Illinois General Assembly - Full Text of SB0332
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Full Text of SB0332  102nd General Assembly




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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 Sections 5 and 25 as follows:
6    (215 ILCS 124/5)
7    Sec. 5. Definitions. In this Act:
8    "Authorized representative" means a person to whom a
9beneficiary has given express written consent to represent the
10beneficiary; a person authorized by law to provide substituted
11consent for a beneficiary; or the beneficiary's treating
12provider only when the beneficiary or his or her family member
13is unable to provide consent.
14    "Beneficiary" means an individual, an enrollee, an
15insured, a participant, or any other person entitled to
16reimbursement for covered expenses of or the discounting of
17provider fees for health care services under a program in
18which the beneficiary has an incentive to utilize the services
19of a provider that has entered into an agreement or
20arrangement with an insurer.
21    "Department" means the Department of Insurance.
22    "Director" means the Director of Insurance.
23    "Family caregiver" means a relative, partner, friend, or



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1neighbor who has a significant relationship with the patient
2and administers or assists them with activities of daily
3living, instrumental activities of daily living, or other
4medical or nursing tasks for the quality and welfare of that
6    "Insurer" means any entity that offers individual or group
7accident and health insurance, including, but not limited to,
8health maintenance organizations, preferred provider
9organizations, exclusive provider organizations, and other
10plan structures requiring network participation, excluding the
11medical assistance program under the Illinois Public Aid Code,
12the State employees group health insurance program, workers
13compensation insurance, and pharmacy benefit managers.
14    "Material change" means a significant reduction in the
15number of providers available in a network plan, including,
16but not limited to, a reduction of 10% or more in a specific
17type of providers, the removal of a major health system that
18causes a network to be significantly different from the
19network when the beneficiary purchased the network plan, or
20any change that would cause the network to no longer satisfy
21the requirements of this Act or the Department's rules for
22network adequacy and transparency.
23    "Network" means the group or groups of preferred providers
24providing services to a network plan.
25    "Network plan" means an individual or group policy of
26accident and health insurance that either requires a covered



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1person to use or creates incentives, including financial
2incentives, for a covered person to use providers managed,
3owned, under contract with, or employed by the insurer.
4    "Ongoing course of treatment" means (1) treatment for a
5life-threatening condition, which is a disease or condition
6for which likelihood of death is probable unless the course of
7the disease or condition is interrupted; (2) treatment for a
8serious acute condition, defined as a disease or condition
9requiring complex ongoing care that the covered person is
10currently receiving, such as chemotherapy, radiation therapy,
11or post-operative visits; (3) a course of treatment for a
12health condition that a treating provider attests that
13discontinuing care by that provider would worsen the condition
14or interfere with anticipated outcomes; or (4) the third
15trimester of pregnancy through the post-partum period.
16    "Preferred provider" means any provider who has entered,
17either directly or indirectly, into an agreement with an
18employer or risk-bearing entity relating to health care
19services that may be rendered to beneficiaries under a network
21    "Providers" means physicians licensed to practice medicine
22in all its branches, other health care professionals,
23hospitals, or other health care institutions that provide
24health care services.
25    "Telehealth" has the meaning given to that term in Section
26356z.22 of the Illinois Insurance Code.



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1    "Telemedicine" has the meaning given to that term in
2Section 49.5 of the Medical Practice Act of 1987.
3    "Tiered network" means a network that identifies and
4groups some or all types of provider and facilities into
5specific groups to which different provider reimbursement,
6covered person cost-sharing or provider access requirements,
7or any combination thereof, apply for the same services.
8    "Woman's principal health care provider" means a physician
9licensed to practice medicine in all of its branches
10specializing in obstetrics, gynecology, or family practice.
11(Source: P.A. 100-502, eff. 9-15-17.)
12    (215 ILCS 124/25)
13    Sec. 25. Network transparency.
14    (a) A network plan shall post electronically an
15up-to-date, accurate, and complete provider directory for each
16of its network plans, with the information and search
17functions, as described in this Section.
18        (1) In making the directory available electronically,
19    the network plans shall ensure that the general public is
20    able to view all of the current providers for a plan
21    through a clearly identifiable link or tab and without
22    creating or accessing an account or entering a policy or
23    contract number.
24        (2) The network plan shall update the online provider
25    directory at least monthly. Providers shall notify the



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



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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



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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; and
25            (J) board certifications, if applicable; and .
26            (K) use of telehealth or telemedicine, including,



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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



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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; and
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;



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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



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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
9(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
10    Section 99. Effective date. This Act takes effect upon
11becoming law.