102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB4220

 

Introduced 11/14/2022, by Sen. Laura Ellman

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.3
215 ILCS 5/356z.3a
215 ILCS 124/10

    Amends the Illinois Insurance Code. Makes a change in provisions concerning disclosure of nonparticipating provider limited benefits. Adds reproductive health care to the definition of "ancillary services". Amends the Network Adequacy and Transparency Act. Provides that an insurer providing a network plan shall file a description with the Director of Insurance of written policies and procedures on how the network plan will provide 24-hour, 7-day per week access to reproductive health care. Provides that the Department of Insurance shall consider establishing ratios for reproductive health care physicians or other providers. Effective July 1, 2023, except that certain changes take effect January 1, 2024.


LRB102 28076 BMS 40119 b

 

 

A BILL FOR

 

SB4220LRB102 28076 BMS 40119 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 Illinois Insurance Code is amended by
5changing Sections 356z.3 and 356z.3a as follows:
 
6    (215 ILCS 5/356z.3)
7    (Text of Section before amendment by P.A. 102-901)
8    Sec. 356z.3. Disclosure of limited benefit. An insurer
9that issues, delivers, amends, or renews an individual or
10group policy of accident and health insurance in this State
11after the effective date of this amendatory Act of the 92nd
12General Assembly and arranges, contracts with, or administers
13contracts with a provider whereby beneficiaries are provided
14an incentive to use the services of such provider must include
15the following disclosure on its contracts and evidences of
16coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
17NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that
18when you elect to utilize the services of a non-participating
19provider for a covered service in non-emergency situations,
20benefit payments to such non-participating provider are not
21based upon the amount billed. The basis of your benefit
22payment will be determined according to your policy's fee
23schedule, usual and customary charge (which is determined by

 

 

SB4220- 2 -LRB102 28076 BMS 40119 b

1comparing charges for similar services adjusted to the
2geographical area where the services are performed), or other
3method as defined by the policy. YOU CAN EXPECT TO PAY MORE
4THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE
5PLAN HAS PAID ITS REQUIRED PORTION. Non-participating
6providers may bill members for any amount up to the billed
7charge after the plan has paid its portion of the bill as
8provided in Section 356z.3a of the Illinois Insurance Code.
9Participating providers have agreed to accept discounted
10payments for services with no additional billing to the member
11other than co-insurance and deductible amounts. You may obtain
12further information about the participating status of
13professional providers and information on out-of-pocket
14expenses by calling the toll free telephone number on your
15identification card.".
16(Source: P.A. 96-1523, eff. 6-1-11; 97-813, eff. 7-13-12.)
 
17    (Text of Section after amendment by P.A. 102-901)
18    Sec. 356z.3. Disclosure of limited benefit. An insurer
19that issues, delivers, amends, or renews an individual or
20group policy of accident and health insurance in this State
21after the effective date of this amendatory Act of the 92nd
22General Assembly and arranges, contracts with, or administers
23contracts with a provider wher
eby beneficiaries are provided
24an incentive to use the services of such provider must include
25the following disclosure on its contracts and evidences of

 

 

SB4220- 3 -LRB102 28076 BMS 40119 b

1coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
2NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that
3when you elect to utilize the services of a non-participating
4provider for a covered service in non-emergency situations,
5benefit payments to such non-participating provider are not
6based upon the amount billed. The basis of your benefit
7payment will be determined according to your policy's fee
8schedule, usual and customary charge (which is determined by
9comparing charges for similar services adjusted to the
10geographical area where the services are performed), or other
11method as defined by the policy. YOU CAN EXPECT TO PAY MORE
12THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE
13PLAN HAS PAID ITS REQUIRED PORTION. Non-participating
14providers may bill members for any amount up to the billed
15charge after the plan has paid its portion of the bill, except
16as provided in Section 356z.3a of the Illinois Insurance Code
17for covered services received at a participating health care
18facility from a nonparticipating provider that are: (a)
19ancillary services, (b) items or services furnished as a
20result of unforeseen, urgent medical needs that arise at the
21time the item or service is furnished, or (c) items or services
22received when the facility or the non-participating provider
23fails to satisfy the notice and consent criteria specified
24under Section 356z.3a, or (d) reproductive health care, as
25defined in Section 1-10 of the Reproductive Health Act.
26Participating providers have agreed to accept discounted

 

 

SB4220- 4 -LRB102 28076 BMS 40119 b

1payments for services with no additional billing to the member
2other than co-insurance and deductible amounts. You may obtain
3further information about the participating status of
4professional providers and information on out-of-pocket
5expenses by calling the toll free telephone number on your
6identification card.".
7(Source: P.A. 102-901, eff. 1-1-23.)
 
8    (215 ILCS 5/356z.3a)
9    Sec. 356z.3a. Billing; emergency services;
10nonparticipating providers.
11    (a) As used in this Section:
12    "Ancillary services" means:
13        (1) items and services related to emergency medicine,
14    anesthesiology, pathology, radiology, and neonatology that
15    are provided by any health care provider;
16        (2) items and services provided by assistant surgeons,
17    hospitalists, and intensivists;
18        (3) diagnostic services, including radiology and
19    laboratory services, except for advanced diagnostic
20    laboratory tests identified on the most current list
21    published by the United States Secretary of Health and
22    Human Services under 42 U.S.C. 300gg-132(b)(3);
23        (4) items and services provided by other specialty
24    practitioners as the United States Secretary of Health and
25    Human Services specifies through rulemaking under 42

 

 

SB4220- 5 -LRB102 28076 BMS 40119 b

1    U.S.C. 300gg-132(b)(3); and
2        (5) items and services provided by a nonparticipating
3    provider if there is no participating provider who can
4    furnish the item or service at the facility; and .
5        (6) reproductive health care, as defined in Section
6    1-10 of the Reproductive Health Act.
7    "Cost sharing" means the amount an insured, beneficiary,
8or enrollee is responsible for paying for a covered item or
9service under the terms of the policy or certificate. "Cost
10sharing" includes copayments, coinsurance, and amounts paid
11toward deductibles, but does not include amounts paid towards
12premiums, balance billing by out-of-network providers, or the
13cost of items or services that are not covered under the policy
14or certificate.
15    "Emergency department of a hospital" means any hospital
16department that provides emergency services, including a
17hospital outpatient department.
18    "Emergency medical condition" has the meaning ascribed to
19that term in Section 10 of the Managed Care Reform and Patient
20Rights Act.
21    "Emergency medical screening examination" has the meaning
22ascribed to that term in Section 10 of the Managed Care Reform
23and Patient Rights Act.
24    "Emergency services" means, with respect to an emergency
25medical condition:
26        (1) in general, an emergency medical screening

 

 

SB4220- 6 -LRB102 28076 BMS 40119 b

1    examination, including ancillary services routinely
2    available to the emergency department to evaluate such
3    emergency medical condition, and such further medical
4    examination and treatment as would be required to
5    stabilize the patient regardless of the department of the
6    hospital or other facility in which such further
7    examination or treatment is furnished; or
8        (2) additional items and services for which benefits
9    are provided or covered under the coverage and that are
10    furnished by a nonparticipating provider or
11    nonparticipating emergency facility regardless of the
12    department of the hospital or other facility in which such
13    items are furnished after the insured, beneficiary, or
14    enrollee is stabilized and as part of outpatient
15    observation or an inpatient or outpatient stay with
16    respect to the visit in which the services described in
17    paragraph (1) are furnished. Services after stabilization
18    cease to be emergency services only when all the
19    conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
20    regulations thereunder are met.
21    "Freestanding Emergency Center" means a facility licensed
22under Section 32.5 of the Emergency Medical Services (EMS)
23Systems Act.
24    "Health care facility" means, in the context of
25non-emergency services, any of the following:
26        (1) a hospital as defined in 42 U.S.C. 1395x(e);

 

 

SB4220- 7 -LRB102 28076 BMS 40119 b

1        (2) a hospital outpatient department;
2        (3) a critical access hospital certified under 42
3    U.S.C. 1395i-4(e);
4        (4) an ambulatory surgical treatment center as defined
5    in the Ambulatory Surgical Treatment Center Act; or
6        (5) any recipient of a license under the Hospital
7    Licensing Act that is not otherwise described in this
8    definition.
9    "Health care provider" means a provider as defined in
10subsection (d) of Section 370g. "Health care provider" does
11not include a provider of air ambulance or ground ambulance
12services.
13    "Health care services" has the meaning ascribed to that
14term in subsection (a) of Section 370g.
15    "Health insurance issuer" has the meaning ascribed to that
16term in Section 5 of the Illinois Health Insurance Portability
17and Accountability Act.
18    "Nonparticipating emergency facility" means, with respect
19to the furnishing of an item or service under a policy of group
20or individual health insurance coverage, any of the following
21facilities that does not have a contractual relationship
22directly or indirectly with a health insurance issuer in
23relation to the coverage:
24        (1) an emergency department of a hospital;
25        (2) a Freestanding Emergency Center;
26        (3) an ambulatory surgical treatment center as defined

 

 

SB4220- 8 -LRB102 28076 BMS 40119 b

1    in the Ambulatory Surgical Treatment Center Act; or
2        (4) with respect to emergency services described in
3    paragraph (2) of the definition of "emergency services", a
4    hospital.
5    "Nonparticipating provider" means, with respect to the
6furnishing of an item or service under a policy of group or
7individual health insurance coverage, any health care provider
8who does not have a contractual relationship directly or
9indirectly with a health insurance issuer in relation to the
10coverage.
11    "Participating emergency facility" means any of the
12following facilities that has a contractual relationship
13directly or indirectly with a health insurance issuer offering
14group or individual health insurance coverage setting forth
15the terms and conditions on which a relevant health care
16service is provided to an insured, beneficiary, or enrollee
17under the coverage:
18        (1) an emergency department of a hospital;
19        (2) a Freestanding Emergency Center;
20        (3) an ambulatory surgical treatment center as defined
21    in the Ambulatory Surgical Treatment Center Act; or
22        (4) with respect to emergency services described in
23    paragraph (2) of the definition of "emergency services", a
24    hospital.
25For purposes of this definition, a single case agreement
26between an emergency facility and an issuer that is used to

 

 

SB4220- 9 -LRB102 28076 BMS 40119 b

1address unique situations in which an insured, beneficiary, or
2enrollee requires services that typically occur out-of-network
3constitutes a contractual relationship and is limited to the
4parties to the agreement.
5    "Participating health care facility" means any health care
6facility that has a contractual relationship directly or
7indirectly with a health insurance issuer offering group or
8individual health insurance coverage setting forth the terms
9and conditions on which a relevant health care service is
10provided to an insured, beneficiary, or enrollee under the
11coverage. A single case agreement between an emergency
12facility and an issuer that is used to address unique
13situations in which an insured, beneficiary, or enrollee
14requires services that typically occur out-of-network
15constitutes a contractual relationship for purposes of this
16definition and is limited to the parties to the agreement.
17    "Participating provider" means any health care provider
18that has a contractual relationship directly or indirectly
19with a health insurance issuer offering group or individual
20health insurance coverage setting forth the terms and
21conditions on which a relevant health care service is provided
22to an insured, beneficiary, or enrollee under the coverage.
23    "Qualifying payment amount" has the meaning given to that
24term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
25promulgated thereunder.
26    "Recognized amount" means the lesser of the amount

 

 

SB4220- 10 -LRB102 28076 BMS 40119 b

1initially billed by the provider or the qualifying payment
2amount.
3    "Stabilize" means "stabilization" as defined in Section 10
4of the Managed Care Reform and Patient Rights Act.
5    "Treating provider" means a health care provider who has
6evaluated the individual.
7    "Visit" means, with respect to health care services
8furnished to an individual at a health care facility, health
9care services furnished by a provider at the facility, as well
10as equipment, devices, telehealth services, imaging services,
11laboratory services, and preoperative and postoperative
12services regardless of whether the provider furnishing such
13services is at the facility.
14    (b) Emergency services. When a beneficiary, insured, or
15enrollee receives emergency services from a nonparticipating
16provider or a nonparticipating emergency facility, the health
17insurance issuer shall ensure that the beneficiary, insured,
18or enrollee shall incur no greater out-of-pocket costs than
19the beneficiary, insured, or enrollee would have incurred with
20a participating provider or a participating emergency
21facility. Any cost-sharing requirements shall be applied as
22though the emergency services had been received from a
23participating provider or a participating facility. Cost
24sharing shall be calculated based on the recognized amount for
25the emergency services. If the cost sharing for the same item
26or service furnished by a participating provider would have

 

 

SB4220- 11 -LRB102 28076 BMS 40119 b

1been a flat-dollar copayment, that amount shall be the
2cost-sharing amount unless the provider has billed a lesser
3total amount. In no event shall the beneficiary, insured,
4enrollee, or any group policyholder or plan sponsor be liable
5to or billed by the health insurance issuer, the
6nonparticipating provider, or the nonparticipating emergency
7facility for any amount beyond the cost sharing calculated in
8accordance with this subsection with respect to the emergency
9services delivered. Administrative requirements or limitations
10shall be no greater than those applicable to emergency
11services received from a participating provider or a
12participating emergency facility.
13    (b-5) Non-emergency services at participating health care
14facilities.
15        (1) When a beneficiary, insured, or enrollee utilizes
16    a participating health care facility and, due to any
17    reason, covered ancillary services are provided by a
18    nonparticipating provider during or resulting from the
19    visit, the health insurance issuer shall ensure that the
20    beneficiary, insured, or enrollee shall incur no greater
21    out-of-pocket costs than the beneficiary, insured, or
22    enrollee would have incurred with a participating provider
23    for the ancillary services. Any cost-sharing requirements
24    shall be applied as though the ancillary services had been
25    received from a participating provider. Cost sharing shall
26    be calculated based on the recognized amount for the

 

 

SB4220- 12 -LRB102 28076 BMS 40119 b

1    ancillary services. If the cost sharing for the same item
2    or service furnished by a participating provider would
3    have been a flat-dollar copayment, that amount shall be
4    the cost-sharing amount unless the provider has billed a
5    lesser total amount. In no event shall the beneficiary,
6    insured, enrollee, or any group policyholder or plan
7    sponsor be liable to or billed by the health insurance
8    issuer, the nonparticipating provider, or the
9    participating health care facility for any amount beyond
10    the cost sharing calculated in accordance with this
11    subsection with respect to the ancillary services
12    delivered. In addition to ancillary services, the
13    requirements of this paragraph shall also apply with
14    respect to covered items or services furnished as a result
15    of unforeseen, urgent medical needs that arise at the time
16    an item or service is furnished, regardless of whether the
17    nonparticipating provider satisfied the notice and consent
18    criteria under paragraph (2) of this subsection.
19        (2) When a beneficiary, insured, or enrollee utilizes
20    a participating health care facility and receives
21    non-emergency covered health care services other than
22    those described in paragraph (1) of this subsection from a
23    nonparticipating provider during or resulting from the
24    visit, the health insurance issuer shall ensure that the
25    beneficiary, insured, or enrollee incurs no greater
26    out-of-pocket costs than the beneficiary, insured, or

 

 

SB4220- 13 -LRB102 28076 BMS 40119 b

1    enrollee would have incurred with a participating provider
2    unless the nonparticipating provider, or the participating
3    health care facility on behalf of the nonparticipating
4    provider, satisfies the notice and consent criteria
5    provided in 42 U.S.C. 300gg-132 and regulations
6    promulgated thereunder. If the notice and consent criteria
7    are not satisfied, then:
8            (A) any cost-sharing requirements shall be applied
9        as though the health care services had been received
10        from a participating provider;
11            (B) cost sharing shall be calculated based on the
12        recognized amount for the health care services; and
13            (C) in no event shall the beneficiary, insured,
14        enrollee, or any group policyholder or plan sponsor be
15        liable to or billed by the health insurance issuer,
16        the nonparticipating provider, or the participating
17        health care facility for any amount beyond the cost
18        sharing calculated in accordance with this subsection
19        with respect to the health care services delivered.
20    (c) Notwithstanding any other provision of this Code,
21except when the notice and consent criteria are satisfied for
22the situation in paragraph (2) of subsection (b-5), any
23benefits a beneficiary, insured, or enrollee receives for
24services under the situations in subsections (b) or (b-5) are
25assigned to the nonparticipating providers or the facility
26acting on their behalf. Upon receipt of the provider's bill or

 

 

SB4220- 14 -LRB102 28076 BMS 40119 b

1facility's bill, the health insurance issuer shall provide the
2nonparticipating provider or the facility with a written
3explanation of benefits that specifies the proposed
4reimbursement and the applicable deductible, copayment or
5coinsurance amounts owed by the insured, beneficiary or
6enrollee. The health insurance issuer shall pay any
7reimbursement subject to this Section directly to the
8nonparticipating provider or the facility.
9    (d) For bills assigned under subsection (c), the
10nonparticipating provider or the facility may bill the health
11insurance issuer for the services rendered, and the health
12insurance issuer may pay the billed amount or attempt to
13negotiate reimbursement with the nonparticipating provider or
14the facility. Within 30 calendar days after the provider or
15facility transmits the bill to the health insurance issuer,
16the issuer shall send an initial payment or notice of denial of
17payment with the written explanation of benefits to the
18provider or facility. If attempts to negotiate reimbursement
19for services provided by a nonparticipating provider do not
20result in a resolution of the payment dispute within 30 days
21after receipt of written explanation of benefits by the health
22insurance issuer, then the health insurance issuer or
23nonparticipating provider or the facility may initiate binding
24arbitration to determine payment for services provided on a
25per bill basis. The party requesting arbitration shall notify
26the other party arbitration has been initiated and state its

 

 

SB4220- 15 -LRB102 28076 BMS 40119 b

1final offer before arbitration. In response to this notice,
2the nonrequesting party shall inform the requesting party of
3its final offer before the arbitration occurs. Arbitration
4shall be initiated by filing a request with the Department of
5Insurance.
6    (e) The Department of Insurance shall publish a list of
7approved arbitrators or entities that shall provide binding
8arbitration. These arbitrators shall be American Arbitration
9Association or American Health Lawyers Association trained
10arbitrators. Both parties must agree on an arbitrator from the
11Department of Insurance's or its approved entity's list of
12arbitrators. If no agreement can be reached, then a list of 5
13arbitrators shall be provided by the Department of Insurance
14or the approved entity. From the list of 5 arbitrators, the
15health insurance issuer can veto 2 arbitrators and the
16provider or facility can veto 2 arbitrators. The remaining
17arbitrator shall be the chosen arbitrator. This arbitration
18shall consist of a review of the written submissions by both
19parties. The arbitrator shall not establish a rebuttable
20presumption that the qualifying payment amount should be the
21total amount owed to the provider or facility by the
22combination of the issuer and the insured, beneficiary, or
23enrollee. Binding arbitration shall provide for a written
24decision within 45 days after the request is filed with the
25Department of Insurance. Both parties shall be bound by the
26arbitrator's decision. The arbitrator's expenses and fees,

 

 

SB4220- 16 -LRB102 28076 BMS 40119 b

1together with other expenses, not including attorney's fees,
2incurred in the conduct of the arbitration, shall be paid as
3provided in the decision.
4    (f) (Blank).
5    (g) Section 368a of this Act shall not apply during the
6pendency of a decision under subsection (d). Upon the issuance
7of the arbitrator's decision, Section 368a applies with
8respect to the amount, if any, by which the arbitrator's
9determination exceeds the issuer's initial payment under
10subsection (c), or the entire amount of the arbitrator's
11determination if initial payment was denied. Any interest
12required to be paid a provider under Section 368a shall not
13accrue until after 30 days of an arbitrator's decision as
14provided in subsection (d), but in no circumstances longer
15than 150 days from date the nonparticipating facility-based
16provider billed for services rendered.
17    (h) Nothing in this Section shall be interpreted to change
18the prudent layperson provisions with respect to emergency
19services under the Managed Care Reform and Patient Rights Act.
20    (i) Nothing in this Section shall preclude a health care
21provider from billing a beneficiary, insured, or enrollee for
22reasonable administrative fees, such as service fees for
23checks returned for nonsufficient funds and missed
24appointments.
25    (j) Nothing in this Section shall preclude a beneficiary,
26insured, or enrollee from assigning benefits to a

 

 

SB4220- 17 -LRB102 28076 BMS 40119 b

1nonparticipating provider when the notice and consent criteria
2are satisfied under paragraph (2) of subsection (b-5) or in
3any other situation not described in subsections (b) or (b-5).
4    (k) Except when the notice and consent criteria are
5satisfied under paragraph (2) of subsection (b-5), if an
6individual receives health care services under the situations
7described in subsections (b) or (b-5), no referral requirement
8or any other provision contained in the policy or certificate
9of coverage shall deny coverage, reduce benefits, or otherwise
10defeat the requirements of this Section for services that
11would have been covered with a participating provider.
12However, this subsection shall not be construed to preclude a
13provider contract with a health insurance issuer, or with an
14administrator or similar entity acting on the issuer's behalf,
15from imposing requirements on the participating provider,
16participating emergency facility, or participating health care
17facility relating to the referral of covered individuals to
18nonparticipating providers.
19    (l) Except if the notice and consent criteria are
20satisfied under paragraph (2) of subsection (b-5),
21cost-sharing amounts calculated in conformity with this
22Section shall count toward any deductible or out-of-pocket
23maximum applicable to in-network coverage.
24    (m) The Department has the authority to enforce the
25requirements of this Section in the situations described in
26subsections (b) and (b-5), and in any other situation for

 

 

SB4220- 18 -LRB102 28076 BMS 40119 b

1which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
2regulations promulgated thereunder would prohibit an
3individual from being billed or liable for emergency services
4furnished by a nonparticipating provider or nonparticipating
5emergency facility or for non-emergency health care services
6furnished by a nonparticipating provider at a participating
7health care facility.
8    (n) This Section does not apply with respect to air
9ambulance or ground ambulance services. This Section does not
10apply to any policy of excepted benefits or to short-term,
11limited-duration health insurance coverage.
12(Source: P.A. 102-901, eff. 7-1-22.)
 
13    Section 10. The Network Adequacy and Transparency Act is
14amended by changing Section 10 as follows:
 
15    (215 ILCS 124/10)
16    Sec. 10. Network adequacy.
17    (a) An insurer providing a network plan shall file a
18description of all of the following with the Director:
19        (1) The written policies and procedures for adding
20    providers to meet patient needs based on increases in the
21    number of beneficiaries, changes in the
22    patient-to-provider ratio, changes in medical and health
23    care capabilities, and increased demand for services.
24        (2) The written policies and procedures for making

 

 

SB4220- 19 -LRB102 28076 BMS 40119 b

1    referrals within and outside the network.
2        (3) The written policies and procedures on how the
3    network plan will provide 24-hour, 7-day per week access
4    to network-affiliated primary care, emergency services,
5    reproductive health care, and woman's principal health
6    care providers.
7    An insurer shall not prohibit a preferred provider from
8discussing any specific or all treatment options with
9beneficiaries irrespective of the insurer's position on those
10treatment options or from advocating on behalf of
11beneficiaries within the utilization review, grievance, or
12appeals processes established by the insurer in accordance
13with any rights or remedies available under applicable State
14or federal law.
15    (b) Insurers must file for review a description of the
16services to be offered through a network plan. The description
17shall include all of the following:
18        (1) A geographic map of the area proposed to be served
19    by the plan by county service area and zip code, including
20    marked locations for preferred providers.
21        (2) As deemed necessary by the Department, the names,
22    addresses, phone numbers, and specialties of the providers
23    who have entered into preferred provider agreements under
24    the network plan.
25        (3) The number of beneficiaries anticipated to be
26    covered by the network plan.

 

 

SB4220- 20 -LRB102 28076 BMS 40119 b

1        (4) An Internet website and toll-free telephone number
2    for beneficiaries and prospective beneficiaries to access
3    current and accurate lists of preferred providers,
4    additional information about the plan, as well as any
5    other information required by Department rule.
6        (5) A description of how health care services to be
7    rendered under the network plan are reasonably accessible
8    and available to beneficiaries. The description shall
9    address all of the following:
10            (A) the type of health care services to be
11        provided by the network plan;
12            (B) the ratio of physicians and other providers to
13        beneficiaries, by specialty and including primary care
14        physicians and facility-based physicians when
15        applicable under the contract, necessary to meet the
16        health care needs and service demands of the currently
17        enrolled population;
18            (C) the travel and distance standards for plan
19        beneficiaries in county service areas; and
20            (D) a description of how the use of telemedicine,
21        telehealth, or mobile care services may be used to
22        partially meet the network adequacy standards, if
23        applicable.
24        (6) A provision ensuring that whenever a beneficiary
25    has made a good faith effort, as evidenced by accessing
26    the provider directory, calling the network plan, and

 

 

SB4220- 21 -LRB102 28076 BMS 40119 b

1    calling the provider, to utilize preferred providers for a
2    covered service and it is determined the insurer does not
3    have the appropriate preferred providers due to
4    insufficient number, type, or unreasonable travel distance
5    or delay, the insurer shall ensure, directly or
6    indirectly, by terms contained in the payer contract, that
7    the beneficiary will be provided the covered service at no
8    greater cost to the beneficiary than if the service had
9    been provided by a preferred provider. This paragraph (6)
10    does not apply to: (A) a beneficiary who willfully chooses
11    to access a non-preferred provider for health care
12    services available through the panel of preferred
13    providers, or (B) a beneficiary enrolled in a health
14    maintenance organization. In these circumstances, the
15    contractual requirements for non-preferred provider
16    reimbursements shall apply unless Section 356z.3a of the
17    Illinois Insurance Code requires otherwise. In no event
18    shall a beneficiary who receives care at a participating
19    health care facility be required to search for
20    participating providers under the circumstances described
21    in subsections (b) or (b-5) of Section 356z.3a of the
22    Illinois Insurance Code except under the circumstances
23    described in paragraph (2) of subsection (b-5).
24        (7) A provision that the beneficiary shall receive
25    emergency care coverage such that payment for this
26    coverage is not dependent upon whether the emergency

 

 

SB4220- 22 -LRB102 28076 BMS 40119 b

1    services are performed by a preferred or non-preferred
2    provider and the coverage shall be at the same benefit
3    level as if the service or treatment had been rendered by a
4    preferred provider. For purposes of this paragraph (7),
5    "the same benefit level" means that the beneficiary is
6    provided the covered service at no greater cost to the
7    beneficiary than if the service had been provided by a
8    preferred provider. This provision shall be consistent
9    with Section 356z.3a of the Illinois Insurance Code.
10        (8) A limitation that, if the plan provides that the
11    beneficiary will incur a penalty for failing to
12    pre-certify inpatient hospital treatment, the penalty may
13    not exceed $1,000 per occurrence in addition to the plan
14    cost sharing provisions.
15    (c) The network plan shall demonstrate to the Director a
16minimum ratio of providers to plan beneficiaries as required
17by the Department.
18        (1) The ratio of physicians or other providers to plan
19    beneficiaries shall be established annually by the
20    Department in consultation with the Department of Public
21    Health based upon the guidance from the federal Centers
22    for Medicare and Medicaid Services. The Department shall
23    not establish ratios for vision or dental providers who
24    provide services under dental-specific or vision-specific
25    benefits. The Department shall consider establishing
26    ratios for the following physicians or other providers:

 

 

SB4220- 23 -LRB102 28076 BMS 40119 b

1            (A) Primary Care;
2            (B) Pediatrics;
3            (C) Cardiology;
4            (D) Gastroenterology;
5            (E) General Surgery;
6            (F) Neurology;
7            (G) OB/GYN;
8            (H) Oncology/Radiation;
9            (I) Ophthalmology;
10            (J) Urology;
11            (K) Behavioral Health;
12            (L) Allergy/Immunology;
13            (M) Chiropractic;
14            (N) Dermatology;
15            (O) Endocrinology;
16            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
17            (Q) Infectious Disease;
18            (R) Nephrology;
19            (S) Neurosurgery;
20            (T) Orthopedic Surgery;
21            (U) Physiatry/Rehabilitative;
22            (V) Plastic Surgery;
23            (W) Pulmonary;
24            (X) Rheumatology;
25            (Y) Anesthesiology;
26            (Z) Pain Medicine;

 

 

SB4220- 24 -LRB102 28076 BMS 40119 b

1            (AA) Pediatric Specialty Services;
2            (BB) Outpatient Dialysis; and
3            (CC) HIV; and .
4            (DD) Reproductive Health Care.
5        (2) The Director shall establish a process for the
6    review of the adequacy of these standards, along with an
7    assessment of additional specialties to be included in the
8    list under this subsection (c).
9    (d) The network plan shall demonstrate to the Director
10maximum travel and distance standards for plan beneficiaries,
11which shall be established annually by the Department in
12consultation with the Department of Public Health based upon
13the guidance from the federal Centers for Medicare and
14Medicaid Services. These standards shall consist of the
15maximum minutes or miles to be traveled by a plan beneficiary
16for each county type, such as large counties, metro counties,
17or rural counties as defined by Department rule.
18    The maximum travel time and distance standards must
19include standards for each physician and other provider
20category listed for which ratios have been established.
21    The Director shall establish a process for the review of
22the adequacy of these standards along with an assessment of
23additional specialties to be included in the list under this
24subsection (d).
25    (d-5)(1) Every insurer shall ensure that beneficiaries
26have timely and proximate access to treatment for mental,

 

 

SB4220- 25 -LRB102 28076 BMS 40119 b

1emotional, nervous, or substance use disorders or conditions
2in accordance with the provisions of paragraph (4) of
3subsection (a) of Section 370c of the Illinois Insurance Code.
4Insurers shall use a comparable process, strategy, evidentiary
5standard, and other factors in the development and application
6of the network adequacy standards for timely and proximate
7access to treatment for mental, emotional, nervous, or
8substance use disorders or conditions and those for the access
9to treatment for medical and surgical conditions. As such, the
10network adequacy standards for timely and proximate access
11shall equally be applied to treatment facilities and providers
12for mental, emotional, nervous, or substance use disorders or
13conditions and specialists providing medical or surgical
14benefits pursuant to the parity requirements of Section 370c.1
15of the Illinois Insurance Code and the federal Paul Wellstone
16and Pete Domenici Mental Health Parity and Addiction Equity
17Act of 2008. Notwithstanding the foregoing, the network
18adequacy standards for timely and proximate access to
19treatment for mental, emotional, nervous, or substance use
20disorders or conditions shall, at a minimum, satisfy the
21following requirements:
22        (A) For beneficiaries residing in the metropolitan
23    counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
24    network adequacy standards for timely and proximate access
25    to treatment for mental, emotional, nervous, or substance
26    use disorders or conditions means a beneficiary shall not

 

 

SB4220- 26 -LRB102 28076 BMS 40119 b

1    have to travel longer than 30 minutes or 30 miles from the
2    beneficiary's residence to receive outpatient treatment
3    for mental, emotional, nervous, or substance use disorders
4    or conditions. Beneficiaries shall not be required to wait
5    longer than 10 business days between requesting an initial
6    appointment and being seen by the facility or provider of
7    mental, emotional, nervous, or substance use disorders or
8    conditions for outpatient treatment or to wait longer than
9    20 business days between requesting a repeat or follow-up
10    appointment and being seen by the facility or provider of
11    mental, emotional, nervous, or substance use disorders or
12    conditions for outpatient treatment; however, subject to
13    the protections of paragraph (3) of this subsection, a
14    network plan shall not be held responsible if the
15    beneficiary or provider voluntarily chooses to schedule an
16    appointment outside of these required time frames.
17        (B) For beneficiaries residing in Illinois counties
18    other than those counties listed in subparagraph (A) of
19    this paragraph, network adequacy standards for timely and
20    proximate access to treatment for mental, emotional,
21    nervous, or substance use disorders or conditions means a
22    beneficiary shall not have to travel longer than 60
23    minutes or 60 miles from the beneficiary's residence to
24    receive outpatient treatment for mental, emotional,
25    nervous, or substance use disorders or conditions.
26    Beneficiaries shall not be required to wait longer than 10

 

 

SB4220- 27 -LRB102 28076 BMS 40119 b

1    business days between requesting an initial appointment
2    and being seen by the facility or provider of mental,
3    emotional, nervous, or substance use disorders or
4    conditions for outpatient treatment or to wait longer than
5    20 business days between requesting a repeat or follow-up
6    appointment and being seen by the facility or provider of
7    mental, emotional, nervous, or substance use disorders or
8    conditions for outpatient treatment; however, subject to
9    the protections of paragraph (3) of this subsection, a
10    network plan shall not be held responsible if the
11    beneficiary or provider voluntarily chooses to schedule an
12    appointment outside of these required time frames.
13    (2) For beneficiaries residing in all Illinois counties,
14network adequacy standards for timely and proximate access to
15treatment for mental, emotional, nervous, or substance use
16disorders or conditions means a beneficiary shall not have to
17travel longer than 60 minutes or 60 miles from the
18beneficiary's residence to receive inpatient or residential
19treatment for mental, emotional, nervous, or substance use
20disorders or conditions.
21    (3) If there is no in-network facility or provider
22available for a beneficiary to receive timely and proximate
23access to treatment for mental, emotional, nervous, or
24substance use disorders or conditions in accordance with the
25network adequacy standards outlined in this subsection, the
26insurer shall provide necessary exceptions to its network to

 

 

SB4220- 28 -LRB102 28076 BMS 40119 b

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

 

 

SB4220- 29 -LRB102 28076 BMS 40119 b

1        (2) if patterns of care in the service area do not
2    support the need for the requested number of provider or
3    facility type and the insurer provides data on local
4    patterns of care, such as claims data, referral patterns,
5    or local provider interviews, indicating where the
6    beneficiaries currently seek this type of care or where
7    the physicians currently refer beneficiaries, or both; or
8        (3) other circumstances deemed appropriate by the
9    Department consistent with the requirements of this Act.
10    (h) Insurers are required to report to the Director any
11material change to an approved network plan within 15 days
12after the change occurs and any change that would result in
13failure to meet the requirements of this Act. Upon notice from
14the insurer, the Director shall reevaluate the network plan's
15compliance with the network adequacy and transparency
16standards of this Act.
17(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22.)
 
18    Section 95. No acceleration or delay. Where this Act makes
19changes in a statute that is represented in this Act by text
20that is not yet or no longer in effect (for example, a Section
21represented by multiple versions), the use of that text does
22not accelerate or delay the taking effect of (i) the changes
23made by this Act or (ii) provisions derived from any other
24Public Act.
 
25    Section 99. Effective date. This Act takes effect July 1,

 

 

SB4220- 30 -LRB102 28076 BMS 40119 b

12023, except that the changes to Section 356z.3 of the
2Illinois Insurance Code take effect January 1, 2024.