Full Text of SB2641 103rd General Assembly
SB2641eng 103RD GENERAL ASSEMBLY | | | SB2641 Engrossed | | LRB103 35049 JAG 64994 b |
|
| 1 | | AN ACT concerning regulation. | 2 | | Be it enacted by the People of the State of Illinois, | 3 | | represented in the General Assembly: | 4 | | Section 5. The Network Adequacy and Transparency Act is | 5 | | amended by changing Section 10 as follows: | 6 | | (215 ILCS 124/10) | 7 | | Sec. 10. Network adequacy. | 8 | | (a) An insurer providing a network plan shall file a | 9 | | description of all of the following with the Director: | 10 | | (1) The written policies and procedures for adding | 11 | | providers to meet patient needs based on increases in the | 12 | | number of beneficiaries, changes in the | 13 | | patient-to-provider ratio, changes in medical and health | 14 | | care capabilities, and increased demand for services. | 15 | | (2) The written policies and procedures for making | 16 | | referrals within and outside the network. | 17 | | (3) The written policies and procedures on how the | 18 | | network plan will provide 24-hour, 7-day per week access | 19 | | to network-affiliated primary care, emergency services, | 20 | | and women's principal health care providers. | 21 | | (4) The process for monitoring health plan | 22 | | beneficiaries' timely in-network access to physician | 23 | | specialist services. |
| | | SB2641 Engrossed | - 2 - | LRB103 35049 JAG 64994 b |
|
| 1 | | An insurer shall not prohibit a preferred provider from | 2 | | discussing any specific or all treatment options with | 3 | | beneficiaries irrespective of the insurer's position on those | 4 | | treatment options or from advocating on behalf of | 5 | | beneficiaries within the utilization review, grievance, or | 6 | | appeals processes established by the insurer in accordance | 7 | | with any rights or remedies available under applicable State | 8 | | or federal law. | 9 | | (a-5) An insurer providing a network plan shall file an | 10 | | insurer's monitoring report for each network hospital and | 11 | | facility, which shall include, but is not limited to, the | 12 | | number and percentage of physician providers under contract in | 13 | | each of the specialties of emergency medicine, anesthesiology, | 14 | | radiology, and pathology practicing in the in-network hospital | 15 | | or facility when such providers are not employees of the | 16 | | hospital or facility. The insurer's monitoring report must be | 17 | | included in an effort to ensure that plan beneficiaries have | 18 | | reasonable and timely in-network access to physician | 19 | | specialist providers at in-network hospitals and facilities. | 20 | | (b) Insurers must file for review a description of the | 21 | | services to be offered through a network plan. The description | 22 | | shall include all of the following: | 23 | | (1) A geographic map of the area proposed to be served | 24 | | by the plan by county service area and zip code, including | 25 | | marked locations for preferred providers. | 26 | | (2) As deemed necessary by the Department, the names, |
| | | SB2641 Engrossed | - 3 - | LRB103 35049 JAG 64994 b |
|
| 1 | | addresses, phone numbers, and specialties of the providers | 2 | | who have entered into preferred provider agreements under | 3 | | the network plan. | 4 | | (3) The number of beneficiaries anticipated to be | 5 | | covered by the network plan. | 6 | | (4) An Internet website and toll-free telephone number | 7 | | for beneficiaries and prospective beneficiaries to access | 8 | | current and accurate lists of preferred providers, | 9 | | additional information about the plan, as well as any | 10 | | other information required by Department rule. | 11 | | (5) A description of how health care services to be | 12 | | rendered under the network plan are reasonably accessible | 13 | | and available to beneficiaries. The description shall | 14 | | address all of the following: | 15 | | (A) the type of health care services to be | 16 | | provided by the network plan; | 17 | | (B) the ratio of physicians and other providers to | 18 | | beneficiaries, by specialty and including primary care | 19 | | physicians and facility-based physicians when | 20 | | applicable under the contract, necessary to meet the | 21 | | health care needs and service demands of the currently | 22 | | enrolled population; | 23 | | (C) the travel and distance standards for plan | 24 | | beneficiaries in county service areas; and | 25 | | (D) a description of how the use of telemedicine, | 26 | | telehealth, or mobile care services may be used to |
| | | SB2641 Engrossed | - 4 - | LRB103 35049 JAG 64994 b |
|
| 1 | | partially meet the network adequacy standards, if | 2 | | applicable. | 3 | | (6) A provision ensuring that whenever a beneficiary | 4 | | has made a good faith effort, as evidenced by accessing | 5 | | the provider directory, calling the network plan, and | 6 | | calling the provider, to utilize preferred providers for a | 7 | | covered service and it is determined the insurer does not | 8 | | have the appropriate preferred providers due to | 9 | | insufficient number, type, unreasonable travel distance or | 10 | | delay, or preferred providers refusing to provide a | 11 | | covered service because it is contrary to the conscience | 12 | | of the preferred providers, as protected by the Health | 13 | | Care Right of Conscience Act, the insurer shall ensure, | 14 | | directly or indirectly, by terms contained in the payer | 15 | | contract, that the beneficiary will be provided the | 16 | | covered service at no greater cost to the beneficiary than | 17 | | if the service had been provided by a preferred provider. | 18 | | This paragraph (6) does not apply to: (A) a beneficiary | 19 | | who willfully chooses to access a non-preferred provider | 20 | | for health care services available through the panel of | 21 | | preferred providers, or (B) a beneficiary enrolled in a | 22 | | health maintenance organization. In these circumstances, | 23 | | the contractual requirements for non-preferred provider | 24 | | reimbursements shall apply unless Section 356z.3a of the | 25 | | Illinois Insurance Code requires otherwise. In no event | 26 | | shall a beneficiary who receives care at a participating |
| | | SB2641 Engrossed | - 5 - | LRB103 35049 JAG 64994 b |
|
| 1 | | health care facility be required to search for | 2 | | participating providers under the circumstances described | 3 | | in subsection (b) or (b-5) of Section 356z.3a of the | 4 | | Illinois Insurance Code except under the circumstances | 5 | | described in paragraph (2) of subsection (b-5). | 6 | | (7) A provision that the beneficiary shall receive | 7 | | emergency care coverage such that payment for this | 8 | | coverage is not dependent upon whether the emergency | 9 | | services are performed by a preferred or non-preferred | 10 | | provider and the coverage shall be at the same benefit | 11 | | level as if the service or treatment had been rendered by a | 12 | | preferred provider. For purposes of this paragraph (7), | 13 | | "the same benefit level" means that the beneficiary is | 14 | | provided the covered service at no greater cost to the | 15 | | beneficiary than if the service had been provided by a | 16 | | preferred provider. This provision shall be consistent | 17 | | with Section 356z.3a of the Illinois Insurance Code. | 18 | | (8) A limitation that, if the plan provides that the | 19 | | beneficiary will incur a penalty for failing to | 20 | | pre-certify inpatient hospital treatment, the penalty may | 21 | | not exceed $1,000 per occurrence in addition to the plan | 22 | | cost sharing provisions. | 23 | | (c) The network plan shall demonstrate to the Director a | 24 | | minimum ratio of providers to plan beneficiaries as required | 25 | | by the Department. | 26 | | (1) The ratio of physicians or other providers to plan |
| | | SB2641 Engrossed | - 6 - | LRB103 35049 JAG 64994 b |
|
| 1 | | beneficiaries shall be established annually by the | 2 | | Department in consultation with the Department of Public | 3 | | Health based upon the guidance from the federal Centers | 4 | | for Medicare and Medicaid Services. The Department shall | 5 | | not establish ratios for vision or dental providers who | 6 | | provide services under dental-specific or vision-specific | 7 | | benefits. The Department shall consider establishing | 8 | | ratios for the following physicians or other providers: | 9 | | (A) Primary Care; | 10 | | (B) Pediatrics; | 11 | | (C) Cardiology; | 12 | | (D) Gastroenterology; | 13 | | (E) General Surgery; | 14 | | (F) Neurology; | 15 | | (G) OB/GYN; | 16 | | (H) Oncology/Radiation; | 17 | | (I) Ophthalmology; | 18 | | (J) Urology; | 19 | | (K) Behavioral Health; | 20 | | (L) Allergy/Immunology; | 21 | | (M) Chiropractic; | 22 | | (N) Dermatology; | 23 | | (O) Endocrinology; | 24 | | (P) Ears, Nose, and Throat (ENT)/Otolaryngology; | 25 | | (Q) Infectious Disease; | 26 | | (R) Nephrology; |
| | | SB2641 Engrossed | - 7 - | LRB103 35049 JAG 64994 b |
|
| 1 | | (S) Neurosurgery; | 2 | | (T) Orthopedic Surgery; | 3 | | (U) Physiatry/Rehabilitative; | 4 | | (V) Plastic Surgery; | 5 | | (W) Pulmonary; | 6 | | (X) Rheumatology; | 7 | | (Y) Anesthesiology; | 8 | | (Z) Pain Medicine; | 9 | | (AA) Pediatric Specialty Services; | 10 | | (BB) Outpatient Dialysis; and | 11 | | (CC) HIV. | 12 | | (2) The Director shall establish a process for the | 13 | | review of the adequacy of these standards, along with an | 14 | | assessment of additional specialties to be included in the | 15 | | list under this subsection (c). | 16 | | (d) The network plan shall demonstrate to the Director | 17 | | maximum travel and distance standards for plan beneficiaries, | 18 | | which shall be established annually by the Department in | 19 | | consultation with the Department of Public Health based upon | 20 | | the guidance from the federal Centers for Medicare and | 21 | | Medicaid Services. These standards shall consist of the | 22 | | maximum minutes or miles to be traveled by a plan beneficiary | 23 | | for each county type, such as large counties, metro counties, | 24 | | or rural counties as defined by Department rule. | 25 | | The maximum travel time and distance standards must | 26 | | include standards for each physician and other provider |
| | | SB2641 Engrossed | - 8 - | LRB103 35049 JAG 64994 b |
|
| 1 | | category listed for which ratios have been established. | 2 | | The Director shall establish a process for the review of | 3 | | the adequacy of these standards along with an assessment of | 4 | | additional specialties to be included in the list under this | 5 | | subsection (d). | 6 | | (d-5)(1) Every insurer shall ensure that beneficiaries | 7 | | have timely and proximate access to treatment for mental, | 8 | | emotional, nervous, or substance use disorders or conditions | 9 | | in accordance with the provisions of paragraph (4) of | 10 | | subsection (a) of Section 370c of the Illinois Insurance Code. | 11 | | Insurers shall use a comparable process, strategy, evidentiary | 12 | | standard, and other factors in the development and application | 13 | | of the network adequacy standards for timely and proximate | 14 | | access to treatment for mental, emotional, nervous, or | 15 | | substance use disorders or conditions and those for the access | 16 | | to treatment for medical and surgical conditions. As such, the | 17 | | network adequacy standards for timely and proximate access | 18 | | shall equally be applied to treatment facilities and providers | 19 | | for mental, emotional, nervous, or substance use disorders or | 20 | | conditions and specialists providing medical or surgical | 21 | | benefits pursuant to the parity requirements of Section 370c.1 | 22 | | of the Illinois Insurance Code and the federal Paul Wellstone | 23 | | and Pete Domenici Mental Health Parity and Addiction Equity | 24 | | Act of 2008. Notwithstanding the foregoing, the network | 25 | | adequacy standards for timely and proximate access to | 26 | | treatment for mental, emotional, nervous, or substance use |
| | | SB2641 Engrossed | - 9 - | LRB103 35049 JAG 64994 b |
|
| 1 | | disorders or conditions shall, at a minimum, satisfy the | 2 | | following requirements: | 3 | | (A) For beneficiaries residing in the metropolitan | 4 | | counties of Cook, DuPage, Kane, Lake, McHenry, and Will, | 5 | | network adequacy standards for timely and proximate access | 6 | | to treatment for mental, emotional, nervous, or substance | 7 | | use disorders or conditions means a beneficiary shall not | 8 | | have to travel longer than 30 minutes or 30 miles from the | 9 | | beneficiary's residence to receive outpatient treatment | 10 | | for mental, emotional, nervous, or substance use disorders | 11 | | or conditions. Beneficiaries shall not be required to wait | 12 | | longer than 10 business days between requesting an initial | 13 | | appointment and being seen by the facility or provider of | 14 | | mental, emotional, nervous, or substance use disorders or | 15 | | conditions for outpatient treatment or to wait longer than | 16 | | 20 business days between requesting a repeat or follow-up | 17 | | appointment and being seen by the facility or provider of | 18 | | mental, emotional, nervous, or substance use disorders or | 19 | | conditions for outpatient treatment; however, subject to | 20 | | the protections of paragraph (3) of this subsection, a | 21 | | network plan shall not be held responsible if the | 22 | | beneficiary or provider voluntarily chooses to schedule an | 23 | | appointment outside of these required time frames. | 24 | | (B) For beneficiaries residing in Illinois counties | 25 | | other than those counties listed in subparagraph (A) of | 26 | | this paragraph, network adequacy standards for timely and |
| | | SB2641 Engrossed | - 10 - | LRB103 35049 JAG 64994 b |
|
| 1 | | proximate access to treatment for mental, emotional, | 2 | | nervous, or substance use disorders or conditions means a | 3 | | beneficiary shall not have to travel longer than 60 | 4 | | minutes or 60 miles from the beneficiary's residence to | 5 | | receive outpatient treatment for mental, emotional, | 6 | | nervous, or substance use disorders or conditions. | 7 | | Beneficiaries shall not be required to wait longer than 10 | 8 | | business days between requesting an initial appointment | 9 | | and being seen by the facility or provider of mental, | 10 | | emotional, nervous, or substance use disorders or | 11 | | conditions for outpatient treatment or to wait longer than | 12 | | 20 business days between requesting a repeat or follow-up | 13 | | appointment and being seen by the facility or provider of | 14 | | mental, emotional, nervous, or substance use disorders or | 15 | | conditions for outpatient treatment; however, subject to | 16 | | the protections of paragraph (3) of this subsection, a | 17 | | network plan shall not be held responsible if the | 18 | | beneficiary or provider voluntarily chooses to schedule an | 19 | | appointment outside of these required time frames. | 20 | | (1.5) Every insurer shall demonstrate to the Director that | 21 | | each in-network hospital and facility has a sufficient number | 22 | | of hospital-based medical specialists to ensure that covered | 23 | | persons have reasonable and timely access to such in-network | 24 | | physicians and the services they direct or supervise. As used | 25 | | in this subsection, "hospital-based medical specialists" means | 26 | | physicians working in specialties that are usually located at |
| | | SB2641 Engrossed | - 11 - | LRB103 35049 JAG 64994 b |
|
| 1 | | in-network hospitals and facilities, including, but not | 2 | | limited to, radiologists, pathologists, anesthesiologists, and | 3 | | emergency room physicians. | 4 | | (2) For beneficiaries residing in all Illinois counties, | 5 | | network adequacy standards for timely and proximate access to | 6 | | treatment for mental, emotional, nervous, or substance use | 7 | | disorders or conditions means a beneficiary shall not have to | 8 | | travel longer than 60 minutes or 60 miles from the | 9 | | beneficiary's residence to receive inpatient or residential | 10 | | treatment for mental, emotional, nervous, or substance use | 11 | | disorders or conditions. | 12 | | (3) If there is no in-network facility or provider | 13 | | available for a beneficiary to receive timely and proximate | 14 | | access to treatment for mental, emotional, nervous, or | 15 | | substance use disorders or conditions in accordance with the | 16 | | network adequacy standards outlined in this subsection, the | 17 | | insurer shall provide necessary exceptions to its network to | 18 | | ensure admission and treatment with a provider or at a | 19 | | treatment facility in accordance with the network adequacy | 20 | | standards in this subsection. | 21 | | (e) Except for network plans solely offered as a group | 22 | | health plan, these ratio and time and distance standards apply | 23 | | to the lowest cost-sharing tier of any tiered network. | 24 | | (f) The network plan may consider use of other health care | 25 | | service delivery options, such as telemedicine or telehealth, | 26 | | mobile clinics, and centers of excellence, or other ways of |
| | | SB2641 Engrossed | - 12 - | LRB103 35049 JAG 64994 b |
|
| 1 | | delivering care to partially meet the requirements set under | 2 | | this Section. | 3 | | (g) Except for the requirements set forth in subsection | 4 | | (d-5), insurers who are not able to comply with the provider | 5 | | ratios and time and distance standards established by the | 6 | | Department may request an exception to these requirements from | 7 | | the Department. The Department may grant an exception in the | 8 | | following circumstances: | 9 | | (1) if no providers or facilities meet the specific | 10 | | time and distance standard in a specific service area and | 11 | | the insurer (i) discloses information on the distance and | 12 | | travel time points that beneficiaries would have to travel | 13 | | beyond the required criterion to reach the next closest | 14 | | contracted provider outside of the service area and (ii) | 15 | | provides contact information, including names, addresses, | 16 | | and phone numbers for the next closest contracted provider | 17 | | or facility; | 18 | | (2) if patterns of care in the service area do not | 19 | | support the need for the requested number of provider or | 20 | | facility type and the insurer provides data on local | 21 | | patterns of care, such as claims data, referral patterns, | 22 | | or local provider interviews, indicating where the | 23 | | beneficiaries currently seek this type of care or where | 24 | | the physicians currently refer beneficiaries, or both; or | 25 | | (3) other circumstances deemed appropriate by the | 26 | | Department consistent with the requirements of this Act. |
| | | SB2641 Engrossed | - 13 - | LRB103 35049 JAG 64994 b |
|
| 1 | | (h) Insurers are required to report to the Director any | 2 | | material change to an approved network plan within 15 days | 3 | | after the change occurs and any change that would result in | 4 | | failure to meet the requirements of this Act. Upon notice from | 5 | | the insurer, the Director shall reevaluate the network plan's | 6 | | compliance with the network adequacy and transparency | 7 | | standards of this Act. | 8 | | (Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; | 9 | | 102-1117, eff. 1-13-23.) |
|