Illinois General Assembly - Full Text of HB5313
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Full Text of HB5313  103rd General Assembly



HB5313 EngrossedLRB103 38443 RPS 68579 b

1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Network Adequacy and Transparency Act is
5amended by changing Section 25 and by adding Section 35 as
7    (215 ILCS 124/25)
8    Sec. 25. Network transparency.
9    (a) A network plan shall post electronically an
10up-to-date, accurate, and complete provider directory for each
11of its network plans, with the information and search
12functions, as described in this Section.
13        (1) In making the directory available electronically,
14    the network plans shall ensure that the general public is
15    able to view all of the current providers for a plan
16    through a clearly identifiable link or tab and without
17    creating or accessing an account or entering a policy or
18    contract number.
19        (2) The network plan shall update the online provider
20    directory at least monthly. Providers shall notify the
21    network plan electronically or in writing of any changes
22    to their information as listed in the provider directory,
23    including the information required in subparagraph (K) of



HB5313 Engrossed- 2 -LRB103 38443 RPS 68579 b

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



HB5313 Engrossed- 3 -LRB103 38443 RPS 68579 b

1    print directory, the following general information:
2            (A) in plain language, a description of the
3        criteria the plan has used to build its provider
4        network;
5            (B) if applicable, in plain language, a
6        description of the criteria the insurer or network
7        plan has used to create tiered networks;
8            (C) if applicable, in plain language, how the
9        network plan designates the different provider tiers
10        or levels in the network and identifies for each
11        specific provider, hospital, or other type of facility
12        in the network which tier each is placed, for example,
13        by name, symbols, or grouping, in order for a
14        beneficiary-covered person or a prospective
15        beneficiary-covered person to be able to identify the
16        provider tier; and
17            (D) if applicable, a notation that authorization
18        or referral may be required to access some providers; .
19            (E) a telephone number and email address for a
20        customer service representative to whom directory
21        inaccuracies may be reported; and
22            (F) a
         detailed description of the process to
23        dispute charges for out-of-network providers or
24        facilities that were incorrectly listed as in-network
25        prior to the provision of care and a telephone number
26        and email address to dispute such charges.



HB5313 Engrossed- 4 -LRB103 38443 RPS 68579 b

1        (6) A network plan shall make it clear for both its
2    electronic and print directories what provider directory
3    applies to which network plan, such as including the
4    specific name of the network plan as marketed and issued
5    in this State. The network plan shall include in both its
6    electronic and print directories a customer service email
7    address and telephone number or electronic link that
8    beneficiaries or the general public may use to notify the
9    network plan of inaccurate provider directory information
10    and contact information for the Department's Office of
11    Consumer Health Insurance.
12        (7) A provider directory, whether in electronic or
13    print format, shall accommodate the communication needs of
14    individuals with disabilities, and include a link to or
15    information regarding available assistance for persons
16    with limited English proficiency.
17    (b) For each network plan, a network plan shall make
18available through an electronic provider directory the
19following information in a searchable format:
20        (1) for health care professionals:
21            (A) name;
22            (B) gender;
23            (C) participating office locations;
24            (D) patient population served (such as pediatric,
25        adult, elderly, or women) and specialty or
26        subspecialty, if applicable;



HB5313 Engrossed- 5 -LRB103 38443 RPS 68579 b

1            (E) medical group affiliations, if applicable;
2            (F) facility affiliations, if applicable;
3            (G) participating facility affiliations, if
4        applicable;
5            (H) languages spoken other than English, if
6        applicable;
7            (I) whether accepting new patients;
8            (J) board certifications, if applicable; and
9            (K) use of telehealth or telemedicine, including,
10        but not limited to:
11                (i) whether the provider offers the use of
12            telehealth or telemedicine to deliver services to
13            patients for whom it would be clinically
14            appropriate;
15                (ii) what modalities are used and what types
16            of services may be provided via telehealth or
17            telemedicine; and
18                (iii) whether the provider has the ability and
19            willingness to include in a telehealth or
20            telemedicine encounter a family caregiver who is
21            in a separate location than the patient if the
22            patient wishes and provides his or her consent;
23            and
24            (L) the anticipated date the provider will leave
25        the network, if applicable, which shall be included
26        not more than 10 days after the network provides



HB5313 Engrossed- 6 -LRB103 38443 RPS 68579 b

1        notice in accordance with Section 15 of this Act; and
2        (2) for hospitals:
3            (A) hospital name;
4            (B) hospital type (such as acute, rehabilitation,
5        children's, or cancer);
6            (C) participating hospital location; and
7            (D) hospital accreditation status; and
8        (3) for facilities, other than hospitals, by type:
9            (A) facility name;
10            (B) facility type;
11            (C) types of services performed; and
12            (D) participating facility location or locations;
13        and .
14            (E) the anticipated date the facility will leave
15        the network, if applicable, which shall be included
16        not more than 10 days after the network confirms the
17        facility is scheduled to leave the network.
18    (c) For the electronic provider directories, for each
19network plan, a network plan shall make available all of the
20following information in addition to the searchable
21information required in this Section:
22        (1) for health care professionals:
23            (A) contact information; and
24            (B) languages spoken other than English by
25        clinical staff, if applicable;
26        (2) for hospitals, telephone number; and



HB5313 Engrossed- 7 -LRB103 38443 RPS 68579 b

1        (3) for facilities other than hospitals, telephone
2    number.
3    (d) The insurer or network plan shall make available in
4print, upon request, the following provider directory
5information for the applicable network plan:
6        (1) for health care professionals:
7            (A) name;
8            (B) contact information;
9            (C) participating office location or locations;
10            (D) patient population (such as pediatric, adult,
11        elderly, or women) and specialty or subspecialty, if
12        applicable;
13            (E) languages spoken other than English, if
14        applicable;
15            (F) whether accepting new patients; and
16            (G) use of telehealth or telemedicine, including,
17        but not limited to:
18                (i) whether the provider offers the use of
19            telehealth or telemedicine to deliver services to
20            patients for whom it would be clinically
21            appropriate;
22                (ii) what modalities are used and what types
23            of services may be provided via telehealth or
24            telemedicine; and
25                (iii) whether the provider has the ability and
26            willingness to include in a telehealth or



HB5313 Engrossed- 8 -LRB103 38443 RPS 68579 b

1            telemedicine encounter a family caregiver who is
2            in a separate location than the patient if the
3            patient wishes and provides his or her consent;
4        (2) for hospitals:
5            (A) hospital name;
6            (B) hospital type (such as acute, rehabilitation,
7        children's, or cancer); and
8            (C) participating hospital location and telephone
9        number; and
10        (3) for facilities, other than hospitals, by type:
11            (A) facility name;
12            (B) facility type;
13            (C) types of services performed; and
14            (D) participating facility location or locations
15        and telephone numbers.
16    (e) The network plan shall include a disclosure in the
17print format provider directory that the information included
18in the directory is accurate as of the date of printing and
19that beneficiaries or prospective beneficiaries should consult
20the insurer's electronic provider directory on its website and
21contact the provider. The network plan shall also include a
22telephone number and email address in the print format
23provider directory for a customer service representative where
24the beneficiary can obtain current provider directory
25information or report directory inaccuracies. The network plan
26shall include in the print format provider directory a



HB5313 Engrossed- 9 -LRB103 38443 RPS 68579 b

1detailed description of the process to dispute charges for
2out-of-network providers or facilities that were incorrectly
3listed as in-network prior to the provision of care and a
4telephone number and email address to dispute those charges.
5    (f) The Director may conduct periodic audits of the
6accuracy of provider directories and shall conduct random
7audits of at least 10% of plans each year. A network plan shall
8not be subject to any fines or penalties for information
9required in this Section that a provider submits that is
10inaccurate or incomplete.
11(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
12    (215 ILCS 124/35 new)
13    Sec. 35. Complaint of incorrect charges.
14    (a) A consumer who incurs a cost for inappropriate
15out-of-network charges for a provider, facility, or hospital
16that was listed as in-network prior to the provision of
17services may file a verified complaint with the Department.
18The Department shall conduct an investigation of any verified
19complaint and determine whether the complaint is sufficient.
20    (b) Upon a finding of sufficiency, the Director shall have
21the authority to levy a fine for not less than the cost
22incurred by the consumer for inappropriate out-of-network
23charges for a provider, facility, or hospital that was listed
24as in-network. The fines collected by the Director shall be
25remitted to the consumer.