Bill Text: IL HB5313 | 2023-2024 | 103rd General Assembly | Engrossed

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Bill Title: Amends the Network Adequacy and Transparency Act. Provides that a network plan shall, at least annually, audit (instead of audit periodically) at least 25% of its provider directories for accuracy, make any corrections necessary, and retain documentation of the audit. Provides that the network plan shall submit the audit to the Department of Insurance (instead of to the Director of Insurance upon request). Provides that the Department shall make the audit publicly available. Provides that a network plan shall include in the print format provider directory (i) a detailed description of the process to dispute charges for out-of-network providers or facilities that were incorrectly listed as in-network prior to the provision of care and (ii) a telephone number and email address to dispute those charges. Makes changes to the information that must be provided in a network plan's electronic and print directory. Requires the Director to conduct random audits of the accuracy of provider directories for at least 10% of plans each year. Provides that a consumer who incurs a cost for inappropriate out-of-network charges for a provider, facility, or hospital that was listed as in-network prior to the provision of services may file a verified complaint with the Department, and the Department shall conduct an investigation of the verified complaint and determine whether the complaint is sufficient. Provides that, upon a finding of sufficiency, the Director shall have the authority to levy a fine for not less than the cost incurred by the consumer for inappropriate out-of-network charges for a provider, facility, or hospital that was listed in-network. Provides that the fines collected by the Director shall be remitted to the consumer.

Spectrum: Strong Partisan Bill (Democrat 17-1)

Status: (Engrossed) 2024-04-24 - Assigned to Insurance [HB5313 Detail]

Download: Illinois-2023-HB5313-Engrossed.html

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HB5313 Engrossed LRB103 38443 RPS 68579 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Network Adequacy and Transparency Act is
amended by changing Section 25 and by adding Section 35 as
follows:
(215 ILCS 124/25)
Sec. 25. Network transparency.
(a) A network plan shall post electronically an
up-to-date, accurate, and complete provider directory for each
of its network plans, with the information and search
functions, as described in this Section.
(1) In making the directory available electronically,
the network plans shall ensure that the general public is
able to view all of the current providers for a plan
through a clearly identifiable link or tab and without
creating or accessing an account or entering a policy or
contract number.
(2) The network plan shall update the online provider
directory at least monthly. Providers shall notify the
network plan electronically or in writing of any changes
to their information as listed in the provider directory,
including the information required in subparagraph (K) of

HB5313 Engrossed - 2 - LRB103 38443 RPS 68579 b
paragraph (1) of subsection (b). The network plan shall
update its online provider directory in a manner
consistent with the information provided by the provider
within 10 business days after being notified of the change
by the provider. Nothing in this paragraph (2) shall void
any contractual relationship between the provider and the
plan.
(3) The network plan shall, at least annually, audit
periodically at least 25% of its provider directories for
accuracy, make any corrections necessary, and retain
documentation of the audit. The network plan shall submit
the audit to the Department, and the Department shall make
the audit publicly available Director upon request. As
part of these audits, the network plan shall contact any
provider in its network that has not submitted a claim to
the plan or otherwise communicated his or her intent to
continue participation in the plan's network.
(4) A network plan shall provide a printed print copy
of a current provider directory or a printed print copy of
the requested directory information upon request of a
beneficiary or a prospective beneficiary. Printed Print
copies must be updated quarterly and an errata that
reflects changes in the provider network must be updated
quarterly.
(5) For each network plan, a network plan shall
include, in plain language in both the electronic and

HB5313 Engrossed - 3 - LRB103 38443 RPS 68579 b
print directory, the following general information:
(A) in plain language, a description of the
criteria the plan has used to build its provider
network;
(B) if applicable, in plain language, a
description of the criteria the insurer or network
plan has used to create tiered networks;
(C) if applicable, in plain language, how the
network plan designates the different provider tiers
or levels in the network and identifies for each
specific provider, hospital, or other type of facility
in the network which tier each is placed, for example,
by name, symbols, or grouping, in order for a
beneficiary-covered person or a prospective
beneficiary-covered person to be able to identify the
provider tier; and
(D) if applicable, a notation that authorization
or referral may be required to access some providers; .
(E) a telephone number and email address for a
customer service representative to whom directory
inaccuracies may be reported; and
(F) a
detailed description of the process to
dispute charges for out-of-network providers or
facilities that were incorrectly listed as in-network
prior to the provision of care and a telephone number
and email address to dispute such charges.

HB5313 Engrossed - 4 - LRB103 38443 RPS 68579 b
(6) A network plan shall make it clear for both its
electronic and print directories what provider directory
applies to which network plan, such as including the
specific name of the network plan as marketed and issued
in this State. The network plan shall include in both its
electronic and print directories a customer service email
address and telephone number or electronic link that
beneficiaries or the general public may use to notify the
network plan of inaccurate provider directory information
and contact information for the Department's Office of
Consumer Health Insurance.
(7) A provider directory, whether in electronic or
print format, shall accommodate the communication needs of
individuals with disabilities, and include a link to or
information regarding available assistance for persons
with limited English proficiency.
(b) For each network plan, a network plan shall make
available through an electronic provider directory the
following information in a searchable format:
(1) for health care professionals:
(A) name;
(B) gender;
(C) participating office locations;
(D) patient population served (such as pediatric,
adult, elderly, or women) and specialty or
subspecialty, if applicable;

HB5313 Engrossed - 5 - LRB103 38443 RPS 68579 b
(E) medical group affiliations, if applicable;
(F) facility affiliations, if applicable;
(G) participating facility affiliations, if
applicable;
(H) languages spoken other than English, if
applicable;
(I) whether accepting new patients;
(J) board certifications, if applicable; and
(K) use of telehealth or telemedicine, including,
but not limited to:
(i) whether the provider offers the use of
telehealth or telemedicine to deliver services to
patients for whom it would be clinically
appropriate;
(ii) what modalities are used and what types
of services may be provided via telehealth or
telemedicine; and
(iii) whether the provider has the ability and
willingness to include in a telehealth or
telemedicine encounter a family caregiver who is
in a separate location than the patient if the
patient wishes and provides his or her consent;
and
(L) the anticipated date the provider will leave
the network, if applicable, which shall be included
not more than 10 days after the network provides

HB5313 Engrossed - 6 - LRB103 38443 RPS 68579 b
notice in accordance with Section 15 of this Act; and
(2) for hospitals:
(A) hospital name;
(B) hospital type (such as acute, rehabilitation,
children's, or cancer);
(C) participating hospital location; and
(D) hospital accreditation status; and
(3) for facilities, other than hospitals, by type:
(A) facility name;
(B) facility type;
(C) types of services performed; and
(D) participating facility location or locations;
and .
(E) the anticipated date the facility will leave
the network, if applicable, which shall be included
not more than 10 days after the network confirms the
facility is scheduled to leave the network.
(c) For the electronic provider directories, for each
network plan, a network plan shall make available all of the
following information in addition to the searchable
information required in this Section:
(1) for health care professionals:
(A) contact information; and
(B) languages spoken other than English by
clinical staff, if applicable;
(2) for hospitals, telephone number; and

HB5313 Engrossed - 7 - LRB103 38443 RPS 68579 b
(3) for facilities other than hospitals, telephone
number.
(d) The insurer or network plan shall make available in
print, upon request, the following provider directory
information for the applicable network plan:
(1) for health care professionals:
(A) name;
(B) contact information;
(C) participating office location or locations;
(D) patient population (such as pediatric, adult,
elderly, or women) and specialty or subspecialty, if
applicable;
(E) languages spoken other than English, if
applicable;
(F) whether accepting new patients; and
(G) use of telehealth or telemedicine, including,
but not limited to:
(i) whether the provider offers the use of
telehealth or telemedicine to deliver services to
patients for whom it would be clinically
appropriate;
(ii) what modalities are used and what types
of services may be provided via telehealth or
telemedicine; and
(iii) whether the provider has the ability and
willingness to include in a telehealth or

HB5313 Engrossed - 8 - LRB103 38443 RPS 68579 b
telemedicine encounter a family caregiver who is
in a separate location than the patient if the
patient wishes and provides his or her consent;
(2) for hospitals:
(A) hospital name;
(B) hospital type (such as acute, rehabilitation,
children's, or cancer); and
(C) participating hospital location and telephone
number; and
(3) for facilities, other than hospitals, by type:
(A) facility name;
(B) facility type;
(C) types of services performed; and
(D) participating facility location or locations
and telephone numbers.
(e) The network plan shall include a disclosure in the
print format provider directory that the information included
in the directory is accurate as of the date of printing and
that beneficiaries or prospective beneficiaries should consult
the insurer's electronic provider directory on its website and
contact the provider. The network plan shall also include a
telephone number and email address in the print format
provider directory for a customer service representative where
the beneficiary can obtain current provider directory
information or report directory inaccuracies. The network plan
shall include in the print format provider directory a

HB5313 Engrossed - 9 - LRB103 38443 RPS 68579 b
detailed description of the process to dispute charges for
out-of-network providers or facilities that were incorrectly
listed as in-network prior to the provision of care and a
telephone number and email address to dispute those charges.
(f) The Director may conduct periodic audits of the
accuracy of provider directories and shall conduct random
audits of at least 10% of plans each year. A network plan shall
not be subject to any fines or penalties for information
required in this Section that a provider submits that is
inaccurate or incomplete.
(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)