215 ILCS 124/1
(215 ILCS 124/1) Sec. 1. Short title. This Act may be cited as the Network Adequacy and Transparency Act. (Source: P.A. 100-502, eff. 9-15-17.)
215 ILCS 124
215 ILCS 124
in effect215 ILCS 124/3 Applicability of Act
(215 ILCS 124/3) Sec. 3. Applicability of Act. This Act applies to an individual or group policy of health insurance coverage 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 with a network plan. This Act does not apply to stand-alone dental plans. If federal law establishes network adequacy and transparency standards for stand-alone dental plans, the Department shall enforce those applicable federal requirements. (Source: P.A. 103-650, eff. 1-1-25; 103-777, eff. 1-1-25; 104-334, eff. 8-15-25; 104-417, eff. 8-15-25.)
215 ILCS 124/5 Definitions
(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 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 issuer. "Department" means the Department of Insurance. "Director" means the Director of Insurance. "Essential community provider" has the meaning given to that term in 45 CFR 156.235. "Excepted benefits" has the meaning given to that term in 42 U.S.C. 300gg-91(c) and implementing regulations. "Excepted benefits" includes individual, group, or blanket coverage. "Exchange" has the meaning given to that term in 45 CFR 155.20. "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. "Group health plan" has the meaning given to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act. "Health insurance coverage" has the meaning given to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act. "Health insurance coverage" does not include any coverage or benefits under Medicare or under the medical assistance program established under Article V of the Illinois Public Aid Code. "Issuer" means a "health insurance issuer" as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act. "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 within any county, the removal of a major health system that causes a network to be significantly different within any county 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 health insurance coverage 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 issuer or by a third party contracted to arrange, contract for, or administer such provider-related incentives for the issuer. "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, post-operative visits, or a serious and complex condition as defined under 42 U.S.C. 300gg-113(b)(2); (3) a course of treatment for a health condition that a treating provider attests that discontinuing care by that provider would worsen the condition or interfere with anticipated outcomes; (4) the third trimester of pregnancy through the post-partum period; (5) undergoing a course of institutional or inpatient care from the provider within the meaning of 42 U.S.C. 300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective surgery from the provider, including receipt of preoperative or postoperative care from such provider with respect to such a surgery; (7) being determined to be terminally ill, as determined under 42 U.S.C. 1395x(dd)(3)(A), and receiving treatment for such illness from such provider; or (8) any other treatment of a condition or disease that requires repeated health care services pursuant to a plan of treatment by a provider because of the potential for changes in the therapeutic regimen or because of the potential for a recurrence of symptoms. "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 or facilities that provide health care services. "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. (Source: P.A. 103-650, eff. 1-1-25; 103-718, eff. 7-19-24; 103-777, eff. 1-1-25; 104-334, eff. 8-15-25.)
215 ILCS 124/10
(215 ILCS 124/10) Sec. 10. Network adequacy. (a) Before issuing, delivering, or renewing a network plan, an issuer 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 obstetrical and gynecological health care professionals. An issuer shall not prohibit a preferred provider from discussing any specific or all treatment options with beneficiaries irrespective of the issuer's position on those treatment options or from advocating on behalf of beneficiaries within the utilization review, grievance, or appeals processes established by the issuer in accordance with any rights or remedies available under applicable State or federal law. (b) Before issuing, delivering, or renewing a network plan, an issuer 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 in each plan, 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 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 issuer 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 issuer shall give the beneficiary a network exception and 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. 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, except that the health maintenance organization must notify the beneficiary when a referral has been granted as a network exception based on any preferred provider access deficiency described in this paragraph or under the circumstances applicable in paragraph (3) of subsection (d-5). 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. (8) A limitation that complies with subsections (d) and (e) of Section 55 of the Prior Authorization Reform Act. (9) For a network plan to be offered through the Exchange in the individual or small group market, as well as any off-Exchange mirror of such a network plan, evidence that the network plan includes essential community providers in accordance with rules established by the Exchange that will operate in this State for the applicable plan year. (c) The issuer shall demonstrate to the Director a minimum ratio of providers to plan beneficiaries as required by the Department for each network plan. (1) The minimum ratio of physicians or other providers to plan beneficiaries shall be established 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; (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; (CC) HIV; and (DD) Genetic Medicine and Genetic Counseling. (1.5) Beginning January 1, 2026, every issuer shall demonstrate to the Director that each in-network hospital has at least one radiologist, pathologist, anesthesiologist, and emergency room physician as a preferred provider in a network plan. The Department may, by rule, require additional types of hospital-based medical specialists to be included as preferred providers in each in-network hospital in a network plan. (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). (3) Notwithstanding any other law or rule, the minimum ratio for each provider type shall be no less than any such ratio established for qualified health plans in Federally-Facilitated Exchanges by federal law or by the federal Centers for Medicare and Medicaid Services, even if the network plan is issued in the large group market or is otherwise not issued through an exchange. Federal standards for stand-alone dental plans shall only apply to such network plans. In the absence of an applicable Department rule, the federal standards shall apply for the time period specified in the federal law, regulation, or guidance. If the Centers for Medicare and Medicaid Services establish standards that are more stringent than the standards in effect under any Department rule, the Department may amend its rules to conform to the more stringent federal standards. (4) 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 and appointment wait-time standards for plan beneficiaries, which shall be established 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). Notwithstanding any other law or Department rule, the maximum travel time and distance standards and appointment wait-time standards shall be no greater than any such standards established for qualified health plans in Federally-Facilitated Exchanges by federal law or by the federal Centers for Medicare and Medicaid Services, even if the network plan is issued in the large group market or is otherwise not issued through an exchange. Federal standards for stand-alone dental plans shall only apply to such network plans. In the absence of an applicable Department rule, the federal standards shall apply for the time period specified in the federal law, regulation, or guidance. If the Centers for Medicare and Medicaid Services establish standards that are more stringent than the standards in effect under any Department rule, the Department may amend its rules to conform to the more stringent federal standards. If the federal area designations for the maximum time or distance or appointment wait-time standards required are changed by the most recent Letter to Issuers in the Federally-facilitated Marketplaces, the Department shall post on its website notice of such changes and may amend its rules to conform to those designations if the Director deems appropriate. 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 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 issuer 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. Issuers 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 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 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 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 issuer 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 at the in-network benefit level. (A) For plan or policy years beginning on or after January 1, 2026, the issuer also shall provide reasonable reimbursement to a beneficiary who has received an exception as outlined in this paragraph (3) for costs including food, lodging, and travel. (i) Reimbursement for food and lodging shall be at the prevailing federal per diem rates then in effect, as set by the United States General Services Administration. Reimbursement for travel by vehicle shall be reimbursed at the current Internal Revenue Service mileage standard for miles driven for transportation or travel expenses. (ii) At the time an issuer grants an exception under this paragraph (3), the issuer shall give written notification to the beneficiary of potential eligibility for reimbursement under this subparagraph (A) and instructions on how to file a claim for such reimbursement, including a link to the claim form on the issuer's public website and a phone number for a beneficiary to request that the issuer send a hard copy of the claim form by postal mail. The Department shall create the template for the reimbursement notification form, which issuers shall fill in and post on their public website. (iii) An issuer may require a beneficiary to submit a claim for food, travel, or lodging reimbursement within 60 days of the last date of the health care service for which travel was undertaken, and the beneficiary may appeal any denial of reimbursement claims. (iv) An issuer may deny reimbursement for food, lodging, and travel if the provider's site of care is neither within this State nor within 100 miles of the beneficiary's residence unless, after a good faith effort, no provider can be found who is available within those parameters to provide the medically necessary health care service within 10 business days of a request for appointment. (B) Notwithstanding any other provision of this Section to the contrary, subparagraph (A) of this paragraph (3) does not apply to policies issued or delivered in this State that provide medical assistance under the Illinois Public Aid Code or the Children's Health Insurance Program Act. (4) If the federal Centers for Medicare and Medicaid Services establishes or law requires more stringent standards for qualified health plans in the Federally-Facilitated Exchanges, the federal standards shall control for all network plans for the time period specified in the federal law, regulation, or guidance, even if the network plan is issued in the large group market, is issued through a different type of Exchange, or is otherwise not issued through an Exchange. (5) 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 delivering care to partially meet the requirements set under this Section. (g) Except for the requirements set forth in subsection (d-5), issuers who are not able to comply with the provider ratios, time and distance standards, and appointment wait-time standards established under this Act or federal law 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 issuer (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 issuer 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 Department consistent with the requirements of this Act. (h) Issuers are required to report to the Director any material change to an approved network plan within 15 business days after the change occurs and any change that would result in failure to meet the requirements of this Act. The issuer shall submit a revised version of the portions of the network adequacy filing affected by the material change, as determined by the Director by rule, and the issuer shall attach versions with the changes indicated for each document that was revised from the previous version of the filing. Upon notice from the issuer, the Director shall reevaluate the network plan's compliance with the network adequacy and transparency standards of this Act. For every day past 15 business days that the issuer fails to submit a revised network adequacy filing to the Director, the Director may order a fine of $5,000 per day. (i) If a network plan is inadequate under this Act with respect to a provider type in a county, and if the network plan does not have an approved exception for that provider type in that county pursuant to subsection (g), an issuer shall cover out-of-network claims for covered health care services received from that provider type within that county at the in-network benefit level and shall retroactively adjudicate and reimburse beneficiaries to achieve that objective if their claims were processed at the out-of-network level contrary to this subsection. Nothing in this subsection shall be construed to supersede Section 356z.3a of the Illinois Insurance Code. (j) If the Director determines that a network is inadequate in any county and no exception has been granted under subsection (g) and the issuer does not have a process in place to comply with subsection (d-5), the Director may prohibit the network plan from being issued or renewed within that county until the Director determines that the network is adequate apart from processes and exceptions described in subsections (d-5) and (g). Nothing in this subsection shall be construed to terminate any beneficiary's health insurance coverage under a network plan before the expiration of the beneficiary's policy period if the Director makes a determination under this subsection after the issuance or renewal of the beneficiary's policy or certificate because of a material change. Policies or certificates issued or renewed in violation of this subsection may subject the issuer to a civil penalty of $5,000 per policy. (k) For the Department to enforce any new or modified federal standard before the Department adopts the standard by rule, the Department must, no later than May 15 before the start of the plan year, give public notice to the affected health insurance issuers through a bulletin. (Source: P.A. 103-650, eff. 1-1-25; 103-656, eff. 1-1-25; 103-718, eff. 7-19-24; 103-777, eff. 1-1-25; 103-906, eff. 1-1-25; 104-28, eff. 1-1-26; 104-175, eff. 1-1-26; 104-334, eff. 8-15-25; 104-852, eff. 8-21-26.)
215 ILCS 124/15
(215 ILCS 124/15) Sec. 15. Notice of nonrenewal or termination. (a) A network plan must give at least 60 days' notice of nonrenewal or termination of a provider to the provider and to the beneficiaries served by the provider. The notice shall include a name and address to which a beneficiary or provider may direct comments and concerns regarding the nonrenewal or termination and the telephone number maintained by the Department for consumer complaints. Immediate written notice may be provided without 60 days' notice when a provider's license has been disciplined by a State licensing board or when the network plan reasonably believes direct imminent physical harm to patients under the provider's care may occur. The notice to the beneficiary shall provide the individual with an opportunity to notify the issuer of the individual's need for transitional care. (b) Primary care providers must notify active affected patients of nonrenewal or termination of the provider from the network plan, except in the case of incapacitation. (Source: P.A. 103-650, eff. 1-1-25.)
215 ILCS 124/20
(215 ILCS 124/20) (Text of Section before amendment by P.A. 104-333) Sec. 20. Transition of services. (a) A network plan shall provide for continuity of care for its beneficiaries as follows: (1) If a beneficiary's provider leaves the network plan's network of providers for reasons other than termination of a contract in situations involving imminent harm to a patient or a final disciplinary action by a State licensing board and the provider remains within the network plan's service area, if benefits provided under such network plan with respect to such provider or facility are terminated because of a change in the terms of the participation of such provider or facility in such plan, or if a contract between a group health plan and a health insurance issuer offering a network plan in connection with the group health plan is terminated and results in a loss of benefits provided under such plan with respect to such provider, then the network plan shall permit the beneficiary to continue an ongoing course of treatment with that provider during a transitional period for the following duration: (A) 90 days from the date of the notice to the beneficiary of the provider's disaffiliation from the network plan if the beneficiary has an ongoing course of treatment; or (B) if the beneficiary has entered the third trimester of pregnancy at the time of the provider's disaffiliation, a period that includes the provision of post-partum care directly related to the delivery. (2) Notwithstanding the provisions of paragraph (1) of this subsection (a), such care shall be authorized by the network plan during the transitional period in accordance with the following: (A) the provider receives continued reimbursement from the network plan at the rates and terms and conditions applicable under the terminated contract prior to the start of the transitional period; (B) the provider adheres to the network plan's quality assurance requirements, including provision to the network plan of necessary medical information related to such care; and (C) the provider otherwise adheres to the network plan's policies and procedures, including, but not limited to, procedures regarding referrals and obtaining preauthorizations for treatment. (3) The provisions of this Section governing health care provided during the transition period do not apply if the beneficiary has successfully transitioned to another provider participating in the network plan, if the beneficiary has already met or exceeded the benefit limitations of the plan, or if the care provided is not medically necessary. (b) A network plan shall provide for continuity of care for new beneficiaries as follows: (1) If a new beneficiary whose provider is not a member of the network plan's provider network, but is within the network plan's service area, enrolls in the network plan, the network plan shall permit the beneficiary to continue an ongoing course of treatment with the beneficiary's current physician during a transitional period: (A) of 90 days from the effective date of enrollment if the beneficiary has an ongoing course of treatment; or (B) if the beneficiary has entered the third trimester of pregnancy at the effective date of enrollment, that includes the provision of post-partum care directly related to the delivery. (2) If a beneficiary, or a beneficiary's authorized representative, elects in writing to continue to receive care from such provider pursuant to paragraph (1) of this subsection (b), such care shall be authorized by the network plan for the transitional period in accordance with the following: (A) the provider receives reimbursement from the network plan at rates established by the network plan; (B) the provider adheres to the network plan's quality assurance requirements, including provision to the network plan of necessary medical information related to such care; and (C) the provider otherwise adheres to the network plan's policies and procedures, including, but not limited to, procedures regarding referrals and obtaining preauthorization for treatment. (3) The provisions of this Section governing health care provided during the transition period do not apply if the beneficiary has successfully transitioned to another provider participating in the network plan, if the beneficiary has already met or exceeded the benefit limitations of the plan, or if the care provided is not medically necessary. (c) In no event shall this Section be construed to require a network plan to provide coverage for benefits not otherwise covered or to diminish or impair preexisting condition limitations contained in the beneficiary's contract. (d) A provider shall comply with the requirements of 42 U.S.C. 300gg-138. (Source: P.A. 103-650, eff. 1-1-25.) (Text of Section after amendment by P.A. 104-333) Sec. 20. Transition of services. (a) A network plan shall provide for continuity of care for its beneficiaries as follows: (1) If a beneficiary's provider leaves the network plan's network of providers for reasons other than termination of a contract in situations involving imminent harm to a patient or a final disciplinary action by a State licensing board and the provider remains within the network plan's service area, if benefits provided under such network plan with respect to such provider or facility are terminated because of a change in the terms of the participation of such provider or facility in such plan, or if a contract between a group health plan and a health insurance issuer offering a network plan in connection with the group health plan is terminated and results in a loss of benefits provided under such plan with respect to such provider, then the network plan shall permit the beneficiary to continue an ongoing course of treatment with that provider during a transitional period for the following duration: (A) 90 days from the date of the notice to the beneficiary of the provider's disaffiliation from the network plan if the beneficiary has an ongoing course of treatment; (A-5) 90 days from the date of the notice to the beneficiary of the provider's disaffiliation from the network plan if the beneficiary has a confirmed appointment and the provider attests that the appointment was scheduled prior to the date of notification; or (B) if the beneficiary has entered the third trimester of pregnancy at the time of the provider's disaffiliation, a period that includes the provision of post-partum care directly related to the delivery. (2) Notwithstanding the provisions of paragraph (1) of this subsection (a), such care shall be authorized by the network plan during the transitional period in accordance with the following: (A) the provider receives continued reimbursement from the network plan at the rates and terms and conditions applicable under the terminated contract prior to the start of the transitional period; (B) the provider adheres to the network plan's quality assurance requirements, including provision to the network plan of necessary medical information related to such care; and (C) the provider otherwise adheres to the network plan's policies and procedures, including, but not limited to, procedures regarding referrals and obtaining preauthorizations for treatment. (3) The provisions of this Section governing health care provided during the transition period do not apply if the beneficiary has successfully transitioned to another provider participating in the network plan, if the beneficiary has already met or exceeded the benefit limitations of the plan, or if the care provided is not medically necessary. (4) The provisions of this Section governing health care provided during the transition period do not apply if the provider or the beneficiary, as set forth in item (A-5) of paragraph (1) of subsection (a), reschedules an appointment or schedules any follow up appointments after 90 days from the date of notice provided in Section 15. (b) A network plan shall provide for continuity of care for new beneficiaries as follows: (1) If a new beneficiary whose provider is not a member of the network plan's provider network, but is within the network plan's service area, enrolls in the network plan, the network plan shall permit the beneficiary to continue an ongoing course of treatment with the beneficiary's current physician during a transitional period: (A) of 90 days from the effective date of enrollment if the beneficiary has an ongoing course of treatment; (A-5) of 90 days from the effective date of enrollment if the beneficiary has a confirmed appointment and the current provider attests that the appointment was scheduled prior to the effective date of enrollment; or (B) if the beneficiary has entered the third trimester of pregnancy at the effective date of enrollment, that includes the provision of post-partum care directly related to the delivery. (2) If a beneficiary, or a beneficiary's authorized representative, elects in writing to continue to receive care from such provider pursuant to paragraph (1) of this subsection (b), such care shall be authorized by the network plan for the transitional period in accordance with the following: (A) the provider receives reimbursement from the network plan at rates established by the network plan; (B) the provider adheres to the network plan's quality assurance requirements, including provision to the network plan of necessary medical information related to such care; and (C) the provider otherwise adheres to the network plan's policies and procedures, including, but not limited to, procedures regarding referrals and obtaining preauthorization for treatment. (3) The provisions of this Section governing health care provided during the transition period do not apply if the beneficiary has successfully transitioned to another provider participating in the network plan, if the beneficiary has already met or exceeded the benefit limitations of the plan, or if the care provided is not medically necessary. (4) The provisions of this subsection governing health care provided during the transition period do not apply if the provider or the beneficiary, as set forth in item (A-5) of paragraph (1) of subsection (b), reschedules an appointment or schedules any follow up appointments after 90 days from the effective date of enrollment. (c) In no event shall this Section be construed to require a network plan to provide coverage for benefits not otherwise covered or to diminish or impair preexisting condition limitations contained in the beneficiary's contract. (d) A provider shall comply with the requirements of 42 U.S.C. 300gg-138. (Source: P.A. 103-650, eff. 1-1-25; 104-333, eff. 1-1-27.)
215 ILCS 124/25
(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) An issuer's failure to update a network plan's directory shall subject the issuer to a civil penalty of $5,000 per month. Providers shall notify the network plan electronically or in writing within 10 business days of any changes to their information as listed in the provider directory, including the information required in subsections (b), (c), and (d). With regard to subparagraph (I) of paragraph (1) of subsection (b), the provider must give notice to the issuer within 20 business days of deciding to cease accepting new patients covered by the plan if the new patient limitation is expected to last 40 business days or longer. The network plan shall update its online provider directory in a manner consistent with the information provided by the provider within 2 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) At least once every 90 days, the issuer shall self-audit each network plan's provider directories for accuracy, make any corrections necessary, and retain documentation of the audit. The issuer shall submit the self-audit and a summary to the Department, and the Department shall make the summary of each self-audit publicly available. The Department shall specify the requirements of the summary, which shall be statistical in nature except for a high-level narrative evaluating the impact of internal and external factors on the accuracy of the directory and the timeliness of updates. As part of these self-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. The self-audits shall comply with 42 U.S.C. 300gg-115(a)(2), except that "provider directory information" shall include all information required to be included in a provider directory pursuant to this Act. (4) A network plan shall provide a printed copy of a current provider directory or a printed copy of the requested directory information upon request of a beneficiary or a prospective beneficiary. Except when an issuer's printed copies use the same provider information as the electronic provider directory on each printed copy's date of printing, printed copies must be updated at least every 90 days and errata that reflects changes in the provider network must be included in each update. (5) For each network plan, a network plan shall 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 issuer 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; (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, hospitals, 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. (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; (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; (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; (L) whether the health care professional accepts appointment requests from patients; and (M) the anticipated date the provider will leave the network, if applicable, which shall be included no more than 10 days after the issuer confirms that the provider is scheduled to leave the network; (2) for hospitals: (A) hospital name; (B) hospital type (such as acute, rehabilitation, children's, or cancer); (C) participating hospital location; (D) hospital accreditation status; and (E) the anticipated date the hospital will leave the network, if applicable, which shall be included no more than 10 days after the issuer confirms the hospital is scheduled to leave the network; and (3) for facilities, other than hospitals, by type: (A) facility name; (B) facility type; (C) types of services performed; (D) participating facility location or locations; and (E) the anticipated date the facility will leave the network, if applicable, which shall be included no more than 10 days after the issuer 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, including both a telephone number and digital contact information if the provider has supplied digital contact information; and (B) languages spoken other than English by clinical staff, if applicable; (2) for hospitals, telephone number and digital contact information; and (3) for facilities other than hospitals, telephone number. (d) The issuer 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, including a telephone number and digital contact information if the provider has supplied digital 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; (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 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 (H) whether the health care professional accepts appointment requests from patients; (2) for hospitals: (A) hospital name; (B) hospital type (such as acute, rehabilitation, children's, or cancer); and (C) participating hospital location, telephone number, and digital contact information; and (3) for facilities, other than hospitals, by type: (A) facility name; (B) facility type; (C) patient population (such as pediatric, adult, elderly, or women) served, if applicable, and types of services performed; and (D) participating facility location or locations, telephone numbers, and digital contact information for each location. (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 issuer'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 provider directory inaccuracies. The printed provider directory shall include a detailed description of the process to dispute charges for out-of-network providers, hospitals, 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. 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) To the extent not otherwise provided in this Act, an issuer shall comply with the requirements of 42 U.S.C. 300gg-115, except that "provider directory information" shall include all information required to be included in a provider directory pursuant to this Section. (h) If the issuer or the Department identifies a provider incorrectly listed in the provider directory, the issuer shall check each of the issuer's network plan provider directories for the provider within 2 business days to ascertain whether the provider is a preferred provider in that network plan and, if the provider is incorrectly listed in the provider directory, remove the provider from the provider directory without delay. (i) If the Director determines that an issuer violated this Section, the Director may assess a fine up to $5,000 per violation, except for inaccurate information given by a provider to the issuer. If an issuer, or any entity or person acting on the issuer's behalf, knew or reasonably should have known that a provider was incorrectly included in a provider directory, the Director may assess a fine of up to $25,000 per violation against the issuer. (j) This Section applies to network plans not otherwise exempt under Section 3. (Source: P.A. 103-605, eff. 7-1-24; 103-650, eff. 1-1-25; 103-777, eff. 1-1-25; 104-334, eff. 8-15-25.)
215 ILCS 124/30
(215 ILCS 124/30) Sec. 30. Administration and enforcement. (a) Issuers, as defined in this Act, have a continuing obligation to comply with the requirements of this Act. Other than the duties specifically created in this Act, nothing in this Act is intended to preclude, prevent, or require the adoption, modification, or termination of any utilization management, quality management, or claims processing methodologies of an issuer. (b) Nothing in this Act precludes, prevents, or requires the adoption, modification, or termination of any network plan term, benefit, coverage or eligibility provision, or payment methodology. (c) The Director shall enforce the provisions of this Act pursuant to the enforcement powers granted to it by law. (d) The Department shall adopt rules to enforce compliance with this Act to the extent necessary. (e) In accordance with Section 5-45 of the Illinois Administrative Procedure Act, the Department may adopt emergency rules to implement federal standards for provider ratios, travel time and distance, and appointment wait times if such standards apply to health insurance coverage regulated by the Department and are more stringent than the State standards extant at the time the final federal standards are published. (Source: P.A. 103-650, eff. 1-1-25.)
215 ILCS 124/35
(215 ILCS 124/35) Sec. 35. Provider requirements. Providers shall comply with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations promulgated thereunder, as well as Section 20, paragraph (2) of subsection (a) of Section 25, subsections (h) and (j) of Section 25, and Section 36 of this Act, except that "provider directory information" includes all information required to be included in a provider directory pursuant to Section 25 of this Act. (Source: P.A. 103-650, eff. 1-1-25.)
215 ILCS 124/36
(215 ILCS 124/36) Sec. 36. Complaint of incorrect charges. (a) A beneficiary who, taking into account the reimbursement, if any, by the issuer, incurs a cost in excess of the in-network cost-sharing for a covered service from a provider, facility, or hospital that was listed as in-network in the plan's provider directory prior to or at the time of the provision of services may file a complaint with the Department. The Department shall investigate the complaint and determine if the provider was incorrectly included in the plan's provider directory when the beneficiary made the appointment or received the service. (b) Upon the Department's confirmation of the allegations in the complaint that the beneficiary incurred a cost in excess of the in-network cost-sharing for covered services provided by an incorrectly included provider when the appointment was made or service was provided, the issuer shall reimburse the beneficiary for all costs incurred in excess of the in-network cost-sharing. However, if the issuer has paid the claim to the provider directly, the issuer shall notify the beneficiary and the provider of the beneficiary's right to reimbursement from the provider for any payments in excess of the in-network cost-sharing amount pursuant to 42 U.S.C. 300gg-139(b), and the issuer's notice shall specify the in-network cost-sharing amount for the covered services. The amounts paid by the beneficiary within the in-network cost-sharing amount shall apply towards the in-network deductible and out-of-pocket maximum, if any. (Source: P.A. 103-650, eff. 1-1-25.)
215 ILCS 124/40 Confidentiality
(215 ILCS 124/40) Sec. 40. Confidentiality. (a) All records in the custody or possession of the Department are presumed to be open to public inspection or copying unless exempt from disclosure by Section 7 or 7.5 of the Freedom of Information Act. Except as otherwise provided in this Section or other applicable law, the filings required under this Act shall be open to public inspection or copying. (b) The following information shall not be deemed confidential: (1) actual or projected ratios of providers to beneficiaries; (2) actual or projected time and distance between network providers and beneficiaries or actual or projected waiting times for a beneficiary to see a network provider; (3) geographic maps of network providers; (4) requests for exceptions under subsection (g) of Section 10, except with respect to any discussion of ongoing or planned contractual negotiations with providers that the issuer requests to be treated as confidential; (5) provider directories and provider lists; (6) self-audit summaries required under paragraph (3) of subsection (a) of Section 25 of this Act; and (7) issuer or Department statements of determination as to whether a network plan has satisfied this Act's requirements regarding the information described in this subsection. (c) An issuer's work papers and reports on the results of a self-audit of its provider directories, including any communications between the issuer and the Department, shall remain confidential unless expressly waived by the issuer or unless deemed public information under federal law. (d) The filings required under Section 10 of this Act shall be confidential while they remain under the Department's review but shall become open to public inspection and copying upon completion of the review, except as provided in this Section or under other applicable law. (e) Nothing in this Section shall supersede the statutory requirement that work papers obtained during a market conduct examination be deemed confidential. (Source: P.A. 103-650, eff. 1-1-25.)
215 ILCS 124/50
(215 ILCS 124/50) Sec. 50. Funds for enforcement. Moneys from fines and penalties collected from issuers for violations of this Act shall be deposited into the Insurance Producer Administration Fund for appropriation by the General Assembly to the Department to be used for providing financial support of the Department's enforcement of this Act. (Source: P.A. 103-650, eff. 1-1-25.)
215 ILCS 124/55
(215 ILCS 124/55) Sec. 55. Uniform electronic provider directory information notification forms. (a) On or before January 1, 2026, the Department shall develop and publish a uniform electronic provider directory information form that issuers shall make available to onboarding, current, and former preferred providers to notify the issuer of the provider's currently accurate provider directory information under Section 25 of this Act and 42 U.S.C. 300gg-139. The form shall address information needed from newly onboarding preferred providers, updates to previously supplied provider directory information, reporting an inaccurate directory entry of previously supplied information, contract terminations, and differences in information for specific network plans offered by an issuer, such as whether the provider is a preferred provider for the network plan or is accepting new patients under that plan. The Department shall allow issuers to implement this form through either a PDF or a web portal that requests the same information. (b) Notwithstanding any other provision of law to the contrary, beginning 6 months after the Department publishes the uniform electronic provider directory information form and no later than July 1, 2026, every provider must use the uniform electronic provider directory information form to notify issuers of their provider directory information as required under Section 25 of this Act and 42 U.S.C. 300gg-139. Issuers shall accept this form as sufficient to update their provider directories. Issuers shall not accept paper or fax submissions of provider directory information from providers. (c) The Uniform Electronic Provider Directory Information Form Task Force is created. The purpose of this task force is to provide input and advice to the Department of Insurance in the development of a uniform electronic provider directory information form. The task force shall include at least the following individuals: (1) the Director of Insurance or a designee, as chair; (2) the Marketplace Director or a designee; (3) the Director of the Division of Professional Regulation or a designee; (4) the Director of Public Health or a designee; (5) the Secretary of Innovation and Technology or a designee; (6) the Director of Healthcare and Family Services or a designee; (7) the following individuals appointed by the Director: (A) one representative of a statewide association representing physicians; (B) one representative of a statewide association representing nurses; (C) one representative of a statewide organization representing a majority of Illinois hospitals; (D) one representative of a statewide organization representing Illinois pharmacies; (E) one representative of a statewide organization representing mental health care providers; (F) one representative of a statewide organization representing substance use disorder health care providers; (G) 2 representatives of health insurance issuers doing business in this State or issuer trade associations, at least one of which represents a State-domiciled mutual health insurance company, with a demonstrated expertise in the business of health insurance or health benefits administration; and (H) 2 representatives of a health insurance consumer advocacy group. (d) The Department shall convene the task force described in this Section no later than April 1, 2025. (e) The Department, in development of the uniform electronic provider directory information form, and the task force, in offering input, shall take into consideration the following: (1) readability and user experience; (2) interoperability; (3) existing regulations established by the federal Centers for Medicare and Medicaid Services, the Department of Insurance, the Department of Healthcare and Family Service, the Department of Financial and Professional Regulation, and the Department of Public Health; (4) potential opportunities to avoid duplication of data collection efforts, including, but not limited to, opportunities related to: (A) integrating any provider reporting required under Section 25 of this Act and 42 U.S.C. 300gg-139 with the provider reporting required under the Health Care Professional Credentials Data Collection Act; (B) furnishing information to any national provider directory established by the federal Centers for Medicare and Medicaid Services or another federal agency with jurisdiction over health care providers; and (C) furnishing information in compliance with the Patients' Right to Know Act; (5) compatibility with the Illinois Health Benefits Exchange; (6) provider licensing requirements and forms; and (7) information needed to classify a provider under any specialty type for which a network adequacy standard may be established under this Act when a specialty board certification or State license does not currently exist. (Source: P.A. 103-650, eff. 1-1-25.)
215 ILCS 124/99
(215 ILCS 124/99) Sec. 99. Effective date. This Act takes effect upon becoming law. (Source: P.A. 100-502, eff. 9-15-17.)
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://www.ilga.gov/legislation/ilcs/ilcs.aspFetched: 10/17/2026