Bill Text: IL SB3130 | 2023-2024 | 103rd General Assembly | Engrossed

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Bill Title: Reinserts the provisions of the introduced bill with the following changes. Amends the Department of Insurance Law of the Civil Administrative Code of Illinois. Provides that the Marketplace Director of the Illinois Health Benefits Exchange shall serve for a term of 2 years, and until a successor is appointed and qualified; except that the term of the first Marketplace Director appointed shall expire on the third Monday in January 2027. Provides that the Marketplace Director may serve for more than one term. Removes language providing that the Marketplace Director may be an existing employee with other duties. Provides that the Marketplace Director shall (instead of shall not) be subject to the Personnel Code. In the Illinois Insurance Code, provides that a pregnant individual has the right to enroll in a qualified health plan through a special enrollment period within 60 days (instead of at any time) after any qualified health care professional certifies that the individual is pregnant. In the Managed Care Reform and Patient Rights Act, provides that each level of coverage that a health insurance carrier offers of a standardized option in each applicable service area shall be deemed to satisfy (instead of shall satisfy) the requirements for a flat-dollar copay structure. Amends the Health Maintenance Organization Act. Provides that health maintenance organizations shall comply with the Illinois Insurance Code's requirements concerning pregnancy as a qualifying life event. Effective immediately, except that the changes to the Network Adequacy and Transparency Act take effect January 1, 2025.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Engrossed) 2024-04-24 - Assigned to Insurance Committee [SB3130 Detail]

Download: Illinois-2023-SB3130-Engrossed.html

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SB3130 Engrossed LRB103 38249 RPS 68384 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Department of Insurance Law of the Civil
Administrative Code of Illinois is amended by changing Section
1405-50 as follows:
(20 ILCS 1405/1405-50)
Sec. 1405-50. Marketplace Director of the Illinois Health
Benefits Exchange. The Governor shall appoint, with the advice
and consent of the Senate, a person within the Department of
Insurance to serve as the Marketplace Director of the Illinois
Health Benefits Exchange. The Marketplace Director shall serve
for a term of 2 years, and until a successor is appointed and
qualified; except that the term of the first Marketplace
Director appointed under this Law shall expire on the third
Monday in January 2027. The Marketplace Director may serve for
more than one term. The Governor may make a temporary
appointment until the next meeting of the Senate. This person
may be an existing employee with other duties. The Marketplace
Director shall receive an annual salary as set by the Governor
and shall be paid out of the appropriations to the Department.
The Marketplace Director shall not be subject to the Personnel
Code. The Marketplace Director, under the direction of the

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Director, shall manage the operations and staff of the
Illinois Health Benefits Exchange to ensure optimal exchange
performance.
(Source: P.A. 103-103, eff. 6-27-23.)
Section 10. The Illinois Insurance Code is amended by
adding Section 356z.40a as follows:
(215 ILCS 5/356z.40a new)
Sec. 356z.40a. Pregnancy as a qualifying life event for
qualified health plans. Beginning with the operation of a
State-based exchange in plan year 2026, a pregnant individual
has the right to enroll in a qualified health plan through a
special enrollment period within 60 days after any qualified
health care professional, including a licensed certified
professional midwife, licensed or certified under the laws of
this State or any other state to provide pregnancy-related
health care services certifies that the individual is
pregnant. Upon enrollment, coverage shall be effective on and
after the first day of the month in which the qualified health
care professional certifies that the individual is pregnant,
unless the individual elects to have coverage effective on the
first day of the month following the date that the individual
received certification of the pregnancy.
Section 15. The Illinois Health Insurance Portability and

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Accountability Act is amended by changing Sections 30, 50, and
60 as follows:
(215 ILCS 97/30)
Sec. 30. Guaranteed renewability of coverage for employers
in the group market.
(A) In general. Except as provided in this Section, if a
health insurance issuer offers health insurance coverage in
the small or large group market in connection with a group
health plan, the issuer must renew or continue in force such
coverage at the option of the plan sponsor of the plan.
(B) General exceptions. A health insurance issuer may
nonrenew or discontinue health insurance coverage offered in
connection with a group health plan in the small or large group
market based only on one or more of the following:
(1) Nonpayment of premiums. The plan sponsor has
failed to pay premiums or contributions in accordance with
the terms of the health insurance coverage or the issuer
has not received timely premium payments.
(2) Fraud. The plan sponsor has performed an act or
practice that constitutes fraud or made an intentional
misrepresentation of material fact under the terms of the
coverage.
(3) Violation of participation or contribution rules.
The plan sponsor has failed to comply with a material plan
provision relating to employer contribution or group

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participation rules, as permitted under Section 40(D) in
the case of the small group market or pursuant to
applicable State law in the case of the large group
market.
(4) Termination of coverage. The issuer is ceasing to
offer coverage in such market in accordance with
subsection (C) and applicable State law.
(5) Movement outside service area. In the case of a
health insurance issuer that offers health insurance
coverage in the market through a network plan, there is no
longer any enrollee in connection with such plan who
lives, resides, or works in the service area of the issuer
(or in the area for which the issuer is authorized to do
business) and, in the case of the small group market, the
issuer would deny enrollment with respect to such plan
under Section 40(C)(1)(a).
(6) Association membership ceases. In the case of
health insurance coverage that is made available in the
small or large group market (as the case may be) only
through one or more bona fide association, the membership
of an employer in the association (on the basis of which
the coverage is provided) ceases but only if such coverage
is terminated under this paragraph uniformly without
regard to any health status-related factor relating to any
covered individual.
(C) Requirements for uniform termination of coverage.

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(1) Particular type of coverage not offered. In any
case in which an issuer decides to discontinue offering a
particular type of group health insurance coverage offered
in the small or large group market, coverage of such type
may be discontinued by the issuer in accordance with
applicable State law in such market only if:
(a) the issuer provides notice to each plan
sponsor provided coverage of this type in such market
(and participants and beneficiaries covered under such
coverage) of such discontinuation at least 90 days
prior to the date of the discontinuation of such
coverage;
(b) the issuer offers to each plan sponsor
provided coverage of this type in such market, the
option to purchase all (or, in the case of the large
group market, any) other health insurance coverage
currently being offered by the issuer to a group
health plan in such market; and
(c) in exercising the option to discontinue
coverage of this type and in offering the option of
coverage under subparagraph (b), the issuer acts
uniformly without regard to the claims experience of
those sponsors or any health status-related factor
relating to any participants or beneficiaries who may
become eligible for such coverage.
(2) Discontinuance of all coverage.

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(a) In general. In any case in which a health
insurance issuer elects to discontinue offering all
health insurance coverage in the small group market or
the large group market, or both markets, in Illinois,
health insurance coverage may be discontinued by the
issuer only in accordance with Illinois law and if:
(i) the issuer provides notice to the
Department and to each plan sponsor (and
participants and beneficiaries covered under such
coverage) of such discontinuation at least 180
days prior to the date of the discontinuation of
such coverage and to the Department as provided in
Section 60 of this Act; and
(ii) all health insurance issued or delivered
for issuance in Illinois in such market (or
markets) are discontinued and coverage under such
health insurance coverage in such market (or
markets) is not renewed.
(b) Prohibition on market reentry. In the case of
a discontinuation under subparagraph (a) in a market,
the issuer may not provide for the issuance of any
health insurance coverage in the Illinois market
involved during the 5-year period beginning on the
date of the discontinuation of the last health
insurance coverage not so renewed.
(D) Exception for uniform modification of coverage. At the

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time of coverage renewal, a health insurance issuer may modify
the health insurance coverage for a product offered to a group
health plan:
(1) in the large group market; or
(2) in the small group market if, for coverage that is
available in such market other than only through one or
more bona fide associations, such modification is
consistent with State law and effective on a uniform basis
among group health plans with that product.
(E) Application to coverage offered only through
associations. In applying this Section in the case of health
insurance coverage that is made available by a health
insurance issuer in the small or large group market to
employers only through one or more associations, a reference
to "plan sponsor" is deemed, with respect to coverage provided
to an employer member of the association, to include a
reference to such employer.
(Source: P.A. 90-30, eff. 7-1-97.)
(215 ILCS 97/50)
Sec. 50. Guaranteed renewability of individual health
insurance coverage.
(A) In general. Except as provided in this Section, a
health insurance issuer that provides individual health
insurance coverage to an individual shall renew or continue in
force such coverage at the option of the individual.

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(B) General exceptions. A health insurance issuer may
nonrenew or discontinue health insurance coverage of an
individual in the individual market based only on one or more
of the following:
(1) Nonpayment of premiums. The individual has failed
to pay premiums or contributions in accordance with the
terms of the health insurance coverage or the issuer has
not received timely premium payments.
(2) Fraud. The individual has performed an act or
practice that constitutes fraud or made an intentional
misrepresentation of material fact under the terms of the
coverage.
(3) Termination of plan. The issuer is ceasing to
offer coverage in the individual market in accordance with
subsection (C) of this Section and applicable Illinois
law.
(4) Movement outside the service area. In the case of
a health insurance issuer that offers health insurance
coverage in the market through a network plan, the
individual no longer resides, lives, or works in the
service area (or in an area for which the issuer is
authorized to do business), but only if such coverage is
terminated under this paragraph uniformly without regard
to any health status-related factor of covered
individuals.
(5) Association membership ceases. In the case of

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health insurance coverage that is made available in the
individual market only through one or more bona fide
associations, the membership of the individual in the
association (on the basis of which the coverage is
provided) ceases, but only if such coverage is terminated
under this paragraph uniformly without regard to any
health status-related factor of covered individuals.
(C) Requirements for uniform termination of coverage.
(1) Particular type of coverage not offered. In any
case in which an issuer decides to discontinue offering a
particular type of health insurance coverage offered in
the individual market, coverage of such type may be
discontinued by the issuer only if:
(a) the issuer provides notice to each covered
individual provided coverage of this type in such
market of such discontinuation at least 90 days prior
to the date of the discontinuation of such coverage;
(b) the issuer offers, to each individual in the
individual market provided coverage of this type, the
option to purchase any other individual health
insurance coverage currently being offered by the
issuer for individuals in such market; and
(c) in exercising the option to discontinue
coverage of that type and in offering the option of
coverage under subparagraph (b), the issuer acts
uniformly without regard to any health status-related

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factor of enrolled individuals or individuals who may
become eligible for such coverage.
(2) Discontinuance of all coverage.
(a) In general. Subject to subparagraph (c), in
any case in which a health insurance issuer elects to
discontinue offering all health insurance coverage in
the individual market in Illinois, health insurance
coverage may be discontinued by the issuer only if:
(i) the issuer provides notice to the Director
and to each individual of the discontinuation at
least 180 days prior to the date of the expiration
of such coverage and to the Director as provided
in Section 60 of this Act;
(ii) all health insurance issued or delivered
for issuance in Illinois in such market is
discontinued and coverage under such health
insurance coverage in such market is not renewed;
and
(iii) in the case where the issuer has
affiliates in the individual market, the issuer
gives notice to each affected individual at least
180 days prior to the date of the expiration of the
coverage of the individual's option to purchase
all other individual health benefit plans
currently offered by any affiliate of the carrier.
(b) Prohibition on market reentry. In the case of

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a discontinuation under subparagraph (a) in the
individual market, the issuer may not provide for the
issuance of any health insurance coverage in Illinois
involved during the 5-year period beginning on the
date of the discontinuation of the last health
insurance coverage not so renewed.
(c) If an issuer elects to discontinue offering
all health insurance coverage in the individual market
under subparagraph (a), its affiliates that offer
health insurance coverage in the individual market in
Illinois shall offer individual health insurance
coverage to all individuals who were covered by the
discontinued health insurance coverage on the date of
the notice provided to affected individuals under
subdivision (iii) of subparagraph (a) of this item (2)
if the individual applies for coverage no later than
63 days after the discontinuation of coverage.
(d) Subject to subparagraph (e) of this item (2),
an affiliate that issues coverage under subparagraph
(c) shall waive the preexisting condition exclusion
period to the extent that the individual has satisfied
the preexisting condition exclusion period under the
individual's prior contract or policy.
(e) An affiliate that issues coverage under
subparagraph (c) may require the individual to satisfy
the remaining part of the preexisting condition

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exclusion period, if any, under the individual's prior
contract or policy that has not been satisfied, unless
the coverage has a shorter preexisting condition
exclusion period, and may include in any coverage
issued under subparagraph (c) any waivers or
limitations of coverage that were included in the
individual's prior contract or policy.
(D) Exception for uniform modification of coverage. At the
time of coverage renewal, a health insurance issuer may modify
the health insurance coverage for a policy form offered to
individuals in the individual market so long as the
modification is consistent with Illinois law and effective on
a uniform basis among all individuals with that policy form.
(E) Application to coverage offered only through
associations. In applying this Section in the case of health
insurance coverage that is made available by a health
insurance issuer in the individual market to individuals only
through one or more associations, a reference to an
"individual" is deemed to include a reference to such an
association (of which the individual is a member).
The changes to this Section made by this amendatory Act of
the 94th General Assembly apply only to discontinuances of
coverage occurring on or after the effective date of this
amendatory Act of the 94th General Assembly.
(Source: P.A. 94-502, eff. 8-8-05.)

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(215 ILCS 97/60)
Sec. 60. Notice requirement. In any case where a health
insurance issuer elects to uniformly modify coverage,
uniformly terminate coverage, or discontinue coverage in a
marketplace in accordance with Sections 30 and 50 of this Act,
the issuer shall provide notice to the Department prior to
notifying the plan sponsors, participants, beneficiaries, and
covered individuals. The notice shall be sent by certified
mail to the Department 45 90 days in advance of any
notification of the company's actions sent to plan sponsors,
participants, beneficiaries, and covered individuals. The
notice shall include: (i) a complete description of the action
to be taken, (ii) a specific description of the type of
coverage affected, (iii) the total number of covered lives
affected, (iv) a sample draft of all letters being sent to the
plan sponsors, participants, beneficiaries, or covered
individuals, (v) time frames for the actions being taken, (vi)
options the plans sponsors, participants, beneficiaries, or
covered individuals may have available to them under this Act,
and (vii) any other information as required by the Department.
The Department may designate an email address or online
platform to receive electronic notification in lieu of
certified mail.
This Section applies only to discontinuances of coverage
occurring on or after the effective date of this amendatory
Act of the 94th General Assembly.

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(Source: P.A. 94-502, eff. 8-8-05.)
Section 20. The Network Adequacy and Transparency Act is
amended by changing Sections 3, 5, 10, and 25 as follows:
(215 ILCS 124/3)
Sec. 3. Applicability of Act. This Act applies to an
individual or group policy of accident and health insurance
with a network plan amended, delivered, issued, or renewed in
this State on or after January 1, 2019. This Act does not apply
to an individual or group policy for excepted benefits or
short-term, limited-duration health insurance coverage dental
or vision insurance or a limited health service organization
with a network plan amended, delivered, issued, or renewed in
this State on or after January 1, 2019 , except to the extent
that federal law establishes network adequacy and transparency
standards for stand-alone dental plans, which the Department
shall enforce.
(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
(215 ILCS 124/5)
Sec. 5. Definitions. In this Act:
"Authorized representative" means a person to whom a
beneficiary has given express written consent to represent the
beneficiary; a person authorized by law to provide substituted
consent for a beneficiary; or the beneficiary's treating

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provider only when the beneficiary or his or her family member
is unable to provide consent.
"Beneficiary" means an individual, an enrollee, an
insured, a participant, or any other person entitled to
reimbursement for covered expenses of or the discounting of
provider fees for health care services under a program in
which the beneficiary has an incentive to utilize the services
of a provider that has entered into an agreement or
arrangement with an insurer.
"Department" means the Department of Insurance.
"Director" means the Director of Insurance.
"Excepted benefits" has the meaning given to that term in
42 U.S.C. 300gg-91(c).
"Family caregiver" means a relative, partner, friend, or
neighbor who has a significant relationship with the patient
and administers or assists the patient with activities of
daily living, instrumental activities of daily living, or
other medical or nursing tasks for the quality and welfare of
that patient.
"Insurer" means any entity that offers individual or group
accident and health insurance, including, but not limited to,
health maintenance organizations, preferred provider
organizations, exclusive provider organizations, and other
plan structures requiring network participation, excluding the
medical assistance program under the Illinois Public Aid Code,
the State employees group health insurance program, workers

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compensation insurance, and pharmacy benefit managers.
"Material change" means a significant reduction in the
number of providers available in a network plan, including,
but not limited to, a reduction of 10% or more in a specific
type of providers, the removal of a major health system that
causes a network to be significantly different from the
network when the beneficiary purchased the network plan, or
any change that would cause the network to no longer satisfy
the requirements of this Act or the Department's rules for
network adequacy and transparency.
"Network" means the group or groups of preferred providers
providing services to a network plan.
"Network plan" means an individual or group policy of
accident and health insurance that either requires a covered
person to use or creates incentives, including financial
incentives, for a covered person to use providers managed,
owned, under contract with, or employed by the insurer.
"Ongoing course of treatment" means (1) treatment for a
life-threatening condition, which is a disease or condition
for which likelihood of death is probable unless the course of
the disease or condition is interrupted; (2) treatment for a
serious acute condition, defined as a disease or condition
requiring complex ongoing care that the covered person is
currently receiving, such as chemotherapy, radiation therapy,
or post-operative visits; (3) a course of treatment for a
health condition that a treating provider attests that

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discontinuing care by that provider would worsen the condition
or interfere with anticipated outcomes; or (4) the third
trimester of pregnancy through the post-partum period.
"Preferred provider" means any provider who has entered,
either directly or indirectly, into an agreement with an
employer or risk-bearing entity relating to health care
services that may be rendered to beneficiaries under a network
plan.
"Providers" means physicians licensed to practice medicine
in all its branches, other health care professionals,
hospitals, or other health care institutions that provide
health care services.
"Short-term, limited-duration health insurance coverage
has the meaning given to that term in Section 5 of the
Short-Term, Limited-Duration Health Insurance Coverage Act.
"Stand-alone dental plan" has the meaning given to that
term in 45 CFR 156.400.
"Telehealth" has the meaning given to that term in Section
356z.22 of the Illinois Insurance Code.
"Telemedicine" has the meaning given to that term in
Section 49.5 of the Medical Practice Act of 1987.
"Tiered network" means a network that identifies and
groups some or all types of provider and facilities into
specific groups to which different provider reimbursement,
covered person cost-sharing or provider access requirements,
or any combination thereof, apply for the same services.

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"Woman's principal health care provider" means a physician
licensed to practice medicine in all of its branches
specializing in obstetrics, gynecology, or family practice.
(Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)
(215 ILCS 124/10)
Sec. 10. Network adequacy.
(a) An insurer providing a network plan shall file a
description of all of the following with the Director:
(1) The written policies and procedures for adding
providers to meet patient needs based on increases in the
number of beneficiaries, changes in the
patient-to-provider ratio, changes in medical and health
care capabilities, and increased demand for services.
(2) The written policies and procedures for making
referrals within and outside the network.
(3) The written policies and procedures on how the
network plan will provide 24-hour, 7-day per week access
to network-affiliated primary care, emergency services,
and women's principal health care providers.
An insurer shall not prohibit a preferred provider from
discussing any specific or all treatment options with
beneficiaries irrespective of the insurer's position on those
treatment options or from advocating on behalf of
beneficiaries within the utilization review, grievance, or
appeals processes established by the insurer in accordance

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with any rights or remedies available under applicable State
or federal law.
(b) Insurers must file for review a description of the
services to be offered through a network plan. The description
shall include all of the following:
(1) A geographic map of the area proposed to be served
by the plan by county service area and zip code, including
marked locations for preferred providers.
(2) As deemed necessary by the Department, the names,
addresses, phone numbers, and specialties of the providers
who have entered into preferred provider agreements under
the network plan.
(3) The number of beneficiaries anticipated to be
covered by the network plan.
(4) An Internet website and toll-free telephone number
for beneficiaries and prospective beneficiaries to access
current and accurate lists of preferred providers,
additional information about the plan, as well as any
other information required by Department rule.
(5) A description of how health care services to be
rendered under the network plan are reasonably accessible
and available to beneficiaries. The description shall
address all of the following:
(A) the type of health care services to be
provided by the network plan;
(B) the ratio of physicians and other providers to

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beneficiaries, by specialty and including primary care
physicians and facility-based physicians when
applicable under the contract, necessary to meet the
health care needs and service demands of the currently
enrolled population;
(C) the travel and distance standards for plan
beneficiaries in county service areas; and
(D) a description of how the use of telemedicine,
telehealth, or mobile care services may be used to
partially meet the network adequacy standards, if
applicable.
(6) A provision ensuring that whenever a beneficiary
has made a good faith effort, as evidenced by accessing
the provider directory, calling the network plan, and
calling the provider, to utilize preferred providers for a
covered service and it is determined the insurer does not
have the appropriate preferred providers due to
insufficient number, type, unreasonable travel distance or
delay, or preferred providers refusing to provide a
covered service because it is contrary to the conscience
of the preferred providers, as protected by the Health
Care Right of Conscience Act, the insurer shall ensure,
directly or indirectly, by terms contained in the payer
contract, that the beneficiary will be provided the
covered service at no greater cost to the beneficiary than
if the service had been provided by a preferred provider.

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This paragraph (6) does not apply to: (A) a beneficiary
who willfully chooses to access a non-preferred provider
for health care services available through the panel of
preferred providers, or (B) a beneficiary enrolled in a
health maintenance organization. In these circumstances,
the contractual requirements for non-preferred provider
reimbursements shall apply unless Section 356z.3a of the
Illinois Insurance Code requires otherwise. In no event
shall a beneficiary who receives care at a participating
health care facility be required to search for
participating providers under the circumstances described
in subsection (b) or (b-5) of Section 356z.3a of the
Illinois Insurance Code except under the circumstances
described in paragraph (2) of subsection (b-5).
(7) A provision that the beneficiary shall receive
emergency care coverage such that payment for this
coverage is not dependent upon whether the emergency
services are performed by a preferred or non-preferred
provider and the coverage shall be at the same benefit
level as if the service or treatment had been rendered by a
preferred provider. For purposes of this paragraph (7),
"the same benefit level" means that the beneficiary is
provided the covered service at no greater cost to the
beneficiary than if the service had been provided by a
preferred provider. This provision shall be consistent
with Section 356z.3a of the Illinois Insurance Code.

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(8) A limitation that, if the plan provides that the
beneficiary will incur a penalty for failing to
pre-certify inpatient hospital treatment, the penalty may
not exceed $1,000 per occurrence in addition to the plan
cost sharing provisions.
(c) The network plan shall demonstrate to the Director a
minimum ratio of providers to plan beneficiaries as required
by the Department.
(1) The ratio of physicians or other providers to plan
beneficiaries shall be established annually by the
Department in consultation with the Department of Public
Health based upon the guidance from the federal Centers
for Medicare and Medicaid Services. The Department shall
not establish ratios for vision or dental providers who
provide services under dental-specific or vision-specific
benefits, except to the extent provided under federal law
for stand-alone dental plans. The Department shall
consider establishing ratios for the following physicians
or other providers:
(A) Primary Care;
(B) Pediatrics;
(C) Cardiology;
(D) Gastroenterology;
(E) General Surgery;
(F) Neurology;
(G) OB/GYN;

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(H) Oncology/Radiation;
(I) Ophthalmology;
(J) Urology;
(K) Behavioral Health;
(L) Allergy/Immunology;
(M) Chiropractic;
(N) Dermatology;
(O) Endocrinology;
(P) Ears, Nose, and Throat (ENT)/Otolaryngology;
(Q) Infectious Disease;
(R) Nephrology;
(S) Neurosurgery;
(T) Orthopedic Surgery;
(U) Physiatry/Rehabilitative;
(V) Plastic Surgery;
(W) Pulmonary;
(X) Rheumatology;
(Y) Anesthesiology;
(Z) Pain Medicine;
(AA) Pediatric Specialty Services;
(BB) Outpatient Dialysis; and
(CC) HIV.
(2) The Director shall establish a process for the
review of the adequacy of these standards, along with an
assessment of additional specialties to be included in the
list under this subsection (c).

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(3) If the federal Centers for Medicare and Medicaid
Services establishes minimum provider ratios for
stand-alone dental plans in the type of exchange in use in
this State for a given plan year, the Department shall
enforce those standards for stand-alone dental plans for
that plan year.
(d) The network plan shall demonstrate to the Director
maximum travel and distance standards for plan beneficiaries,
which shall be established annually by the Department in
consultation with the Department of Public Health based upon
the guidance from the federal Centers for Medicare and
Medicaid Services. These standards shall consist of the
maximum minutes or miles to be traveled by a plan beneficiary
for each county type, such as large counties, metro counties,
or rural counties as defined by Department rule.
The maximum travel time and distance standards must
include standards for each physician and other provider
category listed for which ratios have been established.
The Director shall establish a process for the review of
the adequacy of these standards along with an assessment of
additional specialties to be included in the list under this
subsection (d).
If the federal Centers for Medicare and Medicaid Services
establishes appointment wait-time standards for qualified
health plans, including stand-alone dental plans, in the type
of exchange in use in this State for a given plan year, the

SB3130 Engrossed - 25 - LRB103 38249 RPS 68384 b
Department shall enforce those standards for the same types of
qualified health plans for that plan year. If the federal
Centers for Medicare and Medicaid Services establishes time
and distance standards for stand-alone dental plans in the
type of exchange in use in this State for a given plan year,
the Department shall enforce those standards for stand-alone
dental plans for that plan year.
(d-5)(1) Every insurer shall ensure that beneficiaries
have timely and proximate access to treatment for mental,
emotional, nervous, or substance use disorders or conditions
in accordance with the provisions of paragraph (4) of
subsection (a) of Section 370c of the Illinois Insurance Code.
Insurers shall use a comparable process, strategy, evidentiary
standard, and other factors in the development and application
of the network adequacy standards for timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions and those for the access
to treatment for medical and surgical conditions. As such, the
network adequacy standards for timely and proximate access
shall equally be applied to treatment facilities and providers
for mental, emotional, nervous, or substance use disorders or
conditions and specialists providing medical or surgical
benefits pursuant to the parity requirements of Section 370c.1
of the Illinois Insurance Code and the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008. Notwithstanding the foregoing, the network

SB3130 Engrossed - 26 - LRB103 38249 RPS 68384 b
adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions shall, at a minimum, satisfy the
following requirements:
(A) For beneficiaries residing in the metropolitan
counties of Cook, DuPage, Kane, Lake, McHenry, and Will,
network adequacy standards for timely and proximate access
to treatment for mental, emotional, nervous, or substance
use disorders or conditions means a beneficiary shall not
have to travel longer than 30 minutes or 30 miles from the
beneficiary's residence to receive outpatient treatment
for mental, emotional, nervous, or substance use disorders
or conditions. Beneficiaries shall not be required to wait
longer than 10 business days between requesting an initial
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(B) For beneficiaries residing in Illinois counties

SB3130 Engrossed - 27 - LRB103 38249 RPS 68384 b
other than those counties listed in subparagraph (A) of
this paragraph, network adequacy standards for timely and
proximate access to treatment for mental, emotional,
nervous, or substance use disorders or conditions means a
beneficiary shall not have to travel longer than 60
minutes or 60 miles from the beneficiary's residence to
receive outpatient treatment for mental, emotional,
nervous, or substance use disorders or conditions.
Beneficiaries shall not be required to wait longer than 10
business days between requesting an initial appointment
and being seen by the facility or provider of mental,
emotional, nervous, or substance use disorders or
conditions for outpatient treatment or to wait longer than
20 business days between requesting a repeat or follow-up
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions for outpatient treatment; however, subject to
the protections of paragraph (3) of this subsection, a
network plan shall not be held responsible if the
beneficiary or provider voluntarily chooses to schedule an
appointment outside of these required time frames.
(2) For beneficiaries residing in all Illinois counties,
network adequacy standards for timely and proximate access to
treatment for mental, emotional, nervous, or substance use
disorders or conditions means a beneficiary shall not have to
travel longer than 60 minutes or 60 miles from the

SB3130 Engrossed - 28 - LRB103 38249 RPS 68384 b
beneficiary's residence to receive inpatient or residential
treatment for mental, emotional, nervous, or substance use
disorders or conditions.
(3) If there is no in-network facility or provider
available for a beneficiary to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with the
network adequacy standards outlined in this subsection, the
insurer shall provide necessary exceptions to its network to
ensure admission and treatment with a provider or at a
treatment facility in accordance with the network adequacy
standards in this subsection.
(4) If the federal Centers for Medicare and Medicaid
Services establishes a more stringent standard in any county
than specified in paragraph (1) or (2) of this subsection
(d-5) for qualified health plans in the type of exchange in use
in this State for a given plan year, the federal standard shall
apply in lieu of the standard in paragraph (1) or (2) of this
subsection (d-5) for qualified health plans for that plan
year.
(e) Except for network plans solely offered as a group
health plan, these ratio and time and distance standards apply
to the lowest cost-sharing tier of any tiered network.
(f) The network plan may consider use of other health care
service delivery options, such as telemedicine or telehealth,
mobile clinics, and centers of excellence, or other ways of

SB3130 Engrossed - 29 - LRB103 38249 RPS 68384 b
delivering care to partially meet the requirements set under
this Section.
(g) Except for the requirements set forth in subsection
(d-5), insurers who are not able to comply with the provider
ratios, and time and distance standards, and appointment
wait-time standards established under this Act or federal law
established by the Department may request an exception to
these requirements from the Department. The Department may
grant an exception in the following circumstances:
(1) if no providers or facilities meet the specific
time and distance standard in a specific service area and
the insurer (i) discloses information on the distance and
travel time points that beneficiaries would have to travel
beyond the required criterion to reach the next closest
contracted provider outside of the service area and (ii)
provides contact information, including names, addresses,
and phone numbers for the next closest contracted provider
or facility;
(2) if patterns of care in the service area do not
support the need for the requested number of provider or
facility type and the insurer provides data on local
patterns of care, such as claims data, referral patterns,
or local provider interviews, indicating where the
beneficiaries currently seek this type of care or where
the physicians currently refer beneficiaries, or both; or
(3) other circumstances deemed appropriate by the

SB3130 Engrossed - 30 - LRB103 38249 RPS 68384 b
Department consistent with the requirements of this Act.
(h) Insurers are required to report to the Director any
material change to an approved network plan within 15 days
after the change occurs and any change that would result in
failure to meet the requirements of this Act. Upon notice from
the insurer, the Director shall reevaluate the network plan's
compliance with the network adequacy and transparency
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
102-1117, eff. 1-13-23.)
(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

SB3130 Engrossed - 31 - LRB103 38249 RPS 68384 b
to their information as listed in the provider directory,
including the information required in subparagraph (K) of
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 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
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

SB3130 Engrossed - 32 - LRB103 38249 RPS 68384 b
include, in plain language in both the electronic and
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.
(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

SB3130 Engrossed - 33 - LRB103 38249 RPS 68384 b
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) specialty, if applicable;
(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,

SB3130 Engrossed - 34 - LRB103 38249 RPS 68384 b
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;
(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.
(c) For the electronic provider directories, for each
network plan, a network plan shall make available all of the

SB3130 Engrossed - 35 - LRB103 38249 RPS 68384 b
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
(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) specialty, 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;

SB3130 Engrossed - 36 - LRB103 38249 RPS 68384 b
(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;
(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

SB3130 Engrossed - 37 - LRB103 38249 RPS 68384 b
telephone number in the print format provider directory for a
customer service representative where the beneficiary can
obtain current provider directory information.
(f) The Director may conduct periodic audits of the
accuracy of provider directories. 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.
(g) This Section applies to network plans that are not
otherwise exempt under Section 3, including stand-alone dental
plans that are subject to provider directory requirements
under federal law.
(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
Section 25. The Health Maintenance Organization Act is
amended by changing Section 5-3 as follows:
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
Sec. 5-3. Insurance Code provisions.
(a) Health Maintenance Organizations shall be subject to
the provisions of Sections 133, 134, 136, 137, 139, 140,
141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v,
356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,

SB3130 Engrossed - 38 - LRB103 38249 RPS 68384 b
356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22,
356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30,
356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35,
356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.40a,
356z.41, 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49,
356z.50, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57,
356z.58, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65,
356z.67, 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i,
368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402,
403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c)
of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
Illinois Insurance Code.
(b) For purposes of the Illinois Insurance Code, except
for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
Health Maintenance Organizations in the following categories
are deemed to be "domestic companies":
(1) a corporation authorized under the Dental Service
Plan Act or the Voluntary Health Services Plans Act;
(2) a corporation organized under the laws of this
State; or
(3) a corporation organized under the laws of another
state, 30% or more of the enrollees of which are residents
of this State, except a corporation subject to
substantially the same requirements in its state of
organization as is a "domestic company" under Article VIII

SB3130 Engrossed - 39 - LRB103 38249 RPS 68384 b
1/2 of the Illinois Insurance Code.
(c) In considering the merger, consolidation, or other
acquisition of control of a Health Maintenance Organization
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
(1) the Director shall give primary consideration to
the continuation of benefits to enrollees and the
financial conditions of the acquired Health Maintenance
Organization after the merger, consolidation, or other
acquisition of control takes effect;
(2)(i) the criteria specified in subsection (1)(b) of
Section 131.8 of the Illinois Insurance Code shall not
apply and (ii) the Director, in making his determination
with respect to the merger, consolidation, or other
acquisition of control, need not take into account the
effect on competition of the merger, consolidation, or
other acquisition of control;
(3) the Director shall have the power to require the
following information:
(A) certification by an independent actuary of the
adequacy of the reserves of the Health Maintenance
Organization sought to be acquired;
(B) pro forma financial statements reflecting the
combined balance sheets of the acquiring company and
the Health Maintenance Organization sought to be
acquired as of the end of the preceding year and as of
a date 90 days prior to the acquisition, as well as pro

SB3130 Engrossed - 40 - LRB103 38249 RPS 68384 b
forma financial statements reflecting projected
combined operation for a period of 2 years;
(C) a pro forma business plan detailing an
acquiring party's plans with respect to the operation
of the Health Maintenance Organization sought to be
acquired for a period of not less than 3 years; and
(D) such other information as the Director shall
require.
(d) The provisions of Article VIII 1/2 of the Illinois
Insurance Code and this Section 5-3 shall apply to the sale by
any health maintenance organization of greater than 10% of its
enrollee population (including, without limitation, the health
maintenance organization's right, title, and interest in and
to its health care certificates).
(e) In considering any management contract or service
agreement subject to Section 141.1 of the Illinois Insurance
Code, the Director (i) shall, in addition to the criteria
specified in Section 141.2 of the Illinois Insurance Code,
take into account the effect of the management contract or
service agreement on the continuation of benefits to enrollees
and the financial condition of the health maintenance
organization to be managed or serviced, and (ii) need not take
into account the effect of the management contract or service
agreement on competition.
(f) Except for small employer groups as defined in the
Small Employer Rating, Renewability and Portability Health

SB3130 Engrossed - 41 - LRB103 38249 RPS 68384 b
Insurance Act and except for medicare supplement policies as
defined in Section 363 of the Illinois Insurance Code, a
Health Maintenance Organization may by contract agree with a
group or other enrollment unit to effect refunds or charge
additional premiums under the following terms and conditions:
(i) the amount of, and other terms and conditions with
respect to, the refund or additional premium are set forth
in the group or enrollment unit contract agreed in advance
of the period for which a refund is to be paid or
additional premium is to be charged (which period shall
not be less than one year); and
(ii) the amount of the refund or additional premium
shall not exceed 20% of the Health Maintenance
Organization's profitable or unprofitable experience with
respect to the group or other enrollment unit for the
period (and, for purposes of a refund or additional
premium, the profitable or unprofitable experience shall
be calculated taking into account a pro rata share of the
Health Maintenance Organization's administrative and
marketing expenses, but shall not include any refund to be
made or additional premium to be paid pursuant to this
subsection (f)). The Health Maintenance Organization and
the group or enrollment unit may agree that the profitable
or unprofitable experience may be calculated taking into
account the refund period and the immediately preceding 2
plan years.

SB3130 Engrossed - 42 - LRB103 38249 RPS 68384 b
The Health Maintenance Organization shall include a
statement in the evidence of coverage issued to each enrollee
describing the possibility of a refund or additional premium,
and upon request of any group or enrollment unit, provide to
the group or enrollment unit a description of the method used
to calculate (1) the Health Maintenance Organization's
profitable experience with respect to the group or enrollment
unit and the resulting refund to the group or enrollment unit
or (2) the Health Maintenance Organization's unprofitable
experience with respect to the group or enrollment unit and
the resulting additional premium to be paid by the group or
enrollment unit.
In no event shall the Illinois Health Maintenance
Organization Guaranty Association be liable to pay any
contractual obligation of an insolvent organization to pay any
refund authorized under this Section.
(g) Rulemaking authority to implement Public Act 95-1045,
if any, is conditioned on the rules being adopted in
accordance with all provisions of the Illinois Administrative
Procedure Act and all rules and procedures of the Joint
Committee on Administrative Rules; any purported rule not so
adopted, for whatever reason, is unauthorized.
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;

SB3130 Engrossed - 43 - LRB103 38249 RPS 68384 b
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
Section 30. The Managed Care Reform and Patient Rights Act
is amended by changing Section 45.3 as follows:
(215 ILCS 134/45.3)
Sec. 45.3. Prescription drug benefits; plan choice.
(a) Notwithstanding any other provision of law, beginning
January 1, 2023, every health insurance carrier that offers an
individual health plan that provides coverage for prescription
drugs shall ensure that at least 10% of individual health care
plans offered in each applicable service area and at each
level of coverage as defined in 42 U.S.C. 18022(d) apply a
flat-dollar copayment structure to the entire drug benefit.
Beginning January 1, 2024, every health insurance carrier that
offers an individual health plan that provides coverage for
prescription drugs shall ensure that at least 25% of
individual health care plans offered in each applicable
service area and at each level of coverage as defined in 42
U.S.C. 18022(d) apply a flat-dollar copayment structure to the
entire drug benefit. If a health insurance carrier offers

SB3130 Engrossed - 44 - LRB103 38249 RPS 68384 b
fewer than 4 plans in a service area, then the health insurance
carrier shall ensure that one plan applies a flat-dollar
copayment structure to the entire drug benefit.
(b) Beginning January 1, 2023, every health insurance
carrier that offers a group health plan that provides coverage
for prescription drugs shall offer at least one group health
plan in each applicable service area and at each level of
coverage as defined in 42 U.S.C. 18022 that applies a
flat-dollar copayment structure to the entire drug benefit.
Every Beginning January 1, 2024, every health insurance
carrier that offers a small group health plan that provides
coverage for prescription drugs shall offer at least 2 small
group health plans in each applicable service area and at each
level of coverage as defined in 42 U.S.C. 18022(d) that apply a
flat-dollar copayment structure to the entire drug benefit.
(c) The flat-dollar copayment structure for prescription
drugs under subsections (a) and (b) must be applied
pre-deductible and be reasonably graduated and proportionately
related in all tier levels such that the copayment structure
as a whole does not discriminate against or discourage the
enrollment of individuals with significant health care needs.
Notwithstanding the other provisions of this subsection,
beginning January 1, 2025, each level of coverage that a
health insurance carrier offers of a standardized option in
each applicable service area shall be deemed to satisfy the
requirements for a flat-dollar copay structure in subsection

SB3130 Engrossed - 45 - LRB103 38249 RPS 68384 b
(a).
For purposes of this subsection, "standardized option" has
the meaning given to that term in 45 CFR 155.20 or, when
Illinois has a State-based exchange, a substantially similar
definition to "standardized option" in 45 CFR 155.20 that
substitutes the Illinois Health Benefits Exchange for the
United States Department of Health and Human Services.
(d) A health insurance carrier that offers individual or
small group health care plans shall clearly and appropriately
name the plans described in subsections (a) and (b) to aid in
the individual or small group plan selection process.
(e) A health insurance carrier shall market plans
described in subsections (a) and (b) in the same manner as
plans not described in subsections (a) and (b).
(f) The Department shall adopt rules necessary to
implement and enforce the provisions of this Section.
(Source: P.A. 102-391, eff. 1-1-23.)