Sen. Jacqueline Y. Collins

Filed: 4/9/2021





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2    AMENDMENT NO. ______. Amend Senate Bill 332 by replacing
3everything after the enacting clause with the following:
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



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1provider fees for health care services under a program in
2which the beneficiary has an incentive to utilize the services
3of a provider that has entered into an agreement or
4arrangement with an insurer.
5    "Department" means the Department of Insurance.
6    "Director" means the Director of Insurance.
7    "Family caregiver" means a relative, partner, friend, or
8neighbor who has a significant relationship with the patient
9and administers or assists them with activities of daily
10living, instrumental activities of daily living, or other
11medical or nursing tasks for the quality and welfare of that
13    "Insurer" means any entity that offers individual or group
14accident and health insurance, including, but not limited to,
15health maintenance organizations, preferred provider
16organizations, exclusive provider organizations, and other
17plan structures requiring network participation, excluding the
18medical assistance program under the Illinois Public Aid Code,
19the State employees group health insurance program, workers
20compensation insurance, and pharmacy benefit managers.
21    "Material change" means a significant reduction in the
22number of providers available in a network plan, including,
23but not limited to, a reduction of 10% or more in a specific
24type of providers, the removal of a major health system that
25causes a network to be significantly different from the
26network when the beneficiary purchased the network plan, or



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1any change that would cause the network to no longer satisfy
2the requirements of this Act or the Department's rules for
3network adequacy and transparency.
4    "Network" means the group or groups of preferred providers
5providing services to a network plan.
6    "Network plan" means an individual or group policy of
7accident and health insurance that either requires a covered
8person to use or creates incentives, including financial
9incentives, for a covered person to use providers managed,
10owned, under contract with, or employed by the insurer.
11    "Ongoing course of treatment" means (1) treatment for a
12life-threatening condition, which is a disease or condition
13for which likelihood of death is probable unless the course of
14the disease or condition is interrupted; (2) treatment for a
15serious acute condition, defined as a disease or condition
16requiring complex ongoing care that the covered person is
17currently receiving, such as chemotherapy, radiation therapy,
18or post-operative visits; (3) a course of treatment for a
19health condition that a treating provider attests that
20discontinuing care by that provider would worsen the condition
21or interfere with anticipated outcomes; or (4) the third
22trimester of pregnancy through the post-partum period.
23    "Preferred provider" means any provider who has entered,
24either directly or indirectly, into an agreement with an
25employer or risk-bearing entity relating to health care
26services that may be rendered to beneficiaries under a network



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2    "Providers" means physicians licensed to practice medicine
3in all its branches, other health care professionals,
4hospitals, or other health care institutions that provide
5health care services.
6    "Telehealth" has the meaning given to that term in Section
7356z.22 of the Illinois Insurance Code.
8    "Telemedicine" has the meaning given to that term in
9Section 49.5 of the Medical Practice Act of 1987.
10    "Tiered network" means a network that identifies and
11groups some or all types of provider and facilities into
12specific groups to which different provider reimbursement,
13covered person cost-sharing or provider access requirements,
14or any combination thereof, apply for the same services.
15    "Woman's principal health care provider" means a physician
16licensed to practice medicine in all of its branches
17specializing in obstetrics, gynecology, or family practice.
18(Source: P.A. 100-502, eff. 9-15-17.)
19    (215 ILCS 124/25)
20    Sec. 25. Network transparency.
21    (a) A network plan shall post electronically an
22up-to-date, accurate, and complete provider directory for each
23of its network plans, with the information and search
24functions, as described in this Section.
25        (1) In making the directory available electronically,



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1    the network plans shall ensure that the general public is
2    able to view all of the current providers for a plan
3    through a clearly identifiable link or tab and without
4    creating or accessing an account or entering a policy or
5    contract number.
6        (2) The network plan shall update the online provider
7    directory at least monthly. Providers shall notify the
8    network plan electronically or in writing of any changes
9    to their information as listed in the provider directory,
10    including the information required in subparagraph (K) of
11    paragraph (1) of subsection (b). The network plan shall
12    update its online provider directory in a manner
13    consistent with the information provided by the provider
14    within 10 business days after being notified of the change
15    by the provider. Nothing in this paragraph (2) shall void
16    any contractual relationship between the provider and the
17    plan.
18        (3) The network plan shall audit periodically at least
19    25% of its provider directories for accuracy, make any
20    corrections necessary, and retain documentation of the
21    audit. The network plan shall submit the audit to the
22    Director upon request. As part of these audits, the
23    network plan shall contact any provider in its network
24    that has not submitted a claim to the plan or otherwise
25    communicated his or her intent to continue participation
26    in the plan's network.



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1        (4) A network plan shall provide a print copy of a
2    current provider directory or a print copy of the
3    requested directory information upon request of a
4    beneficiary or a prospective beneficiary. Print copies
5    must be updated quarterly and an errata that reflects
6    changes in the provider network must be updated quarterly.
7        (5) For each network plan, a network plan shall
8    include, in plain language in both the electronic and
9    print directory, the following general information:
10            (A) in plain language, a description of the
11        criteria the plan has used to build its provider
12        network;
13            (B) if applicable, in plain language, a
14        description of the criteria the insurer or network
15        plan has used to create tiered networks;
16            (C) if applicable, in plain language, how the
17        network plan designates the different provider tiers
18        or levels in the network and identifies for each
19        specific provider, hospital, or other type of facility
20        in the network which tier each is placed, for example,
21        by name, symbols, or grouping, in order for a
22        beneficiary-covered person or a prospective
23        beneficiary-covered person to be able to identify the
24        provider tier; and
25            (D) if applicable, a notation that authorization
26        or referral may be required to access some providers.



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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) specialty, if applicable;
25            (E) medical group affiliations, if applicable;
26            (F) facility affiliations, if applicable;



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1            (G) participating facility affiliations, if
2        applicable;
3            (H) languages spoken other than English, if
4        applicable;
5            (I) whether accepting new patients; and
6            (J) board certifications, if applicable; and .
7            (K) use of telehealth or telemedicine, including,
8        but not limited to:
9                (i) whether the provider offers the use of
10            telehealth or telemedicine to deliver services to
11            patients for whom it would be clinically
12            appropriate;
13                (ii) what modalities are used and what types
14            of services may be provided via telehealth or
15            telemedicine; and
16                (iii) whether the provider has the ability and
17            willingness to include in a telehealth or
18            telemedicine encounter a family caregiver who is
19            in a separate location than the patient if the
20            patient wishes and provides his or her consent;
21        (2) for hospitals:
22            (A) hospital name;
23            (B) hospital type (such as acute, rehabilitation,
24        children's, or cancer);
25            (C) participating hospital location; and
26            (D) hospital accreditation status; and



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1        (3) for facilities, other than hospitals, by type:
2            (A) facility name;
3            (B) facility type;
4            (C) types of services performed; and
5            (D) participating facility location or locations.
6    (c) For the electronic provider directories, for each
7network plan, a network plan shall make available all of the
8following information in addition to the searchable
9information required in this Section:
10        (1) for health care professionals:
11            (A) contact information; and
12            (B) languages spoken other than English by
13        clinical staff, if applicable;
14        (2) for hospitals, telephone number; and
15        (3) for facilities other than hospitals, telephone
16    number.
17    (d) The insurer or network plan shall make available in
18print, upon request, the following provider directory
19information for the applicable network plan:
20        (1) for health care professionals:
21            (A) name;
22            (B) contact information;
23            (C) participating office location or locations;
24            (D) specialty, if applicable;
25            (E) languages spoken other than English, if
26        applicable; and



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



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1        and telephone numbers.
2    (e) The network plan shall include a disclosure in the
3print format provider directory that the information included
4in the directory is accurate as of the date of printing and
5that beneficiaries or prospective beneficiaries should consult
6the insurer's electronic provider directory on its website and
7contact the provider. The network plan shall also include a
8telephone number in the print format provider directory for a
9customer service representative where the beneficiary can
10obtain current provider directory information.
11    (f) The Director may conduct periodic audits of the
12accuracy of provider directories. A network plan shall not be
13subject to any fines or penalties for information required in
14this Section that a provider submits that is inaccurate or
16(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
17    Section 99. Effective date. This Act takes effect upon
18becoming law.".