Bill Amendment: IL HB5313 | 2023-2024 | 103rd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: INS-NETWORK ADEQUACY-DIRECTORY
Status: 2024-05-17 - Rule 3-9(a) / Re-referred to Assignments [HB5313 Detail]
Download: Illinois-2023-HB5313-House_Amendment_002.html
Bill Title: INS-NETWORK ADEQUACY-DIRECTORY
Status: 2024-05-17 - Rule 3-9(a) / Re-referred to Assignments [HB5313 Detail]
Download: Illinois-2023-HB5313-House_Amendment_002.html
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1 | AMENDMENT TO HOUSE BILL 5313 | ||||||
2 | AMENDMENT NO. ______. Amend House Bill 5313 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Network Adequacy and Transparency Act is | ||||||
5 | amended by changing Section 25 and by adding Section 35 as | ||||||
6 | follows:
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7 | (215 ILCS 124/25) | ||||||
8 | Sec. 25. Network transparency. | ||||||
9 | (a) A network plan shall post electronically an | ||||||
10 | up-to-date, accurate, and complete provider directory for each | ||||||
11 | of its network plans, with the information and search | ||||||
12 | functions, 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 |
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1 | creating or accessing an account or entering a policy or | ||||||
2 | contract number. | ||||||
3 | (2) The network plan shall update the online provider | ||||||
4 | directory at least monthly. Providers shall notify the | ||||||
5 | network plan electronically or in writing of any changes | ||||||
6 | to their information as listed in the provider directory, | ||||||
7 | including the information required in subparagraph (K) of | ||||||
8 | paragraph (1) of subsection (b). The network plan shall | ||||||
9 | update its online provider directory in a manner | ||||||
10 | consistent with the information provided by the provider | ||||||
11 | within 2 10 business days after being notified of the | ||||||
12 | change by the provider. Nothing in this paragraph (2) | ||||||
13 | shall void any contractual relationship between the | ||||||
14 | provider and the plan. | ||||||
15 | (3) The network plan shall , at least every 90 days, | ||||||
16 | audit each periodically at least 25% of its provider | ||||||
17 | directories for accuracy, make any corrections necessary, | ||||||
18 | and retain documentation of the audit. If inaccurate | ||||||
19 | information for a provider is found in any provider | ||||||
20 | directory, the health carrier, as defined in Section 10 of | ||||||
21 | the Health Carrier External Review Act shall check all its | ||||||
22 | network plan directories to identify and correct all | ||||||
23 | inaccuracies associated with that provider. The network | ||||||
24 | plan shall submit the audit to the Department, and the | ||||||
25 | Department shall make a summary of each audit publicly | ||||||
26 | available Director upon request . The Department shall |
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1 | specify the requirements of the summary. As part of these | ||||||
2 | audits, the network plan shall contact any provider in its | ||||||
3 | network that has not submitted a claim to the plan or | ||||||
4 | otherwise communicated his or her intent to continue | ||||||
5 | participation in the plan's network. The audit shall | ||||||
6 | comply with 42 U.S.C. 300gg-115(a)(2), except that | ||||||
7 | "provider directory information" shall include all | ||||||
8 | information required under this Act. | ||||||
9 | (4) A network plan shall provide a printed print copy | ||||||
10 | of a current provider directory or a printed print copy of | ||||||
11 | the requested directory information upon request of a | ||||||
12 | beneficiary or a prospective beneficiary. Printed Print | ||||||
13 | copies must be updated at least every 90 days quarterly , | ||||||
14 | and an errata that reflect reflects changes in the | ||||||
15 | provider network must be updated quarterly. | ||||||
16 | (5) For each network plan, a network plan shall | ||||||
17 | include, in plain language in both the electronic and | ||||||
18 | print directory, the following general information: | ||||||
19 | (A) in plain language, a description of the | ||||||
20 | criteria the plan has used to build its provider | ||||||
21 | network; | ||||||
22 | (B) if applicable, in plain language, a | ||||||
23 | description of the criteria the insurer or network | ||||||
24 | plan has used to create tiered networks; | ||||||
25 | (C) if applicable, in plain language, how the | ||||||
26 | network plan designates the different provider tiers |
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1 | or levels in the network and identifies for each | ||||||
2 | specific provider, hospital, or other type of facility | ||||||
3 | in the network which tier each is placed, for example, | ||||||
4 | by name, symbols, or grouping, in order for a | ||||||
5 | beneficiary-covered person or a prospective | ||||||
6 | beneficiary-covered person to be able to identify the | ||||||
7 | provider tier; and | ||||||
8 | (D) if applicable, a notation that authorization | ||||||
9 | or referral may be required to access some providers ; | ||||||
10 | and . | ||||||
11 | (E) a detailed description of the process to | ||||||
12 | dispute charges for out-of-network providers or | ||||||
13 | facilities that were incorrectly listed as in-network | ||||||
14 | prior to the provision of care and a telephone number | ||||||
15 | and email address to dispute such charges. | ||||||
16 | (6) A network plan shall make it clear for both its | ||||||
17 | electronic and print directories what provider directory | ||||||
18 | applies to which network plan, such as including the | ||||||
19 | specific name of the network plan as marketed and issued | ||||||
20 | in this State. The network plan shall include in both its | ||||||
21 | electronic and print directories a customer service email | ||||||
22 | address and telephone number or electronic link that | ||||||
23 | beneficiaries or the general public may use to notify the | ||||||
24 | network plan of inaccurate provider directory information | ||||||
25 | and contact information for the Department's Office of | ||||||
26 | Consumer Health Insurance. |
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1 | (7) A provider directory, whether in electronic or | ||||||
2 | print format, shall accommodate the communication needs of | ||||||
3 | individuals with disabilities, and include a link to or | ||||||
4 | information regarding available assistance for persons | ||||||
5 | with limited English proficiency. | ||||||
6 | (b) For each network plan, a network plan shall make | ||||||
7 | available through an electronic provider directory the | ||||||
8 | following information in a searchable format: | ||||||
9 | (1) for health care professionals: | ||||||
10 | (A) name; | ||||||
11 | (B) gender; | ||||||
12 | (C) participating office locations; | ||||||
13 | (D) patient population served (such as pediatric, | ||||||
14 | adult, elderly, or women) and specialty or | ||||||
15 | subspecialty , if applicable; | ||||||
16 | (E) medical group affiliations, if applicable; | ||||||
17 | (F) facility affiliations, if applicable; | ||||||
18 | (G) participating facility affiliations, if | ||||||
19 | applicable; | ||||||
20 | (H) languages spoken other than English, if | ||||||
21 | applicable; | ||||||
22 | (I) whether accepting new patients; | ||||||
23 | (J) board certifications, if applicable; and | ||||||
24 | (K) use of telehealth or telemedicine, including, | ||||||
25 | but not limited to: | ||||||
26 | (i) whether the provider offers the use of |
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1 | telehealth or telemedicine to deliver services to | ||||||
2 | patients for whom it would be clinically | ||||||
3 | appropriate; | ||||||
4 | (ii) what modalities are used and what types | ||||||
5 | of services may be provided via telehealth or | ||||||
6 | telemedicine; and | ||||||
7 | (iii) whether the provider has the ability and | ||||||
8 | willingness to include in a telehealth or | ||||||
9 | telemedicine encounter a family caregiver who is | ||||||
10 | in a separate location than the patient if the | ||||||
11 | patient wishes and provides his or her consent; | ||||||
12 | and | ||||||
13 | (L) the anticipated date the provider will leave | ||||||
14 | the network, if applicable, which shall be included | ||||||
15 | not more than 10 days after the network confirms that | ||||||
16 | the provider is scheduled to leave the network in | ||||||
17 | accordance with Section 15 of this Act; and | ||||||
18 | (2) for hospitals: | ||||||
19 | (A) hospital name; | ||||||
20 | (B) hospital type (such as acute, rehabilitation, | ||||||
21 | children's, or cancer); | ||||||
22 | (C) participating hospital location; and | ||||||
23 | (D) hospital accreditation status; and | ||||||
24 | (3) for facilities, other than hospitals, by type: | ||||||
25 | (A) facility name; | ||||||
26 | (B) facility type; |
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1 | (C) types of services performed; and | ||||||
2 | (D) participating facility location or locations ; | ||||||
3 | and . | ||||||
4 | (E) the anticipated date the facility will leave | ||||||
5 | the network, if applicable, which shall be included | ||||||
6 | not more than 10 days after the network confirms the | ||||||
7 | facility is scheduled to leave the network. | ||||||
8 | (c) For the electronic provider directories, for each | ||||||
9 | network plan, a network plan shall make available all of the | ||||||
10 | following information in addition to the searchable | ||||||
11 | information required in this Section: | ||||||
12 | (1) for health care professionals: | ||||||
13 | (A) contact information , including a telephone | ||||||
14 | number and any other digital contact information the | ||||||
15 | provider has supplied ; and | ||||||
16 | (B) languages spoken other than English by | ||||||
17 | clinical staff, if applicable; | ||||||
18 | (2) for hospitals, telephone number; and | ||||||
19 | (3) for facilities other than hospitals, telephone | ||||||
20 | number. | ||||||
21 | (d) The insurer or network plan shall make available in | ||||||
22 | print, upon request, the following provider directory | ||||||
23 | information for the applicable network plan: | ||||||
24 | (1) for health care professionals: | ||||||
25 | (A) name; | ||||||
26 | (B) contact information , including a telephone |
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1 | number and any other digital contact information the | ||||||
2 | provider has supplied ; | ||||||
3 | (C) participating office location or locations; | ||||||
4 | (D) patient population (such as pediatric, adult, | ||||||
5 | elderly, or women) and specialty or subspecialty , if | ||||||
6 | applicable; | ||||||
7 | (E) languages spoken other than English, if | ||||||
8 | applicable; | ||||||
9 | (F) whether accepting new patients; and | ||||||
10 | (G) use of telehealth or telemedicine, including, | ||||||
11 | but not limited to: | ||||||
12 | (i) whether the provider offers the use of | ||||||
13 | telehealth or telemedicine to deliver services to | ||||||
14 | patients for whom it would be clinically | ||||||
15 | appropriate; | ||||||
16 | (ii) what modalities are used and what types | ||||||
17 | of services may be provided via telehealth or | ||||||
18 | telemedicine; and | ||||||
19 | (iii) whether the provider has the ability and | ||||||
20 | willingness to include in a telehealth or | ||||||
21 | telemedicine encounter a family caregiver who is | ||||||
22 | in a separate location than the patient if the | ||||||
23 | patient wishes and provides his or her consent; | ||||||
24 | (2) for hospitals: | ||||||
25 | (A) hospital name; | ||||||
26 | (B) hospital type (such as acute, rehabilitation, |
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1 | children's, or cancer); and | ||||||
2 | (C) participating hospital location , and telephone | ||||||
3 | number , and digital contact information ; and | ||||||
4 | (3) for facilities, other than hospitals, by type: | ||||||
5 | (A) facility name; | ||||||
6 | (B) facility type; | ||||||
7 | (C) patient population (such as pediatric, adult, | ||||||
8 | elderly, or women) served, if applicable, and types of | ||||||
9 | services performed; and | ||||||
10 | (D) participating facility location or locations , | ||||||
11 | and telephone numbers , and digital contact | ||||||
12 | information . | ||||||
13 | (e) The network plan shall include a disclosure in the | ||||||
14 | print format provider directory that the information included | ||||||
15 | in the directory is accurate as of the date of printing and | ||||||
16 | that beneficiaries or prospective beneficiaries should consult | ||||||
17 | the insurer's electronic provider directory on its website and | ||||||
18 | contact the provider. The network plan shall also include a | ||||||
19 | telephone number and email address in the print format | ||||||
20 | provider directory for a customer service representative where | ||||||
21 | the beneficiary can obtain current provider directory | ||||||
22 | information or report directory inaccuracies . The network plan | ||||||
23 | shall include in the print format provider directory a | ||||||
24 | detailed description of the process to dispute charges for | ||||||
25 | out-of-network providers or facilities that were incorrectly | ||||||
26 | listed as in-network prior to the provision of care and a |
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1 | telephone number and email address to dispute those charges. | ||||||
2 | (f) The Director may conduct periodic audits of the | ||||||
3 | accuracy of provider directories and shall conduct audits of | ||||||
4 | at least 10% of plans each year, with at least one plan from | ||||||
5 | each health carrier under the Department's jurisdiction. The | ||||||
6 | Director shall require a network plan to correct any | ||||||
7 | inaccuracies found within 2 business days after the network | ||||||
8 | plan is notified of an inaccuracy. If an audit of any health | ||||||
9 | carrier's plan finds that more than 1% of providers listed in | ||||||
10 | the audited directory are not participating providers, the | ||||||
11 | Director shall require the health carrier to have an audit | ||||||
12 | conducted of each of the health carrier's network plans by an | ||||||
13 | unaffiliated independent firm qualified to conduct such audits | ||||||
14 | at the health carrier's expense and shall provide all audits | ||||||
15 | to the Director. The Director shall specify requirements, | ||||||
16 | including qualifications of the auditor, relating to those | ||||||
17 | audits and audit summaries. The Department shall make | ||||||
18 | summaries of audits publicly available on its website . A | ||||||
19 | network plan shall not be subject to any fines or penalties for | ||||||
20 | information required in this Section that a provider submits | ||||||
21 | that is inaccurate or incomplete. | ||||||
22 | (g) If a nonparticipating provider listed in a network | ||||||
23 | plan directory is identified by the network plan or Director, | ||||||
24 | the health carrier shall do all of the following: | ||||||
25 | (1) Check each of the health carrier's network plan | ||||||
26 | directories for the provider within 2 business days to |
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1 | ascertain whether the provider is participating in that | ||||||
2 | network plan and, if the provider is incorrectly listed as | ||||||
3 | participating, remove the provider without delay. | ||||||
4 | (2) Identify the dates across each of the health | ||||||
5 | carrier's network plan directories that the provider was | ||||||
6 | listed when the provider was not a participating provider. | ||||||
7 | (3) For network plans with an out-of-network benefit, | ||||||
8 | identify all claims for services provided by the provider | ||||||
9 | on an out-of-network basis during the period which the | ||||||
10 | provider was incorrectly listed as a participating | ||||||
11 | provider in the network directory and reimburse each | ||||||
12 | affected beneficiary the amount necessary to ensure the | ||||||
13 | beneficiary is held harmless for all amounts exceeding the | ||||||
14 | amount the beneficiary would have paid had the services | ||||||
15 | been provided in-network. All out-of-pocket costs incurred | ||||||
16 | by the beneficiary shall apply toward the in-network | ||||||
17 | deductible and out-of-pocket maximum. | ||||||
18 | (4) For each beneficiary who had an in-network claim | ||||||
19 | for services from the provider during the year prior to | ||||||
20 | the date that the provider ceased to be a participating in | ||||||
21 | the network plan, send mail and electronic communications | ||||||
22 | to the beneficiary informing the beneficiary of the | ||||||
23 | inaccurate listing, including the dates thereof, and the | ||||||
24 | beneficiary's rights as described in subparagraph (F) of | ||||||
25 | paragraph (5) of subsection (a) if the beneficiary | ||||||
26 | received services from the provider on dates when the |
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1 | provider was inaccurately listed in the directory as | ||||||
2 | in-network. The Director may specify required language and | ||||||
3 | additional content of such communications. | ||||||
4 | (h) Each network plan shall maintain records, for a | ||||||
5 | minimum of 5 years, of all providers listed in its network | ||||||
6 | directory, including the dates each provider was listed in the | ||||||
7 | network, the information listed, and the date and content of | ||||||
8 | any changes to directory information. | ||||||
9 | (i) If a network plan fails to provide notice to | ||||||
10 | beneficiaries of a nonrenewal or termination of a provider | ||||||
11 | pursuant to Section 15 of this Act and that nonrenewal or | ||||||
12 | termination takes effect, services delivered by the provider | ||||||
13 | shall be reimbursed as if the provider was in-network until | ||||||
14 | the requirements, including any relevant notice period, of | ||||||
15 | Section 15 have been met. In such cases, the network plan shall | ||||||
16 | hold the beneficiary harmless for all amounts exceeding the | ||||||
17 | amount the beneficiary would have paid had the services been | ||||||
18 | provided in-network. The amounts paid by the beneficiary shall | ||||||
19 | apply toward the in-network deductible and out-of-pocket | ||||||
20 | maximum. | ||||||
21 | (j) If the Director determines that a network plan or any | ||||||
22 | entity or person acting on the network plan's behalf has | ||||||
23 | violated this Section, the Director may, after appropriate | ||||||
24 | notice and opportunity for hearing, by order, assess a civil | ||||||
25 | penalty up to $5,000 per violation, as adjusted under | ||||||
26 | subsection (k), except for inaccurate contact information |
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1 | given by the provider. If a network plan or any entity or | ||||||
2 | person acting on the network plan's behalf knew or reasonably | ||||||
3 | should have known that the action was in violation of this | ||||||
4 | Section, the Director may, after appropriate notice and | ||||||
5 | opportunity for hearing, by order, assess a civil penalty up | ||||||
6 | to $25,000 per violation, as adjusted under subsection (k). | ||||||
7 | The civil penalties available to the Director under this | ||||||
8 | Section are not exclusive and may be sought and employed in | ||||||
9 | combination with any other remedies available to the Director | ||||||
10 | under this Act. | ||||||
11 | (k) Beginning January 1, 2030, and every 5 years | ||||||
12 | thereafter, the penalty amounts specified in this Section | ||||||
13 | shall be adjusted based on the average rate of change in | ||||||
14 | premium rates for the individual and small group markets, and | ||||||
15 | weighted by enrollment, since the previous adjustment. | ||||||
16 | (Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
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17 | (215 ILCS 124/35 new) | ||||||
18 | Sec. 35. Complaint of incorrect charges. | ||||||
19 | (a) A beneficiary who incurs a cost for inappropriate | ||||||
20 | out-of-network charges for a provider, facility, or hospital | ||||||
21 | that was listed as in-network prior to the provision of | ||||||
22 | services may file a complaint with the Department. The | ||||||
23 | Department shall conduct an investigation of any complaint and | ||||||
24 | shall determine that the complaint is confirmed if the | ||||||
25 | beneficiary was provided with inaccurate information provided |
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1 | by the network plan. | ||||||
2 | (b) Upon a finding that a complaint is confirmed, a | ||||||
3 | network plan shall reimburse the beneficiary the amount | ||||||
4 | necessary to ensure the beneficiary is held harmless for all | ||||||
5 | amounts exceeding the amount the beneficiary would have paid | ||||||
6 | had the services been provided in-network. All out-of-pocket | ||||||
7 | costs incurred by the beneficiary shall apply toward the | ||||||
8 | in-network deductible and out-of-pocket maximum.
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