15flat-dollar copayment structure to the entire drug benefit.
16    (c) The flat-dollar copayment structure for prescription
17drugs under subsections (a) and (b) must be applied
18pre-deductible and be reasonably graduated and proportionately
19related in all tier levels such that the copayment structure
20as a whole does not discriminate against or discourage the
21enrollment of individuals with significant health care needs.
22Notwithstanding the other provisions of this subsection,
23beginning January 1, 2025, each level of coverage that a
24health insurance carrier offers of a standardized option in
25each applicable service area shall be deemed to satisfy the
26requirements for a flat-dollar copay structure in subsection

 

 

SB3130 Engrossed- 45 -LRB103 38249 RPS 68384 b

1(a).
2    For purposes of this subsection, "standardized option" has
3the meaning given to that term in 45 CFR 155.20 or, when
4Illinois has a State-based exchange, a substantially similar
5definition to "standardized option" in 45 CFR 155.20 that
6substitutes the Illinois Health Benefits Exchange for the
7United States Department of Health and Human Services.
8    (d) A health insurance carrier that offers individual or
9small group health care plans shall clearly and appropriately
10name the plans described in subsections (a) and (b) to aid in
11the individual or small group plan selection process.
12    (e) A health insurance carrier shall market plans
13described in subsections (a) and (b) in the same manner as
14plans not described in subsections (a) and (b).
15    (f) The Department shall adopt rules necessary to
16implement and enforce the provisions of this Section.
17(Source: P.A. 102-391, eff. 1-1-23.)
 
18    Section 99. Effective date. This Act takes effect upon
19becoming law, except that the changes to Sections 3, 5, 10, and
2025 of the Network Adequacy and Transparency Act take effect
21January 1, 2025.