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

NOTE: For additional amemendments please see the Bill Drafting List

---

Bill Title: INS-NETWORK ADEQUACY-DIRECTORY

Status: 2025-01-07 - Session Sine Die [HB5313 Detail]

Download: Illinois-2023-HB5313-House_Amendment_002.html

---

Rep. Margaret Croke

Filed: 4/12/2024

10300HB5313ham002 LRB103 38443 RPS 72151 a
AMENDMENT TO HOUSE BILL 5313
AMENDMENT NO. ______. Amend House Bill 5313 by replacing
everything after the enacting clause with the following:
"Section 5. The Network Adequacy and Transparency Act is
amended by changing Section 25 and by adding Section 35 as
follows:
(215 ILCS 124/25)
Sec. 25. Network transparency.
(a) A network plan shall post electronically an
up-to-date, accurate, and complete provider directory for each
of its network plans, with the information and search
functions, as described in this Section.
(1) In making the directory available electronically,
the network plans shall ensure that the general public is
able to view all of the current providers for a plan
through a clearly identifiable link or tab and without

10300HB5313ham002 - 2 - LRB103 38443 RPS 72151 a
creating or accessing an account or entering a policy or
contract number.
(2) The network plan shall update the online provider
directory at least monthly. Providers shall notify the
network plan electronically or in writing of any changes
to their information as listed in the provider directory,
including the information required in subparagraph (K) of
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 2 10 business days after being notified of the
change by the provider. Nothing in this paragraph (2)
shall void any contractual relationship between the
provider and the plan.
(3) The network plan shall, at least every 90 days,
audit each periodically at least 25% of its provider
directories for accuracy, make any corrections necessary,
and retain documentation of the audit. If inaccurate
information for a provider is found in any provider
directory, the health carrier, as defined in Section 10 of
the Health Carrier External Review Act shall check all its
network plan directories to identify and correct all
inaccuracies associated with that provider. The network
plan shall submit the audit to the Department, and the
Department shall make a summary of each audit publicly
available Director upon request. The Department shall

10300HB5313ham002 - 3 - LRB103 38443 RPS 72151 a
specify the requirements of the summary. 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. The audit shall
comply with 42 U.S.C. 300gg-115(a)(2), except that
"provider directory information" shall include all
information required under this Act.
(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 at least every 90 days quarterly ,
and an errata that reflect reflects changes in the
provider network must be updated quarterly.
(5) For each network plan, a network plan shall
include, in plain language in both the electronic and
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

10300HB5313ham002 - 4 - LRB103 38443 RPS 72151 a
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;
and .
(E) a detailed description of the process to
dispute charges for out-of-network providers or
facilities that were incorrectly listed as in-network
prior to the provision of care and a telephone number
and email address to dispute such charges.
(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.

10300HB5313ham002 - 5 - LRB103 38443 RPS 72151 a
(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; and
(K) use of telehealth or telemedicine, including,
but not limited to:
(i) whether the provider offers the use of

10300HB5313ham002 - 6 - LRB103 38443 RPS 72151 a
telehealth or telemedicine to deliver services to
patients for whom it would be clinically
appropriate;
(ii) what modalities are used and what types
of services may be provided via telehealth or
telemedicine; and
(iii) whether the provider has the ability and
willingness to include in a telehealth or
telemedicine encounter a family caregiver who is
in a separate location than the patient if the
patient wishes and provides his or her consent;
and
(L) the anticipated date the provider will leave
the network, if applicable, which shall be included
not more than 10 days after the network confirms that
the provider is scheduled to leave the network in
accordance with Section 15 of this Act; and
(2) for hospitals:
(A) hospital name;
(B) hospital type (such as acute, rehabilitation,
children's, or cancer);
(C) participating hospital location; and
(D) hospital accreditation status; and
(3) for facilities, other than hospitals, by type:
(A) facility name;
(B) facility type;

10300HB5313ham002 - 7 - LRB103 38443 RPS 72151 a
(C) types of services performed; and
(D) participating facility location or locations;
and .
(E) the anticipated date the facility will leave
the network, if applicable, which shall be included
not more than 10 days after the network confirms the
facility is scheduled to leave the network.
(c) For the electronic provider directories, for each
network plan, a network plan shall make available all of the
following information in addition to the searchable
information required in this Section:
(1) for health care professionals:
(A) contact information, including a telephone
number and any other digital contact information the
provider has supplied; 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, including a telephone

10300HB5313ham002 - 8 - LRB103 38443 RPS 72151 a
number and any other digital contact information the
provider has supplied;
(C) participating office location or locations;
(D) patient population (such as pediatric, adult,
elderly, or women) and specialty or subspecialty, if
applicable;
(E) languages spoken other than English, if
applicable;
(F) whether accepting new patients; and
(G) use of telehealth or telemedicine, including,
but not limited to:
(i) whether the provider offers the use of
telehealth or telemedicine to deliver services to
patients for whom it would be clinically
appropriate;
(ii) what modalities are used and what types
of services may be provided via telehealth or
telemedicine; and
(iii) whether the provider has the ability and
willingness to include in a telehealth or
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,

10300HB5313ham002 - 9 - LRB103 38443 RPS 72151 a
children's, or cancer); and
(C) participating hospital location, and 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,
and telephone numbers, and digital contact
information.
(e) The network plan shall include a disclosure in the
print format provider directory that the information included
in the directory is accurate as of the date of printing and
that beneficiaries or prospective beneficiaries should consult
the insurer's electronic provider directory on its website and
contact the provider. The network plan shall also include a
telephone number and email address in the print format
provider directory for a customer service representative where
the beneficiary can obtain current provider directory
information or report directory inaccuracies. The network plan
shall include in the print format provider directory a
detailed description of the process to dispute charges for
out-of-network providers or facilities that were incorrectly
listed as in-network prior to the provision of care and a

10300HB5313ham002 - 10 - LRB103 38443 RPS 72151 a
telephone number and email address to dispute those charges.
(f) The Director may conduct periodic audits of the
accuracy of provider directories and shall conduct audits of
at least 10% of plans each year, with at least one plan from
each health carrier under the Department's jurisdiction. The
Director shall require a network plan to correct any
inaccuracies found within 2 business days after the network
plan is notified of an inaccuracy. If an audit of any health
carrier's plan finds that more than 1% of providers listed in
the audited directory are not participating providers, the
Director shall require the health carrier to have an audit
conducted of each of the health carrier's network plans by an
unaffiliated independent firm qualified to conduct such audits
at the health carrier's expense and shall provide all audits
to the Director. The Director shall specify requirements,
including qualifications of the auditor, relating to those
audits and audit summaries. The Department shall make
summaries of audits publicly available on its website. 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) If a nonparticipating provider listed in a network
plan directory is identified by the network plan or Director,
the health carrier shall do all of the following:
(1) Check each of the health carrier's network plan
directories for the provider within 2 business days to

10300HB5313ham002 - 11 - LRB103 38443 RPS 72151 a
ascertain whether the provider is participating in that
network plan and, if the provider is incorrectly listed as
participating, remove the provider without delay.
(2) Identify the dates across each of the health
carrier's network plan directories that the provider was
listed when the provider was not a participating provider.
(3) For network plans with an out-of-network benefit,
identify all claims for services provided by the provider
on an out-of-network basis during the period which the
provider was incorrectly listed as a participating
provider in the network directory and reimburse each
affected beneficiary the amount necessary to ensure the
beneficiary is held harmless for all amounts exceeding the
amount the beneficiary would have paid had the services
been provided in-network. All out-of-pocket costs incurred
by the beneficiary shall apply toward the in-network
deductible and out-of-pocket maximum.
(4) For each beneficiary who had an in-network claim
for services from the provider during the year prior to
the date that the provider ceased to be a participating in
the network plan, send mail and electronic communications
to the beneficiary informing the beneficiary of the
inaccurate listing, including the dates thereof, and the
beneficiary's rights as described in subparagraph (F) of
paragraph (5) of subsection (a) if the beneficiary
received services from the provider on dates when the

10300HB5313ham002 - 12 - LRB103 38443 RPS 72151 a
provider was inaccurately listed in the directory as
in-network. The Director may specify required language and
additional content of such communications.
(h) Each network plan shall maintain records, for a
minimum of 5 years, of all providers listed in its network
directory, including the dates each provider was listed in the
network, the information listed, and the date and content of
any changes to directory information.
(i) If a network plan fails to provide notice to
beneficiaries of a nonrenewal or termination of a provider
pursuant to Section 15 of this Act and that nonrenewal or
termination takes effect, services delivered by the provider
shall be reimbursed as if the provider was in-network until
the requirements, including any relevant notice period, of
Section 15 have been met. In such cases, the network plan shall
hold the beneficiary harmless for all amounts exceeding the
amount the beneficiary would have paid had the services been
provided in-network. The amounts paid by the beneficiary shall
apply toward the in-network deductible and out-of-pocket
maximum.
(j) If the Director determines that a network plan or any
entity or person acting on the network plan's behalf has
violated this Section, the Director may, after appropriate
notice and opportunity for hearing, by order, assess a civil
penalty up to $5,000 per violation, as adjusted under
subsection (k), except for inaccurate contact information

10300HB5313ham002 - 13 - LRB103 38443 RPS 72151 a
given by the provider. If a network plan or any entity or
person acting on the network plan's behalf knew or reasonably
should have known that the action was in violation of this
Section, the Director may, after appropriate notice and
opportunity for hearing, by order, assess a civil penalty up
to $25,000 per violation, as adjusted under subsection (k).
The civil penalties available to the Director under this
Section are not exclusive and may be sought and employed in
combination with any other remedies available to the Director
under this Act.
(k) Beginning January 1, 2030, and every 5 years
thereafter, the penalty amounts specified in this Section
shall be adjusted based on the average rate of change in
premium rates for the individual and small group markets, and
weighted by enrollment, since the previous adjustment.
(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)
(215 ILCS 124/35 new)
Sec. 35. Complaint of incorrect charges.
(a) A beneficiary who incurs a cost for inappropriate
out-of-network charges for a provider, facility, or hospital
that was listed as in-network prior to the provision of
services may file a complaint with the Department. The
Department shall conduct an investigation of any complaint and
shall determine that the complaint is confirmed if the
beneficiary was provided with inaccurate information provided

10300HB5313ham002 - 14 - LRB103 38443 RPS 72151 a
by the network plan.
(b) Upon a finding that a complaint is confirmed, a
network plan shall reimburse the beneficiary the amount
necessary to ensure the beneficiary is held harmless for all
amounts exceeding the amount the beneficiary would have paid
had the services been provided in-network. All out-of-pocket
costs incurred by the beneficiary shall apply toward the
in-network deductible and out-of-pocket maximum.