Bill Amendment: IL SB0708 | 2025-2026 | 104th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: REGULATION-TECH

Status: 2025-06-02 - Rule 3-9(a) / Re-referred to Assignments [SB0708 Detail]

Download: Illinois-2025-SB0708-Senate_Amendment_003.html

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Sen. Laura Fine

Filed: 5/26/2025

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AMENDMENT TO SENATE BILL 708
AMENDMENT NO. ______. Amend Senate Bill 708 by replacing
everything after the enacting clause with the following:
"Section 5. The Illinois Insurance Code is amended by
changing Sections 356z.14, 356z.40, and 370c and by adding
Section 355.7 as follows:
(215 ILCS 5/355.7 new)
Sec. 355.7. Medical loss ratio report and premium rebate.
(a) A health insurance issuer offering group or individual
health insurance coverage, including a grandfathered health
plan, shall, with respect to each plan year, submit to the
Director a report concerning the ratio of the incurred loss or
incurred claims plus the loss adjustment expense or change in
contract reserves to earned premiums. The report shall include
the percentage of total premium revenue, after accounting for
collections or receipts for risk adjustment and risk corridors

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and payments of reinsurance, that such coverage expends:
(1) on reimbursement for clinical services provided to
enrollees under such coverage;
(2) for activities that improve health care quality;
and
(3) on all other non-claims costs, including an
explanation of the nature of such costs, and excluding
federal and State taxes and licensing or regulatory fees.
(b) A health insurance issuer shall comply with subsection
(a) by filing with the Director a copy of the report submitted
to the United States Department of Health and Human Services
under 42 U.S.C. 300gg-18, which must comply with federal
regulations promulgated thereunder. The Department shall make
the reports received under this Section available to the
public on its website.
(c) If 42 U.S.C. 300gg-18 or the federal regulations
promulgated thereunder are amended after January 15, 2025 to
repeal the reporting or rebate requirements, reduce the amount
or types of information required to be reported, or adopt a
calculation method that reduces the amount of rebates in this
State, a health insurance issuer shall file a supplemental
report with the Director or make supplemental rebate payments,
as applicable, for group or individual health insurance
coverage regulated by this State to ensure that the same total
information is filed with the Director and the same total
rebates are remitted to enrollees as before the federal

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repeal, reduction, or recalculation took effect.
(d) Notwithstanding any other provision of this Section,
under no circumstances may the costs described in paragraphs
(1) and (2) of subsection (a) include:
(1) executive compensation beyond base salary;
(2) entity surplus or accumulated profit; or
(3) costs attendant with an application for lifestyle
management, weight loss, or wellness when the application
falls outside the scope of 45 CFR 158.140 through 158.160.
(e) This Section does not apply with respect to any policy
of excepted benefits as defined under 42 U.S.C. 300gg-91.
(f) Notwithstanding anything in this Section to the
contrary, this Section 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.
(215 ILCS 5/356z.14)
Sec. 356z.14. Autism spectrum disorders.
(a) A group or individual policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed after December 12, 2008 (the effective date of Public
Act 95-1005) must provide individuals under 21 years of age
coverage for the diagnosis of autism spectrum disorders and
for the treatment of autism spectrum disorders to the extent
that the diagnosis and treatment of autism spectrum disorders

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are not already covered by the policy of accident and health
insurance or managed care plan.
(b) Coverage provided under this Section shall be subject
to a maximum benefit of $36,000 per year, but shall not be
subject to any limits on the number of visits to a service
provider. The After December 30, 2009, the Director of the
Division of Insurance shall, on an annual basis, adjust the
maximum benefit for inflation using the Medical Care Component
of the United States Department of Labor Consumer Price Index
for All Urban Consumers. Payments made by an insurer on behalf
of a covered individual for any care, treatment, intervention,
service, or item, the provision of which was for the treatment
of a health condition not diagnosed as an autism spectrum
disorder, shall not be applied toward any maximum benefit
established under this subsection.
(c) Coverage under this Section shall be subject to
copayment, deductible, and coinsurance provisions of a policy
of accident and health insurance or managed care plan to the
extent that other medical services covered by the policy of
accident and health insurance or managed care plan are subject
to these provisions.
(d) This Section shall not be construed as limiting
benefits that are otherwise available to an individual under a
policy of accident and health insurance or managed care plan
and benefits provided under this Section may not be subject to
dollar limits, deductibles, copayments, or coinsurance

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provisions that are less favorable to the insured than the
dollar limits, deductibles, or coinsurance provisions that
apply to physical illness generally.
(e) An insurer may not deny or refuse to provide otherwise
covered services, or refuse to renew, refuse to reissue, or
otherwise terminate or restrict coverage under an individual
contract to provide services to an individual because the
individual or the individual's their dependent is diagnosed
with an autism spectrum disorder or due to the individual
utilizing benefits in this Section.
(e-5) An insurer may not deny or refuse to provide
otherwise covered services under a group or individual policy
of accident and health insurance or a managed care plan solely
because of the location wherein the clinically appropriate
services are provided.
(f) Upon request of the reimbursing insurer, a provider of
treatment for autism spectrum disorders shall furnish medical
records, clinical notes, or other necessary data that
substantiate that initial or continued medical treatment is
medically necessary and is resulting in improved clinical
status. When treatment is anticipated to require continued
services to achieve demonstrable progress, the insurer may
request a treatment plan consisting of diagnosis, proposed
treatment by type, frequency, anticipated duration of
treatment, the anticipated outcomes stated as goals, and the
frequency by which the treatment plan will be updated. Nothing

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in this subsection supersedes the prohibition on prior
authorization for mental health treatment under subsection (w)
of Section 370c.
(g) When making a determination of medical necessity for a
treatment modality for autism spectrum disorders, an insurer
must make the determination in a manner that is consistent
with the manner used to make that determination with respect
to other diseases or illnesses covered under the policy,
including an appeals process. During the appeals process, any
challenge to medical necessity must be viewed as reasonable
only if the review includes a physician with expertise in the
most current and effective treatment modalities for autism
spectrum disorders.
(h) Coverage for medically necessary early intervention
services must be delivered by certified early intervention
specialists, as defined in 89 Ill. Adm. Code 500 and any
subsequent amendments thereto.
(h-5) If an individual has been diagnosed as having an
autism spectrum disorder, meeting the diagnostic criteria in
place at the time of diagnosis, and treatment is determined
medically necessary, then that individual shall remain
eligible for coverage under this Section even if subsequent
changes to the diagnostic criteria are adopted by the American
Psychiatric Association. If no changes to the diagnostic
criteria are adopted after April 1, 2012, and before December
31, 2014, then this subsection (h-5) shall be of no further

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force and effect.
(h-10) An insurer may not deny or refuse to provide
covered services, or refuse to renew, refuse to reissue, or
otherwise terminate or restrict coverage under an individual
contract, for a person diagnosed with an autism spectrum
disorder on the basis that the individual declined an
alternative medication or covered service when the
individual's health care provider has determined that such
medication or covered service may exacerbate clinical
symptomatology and is medically contraindicated for the
individual and the individual has requested and received a
medical exception as provided for under Section 45.1 of the
Managed Care Reform and Patient Rights Act. For the purposes
of this subsection (h-10), "clinical symptomatology" means any
indication of disorder or disease when experienced by an
individual as a change from normal function, sensation, or
appearance.
(h-15) If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost

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of any coverage outlined in subsection (h-10), then subsection
(h-10) is inoperative with respect to all coverage outlined in
subsection (h-10) other than that authorized under Section
1902 of the Social Security Act, 42 U.S.C. 1396a, and the State
shall not assume any obligation for the cost of the coverage
set forth in subsection (h-10).
(i) As used in this Section:
"Autism spectrum disorders" means pervasive developmental
disorders as defined in the most recent edition of the
Diagnostic and Statistical Manual of Mental Disorders,
including autism, Asperger's disorder, and pervasive
developmental disorder not otherwise specified.
"Diagnosis of autism spectrum disorders" means one or more
tests, evaluations, or assessments to diagnose whether an
individual has autism spectrum disorder that is prescribed,
performed, or ordered by (A) a physician licensed to practice
medicine in all its branches or (B) a licensed clinical
psychologist with expertise in diagnosing autism spectrum
disorders.
"Medically necessary" means any care, treatment,
intervention, service, or item which will or is reasonably
expected to do any of the following: (i) prevent the onset of
an illness, condition, injury, disease, or disability; (ii)
reduce or ameliorate the physical, mental, or developmental
effects of an illness, condition, injury, disease, or
disability; or (iii) assist to achieve or maintain maximum

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functional activity in performing daily activities.
"Treatment for autism spectrum disorders" shall include
the following care prescribed, provided, or ordered for an
individual diagnosed with an autism spectrum disorder by (A) a
physician licensed to practice medicine in all its branches or
(B) a certified, registered, or licensed health care
professional with expertise in treating effects of autism
spectrum disorders when the care is determined to be medically
necessary and ordered by a physician licensed to practice
medicine in all its branches:
(1) Psychiatric care, meaning direct, consultative, or
diagnostic services provided by a licensed psychiatrist.
(2) Psychological care, meaning direct or consultative
services provided by a licensed psychologist.
(3) Habilitative or rehabilitative care, meaning
professional, counseling, and guidance services and
treatment programs, including applied behavior analysis,
that are intended to develop, maintain, and restore the
functioning of an individual. As used in this subsection
(i), "applied behavior analysis" means the design,
implementation, and evaluation of environmental
modifications using behavioral stimuli and consequences to
produce socially significant improvement in human
behavior, including the use of direct observation,
measurement, and functional analysis of the relations
between environment and behavior.

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(4) Therapeutic care, including behavioral, speech,
occupational, and physical therapies that provide
treatment in the following areas: (i) self care and
feeding, (ii) pragmatic, receptive, and expressive
language, (iii) cognitive functioning, (iv) applied
behavior analysis, intervention, and modification, (v)
motor planning, and (vi) sensory processing.
(j) Rulemaking authority to implement this amendatory Act
of the 95th General Assembly, 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. 102-322, eff. 1-1-22; 103-154, eff. 6-30-23;
revised 7-23-24.)
(215 ILCS 5/356z.40)
(Text of Section before amendment by P.A. 103-701 and
103-720)
Sec. 356z.40. Pregnancy and postpartum coverage.
(a) An individual or group policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed on or after October 8, 2021 (the effective date of
Public Act 102-665) this amendatory Act of the 102nd General
Assembly shall provide coverage for pregnancy and newborn care

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in accordance with 42 U.S.C. 18022(b) regarding essential
health benefits.
(b) Benefits under this Section shall be as follows:
(1) An individual who has been identified as
experiencing a high-risk pregnancy by the individual's
treating provider shall have access to clinically
appropriate case management programs. As used in this
subsection, "case management" means a mechanism to
coordinate and assure continuity of services, including,
but not limited to, health services, social services, and
educational services necessary for the individual. "Case
management" involves individualized assessment of needs,
planning of services, referral, monitoring, and advocacy
to assist an individual in gaining access to appropriate
services and closure when services are no longer required.
"Case management" is an active and collaborative process
involving a single qualified case manager, the individual,
the individual's family, the providers, and the community.
This includes close coordination and involvement with all
service providers in the management plan for that
individual or family, including assuring that the
individual receives the services. As used in this
subsection, "high-risk pregnancy" means a pregnancy in
which the pregnant or postpartum individual or baby is at
an increased risk for poor health or complications during
pregnancy or childbirth, including, but not limited to,

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hypertension disorders, gestational diabetes, and
hemorrhage.
(2) An individual shall have access to medically
necessary treatment of a mental, emotional, nervous, or
substance use disorder or condition consistent with the
requirements set forth in this Section and in Sections
370c and 370c.1 of this Code. Prior authorization
requirements are prohibited to the extent provided in
Section 370c.
(3) The benefits provided for inpatient and outpatient
services for the medically necessary treatment of a
mental, emotional, nervous, or substance use disorder or
condition related to pregnancy or postpartum complications
shall be provided if determined to be medically necessary,
consistent with the requirements of Sections 370c and
370c.1 of this Code. The facility or provider shall notify
the insurer of both the admission and the initial
treatment plan within 48 hours after admission or
initiation of treatment. Subject to the requirements of
Sections 370c and 370c.1 of this Code, nothing in this
paragraph shall prevent an insurer from applying
concurrent and post-service utilization review of health
care services, including review of medical necessity, case
management, experimental and investigational treatments,
managed care provisions, and other terms and conditions of
the insurance policy.

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(4) The benefits for the first 48 hours of initiation
of services for an inpatient admission, detoxification or
withdrawal management program, or partial hospitalization
admission for the treatment of a mental, emotional,
nervous, or substance use disorder or condition related to
pregnancy or postpartum complications shall be provided
without post-service or concurrent review of medical
necessity, as the medical necessity for the first 48 hours
of such services shall be determined solely by the covered
pregnant or postpartum individual's provider. Subject to
Sections Section 370c and 370c.1 of this Code, nothing in
this paragraph shall prevent an insurer from applying
concurrent and post-service utilization review, including
the review of medical necessity, case management,
experimental and investigational treatments, managed care
provisions, and other terms and conditions of the
insurance policy, of any inpatient admission,
detoxification or withdrawal management program admission,
or partial hospitalization admission services for the
treatment of a mental, emotional, nervous, or substance
use disorder or condition related to pregnancy or
postpartum complications received 48 hours after the
initiation of such services. If an insurer determines that
the services are no longer medically necessary, then the
covered person shall have the right to external review
pursuant to the requirements of the Health Carrier

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External Review Act.
(5) If an insurer determines that continued inpatient
care, detoxification or withdrawal management, partial
hospitalization, intensive outpatient treatment, or
outpatient treatment in a facility is no longer medically
necessary, the insurer shall, within 24 hours, provide
written notice to the covered pregnant or postpartum
individual and the covered pregnant or postpartum
individual's provider of its decision and the right to
file an expedited internal appeal of the determination.
The insurer shall review and make a determination with
respect to the internal appeal within 24 hours and
communicate such determination to the covered pregnant or
postpartum individual and the covered pregnant or
postpartum individual's provider. If the determination is
to uphold the denial, the covered pregnant or postpartum
individual and the covered pregnant or postpartum
individual's provider have the right to file an expedited
external appeal. An independent review organization shall
make a determination within 72 hours. If the insurer's
determination is upheld and it is determined that
continued inpatient care, detoxification or withdrawal
management, partial hospitalization, intensive outpatient
treatment, or outpatient treatment is not medically
necessary, or if the insurer's determination is not
appealed, the insurer shall remain responsible for

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providing benefits for the inpatient care, detoxification
or withdrawal management, partial hospitalization,
intensive outpatient treatment, or outpatient treatment
through the day following the date the determination is
made, and the covered pregnant or postpartum individual
shall only be responsible for any applicable copayment,
deductible, and coinsurance for the stay through that date
as applicable under the policy. The covered pregnant or
postpartum individual shall not be discharged or released
from the inpatient facility, detoxification or withdrawal
management, partial hospitalization, intensive outpatient
treatment, or outpatient treatment until all internal
appeals and independent utilization review organization
appeals are exhausted. A decision to reverse an adverse
determination shall comply with the Health Carrier
External Review Act.
(6) Except as otherwise stated in this subsection (b),
the benefits and cost-sharing shall be provided to the
same extent as for any other medical condition covered
under the policy.
(7) The benefits required by paragraphs (2) and (6) of
this subsection (b) are to be provided to all covered
pregnant or postpartum individuals with a diagnosis of a
mental, emotional, nervous, or substance use disorder or
condition. The presence of additional related or unrelated
diagnoses shall not be a basis to reduce or deny the

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benefits required by this subsection (b).
(Source: P.A. 102-665, eff. 10-8-21; 103-650, eff. 1-1-25;
revised 9-10-24.)
(Text of Section after amendment by P.A. 103-701 and
103-720)
Sec. 356z.40. Pregnancy and postpartum coverage.
(a) An individual or group policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed on or after October 8, 2021 (the effective date of
Public Act 102-665) shall provide coverage for pregnancy and
newborn care in accordance with 42 U.S.C. 18022(b) regarding
essential health benefits. For policies amended, delivered,
issued, or renewed on or after January 1, 2026, this
subsection also applies to coverage for postpartum care.
(b) Benefits under this Section shall be as follows:
(1) An individual who has been identified as
experiencing a high-risk pregnancy by the individual's
treating provider shall have access to clinically
appropriate case management programs. As used in this
subsection, "case management" means a mechanism to
coordinate and assure continuity of services, including,
but not limited to, health services, social services, and
educational services necessary for the individual. "Case
management" involves individualized assessment of needs,
planning of services, referral, monitoring, and advocacy

10400SB0708sam003 - 17 - LRB104 07006 BAB 26513 a
to assist an individual in gaining access to appropriate
services and closure when services are no longer required.
"Case management" is an active and collaborative process
involving a single qualified case manager, the individual,
the individual's family, the providers, and the community.
This includes close coordination and involvement with all
service providers in the management plan for that
individual or family, including assuring that the
individual receives the services. As used in this
subsection, "high-risk pregnancy" means a pregnancy in
which the pregnant or postpartum individual or baby is at
an increased risk for poor health or complications during
pregnancy or childbirth, including, but not limited to,
hypertension disorders, gestational diabetes, and
hemorrhage.
(2) An individual shall have access to medically
necessary treatment of a mental, emotional, nervous, or
substance use disorder or condition consistent with the
requirements set forth in this Section and in Sections
370c and 370c.1 of this Code. Prior authorization
requirements are prohibited to the extent provided in
Section 370c.
(3) The benefits provided for inpatient and outpatient
services for the medically necessary treatment of a
mental, emotional, nervous, or substance use disorder or
condition related to pregnancy or postpartum complications

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shall be provided if determined to be medically necessary,
consistent with the requirements of Sections 370c and
370c.1 of this Code. The facility or provider shall notify
the insurer of both the admission and the initial
treatment plan within 48 hours after admission or
initiation of treatment. Subject to the requirements of
Sections 370c and 370c.1 of this Code, nothing in this
paragraph shall prevent an insurer from applying
concurrent and post-service utilization review of health
care services, including review of medical necessity, case
management, experimental and investigational treatments,
managed care provisions, and other terms and conditions of
the insurance policy.
(4) The benefits for the first 48 hours of initiation
of services for an inpatient admission, detoxification or
withdrawal management program, or partial hospitalization
admission for the treatment of a mental, emotional,
nervous, or substance use disorder or condition related to
pregnancy or postpartum complications shall be provided
without post-service or concurrent review of medical
necessity, as the medical necessity for the first 48 hours
of such services shall be determined solely by the covered
pregnant or postpartum individual's provider. Subject to
Sections Section 370c and 370c.1 of this Code, nothing in
this paragraph shall prevent an insurer from applying
concurrent and post-service utilization review, including

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the review of medical necessity, case management,
experimental and investigational treatments, managed care
provisions, and other terms and conditions of the
insurance policy, of any inpatient admission,
detoxification or withdrawal management program admission,
or partial hospitalization admission services for the
treatment of a mental, emotional, nervous, or substance
use disorder or condition related to pregnancy or
postpartum complications received 48 hours after the
initiation of such services. If an insurer determines that
the services are no longer medically necessary, then the
covered person shall have the right to external review
pursuant to the requirements of the Health Carrier
External Review Act.
(5) If an insurer determines that continued inpatient
care, detoxification or withdrawal management, partial
hospitalization, intensive outpatient treatment, or
outpatient treatment in a facility is no longer medically
necessary, the insurer shall, within 24 hours, provide
written notice to the covered pregnant or postpartum
individual and the covered pregnant or postpartum
individual's provider of its decision and the right to
file an expedited internal appeal of the determination.
The insurer shall review and make a determination with
respect to the internal appeal within 24 hours and
communicate such determination to the covered pregnant or

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postpartum individual and the covered pregnant or
postpartum individual's provider. If the determination is
to uphold the denial, the covered pregnant or postpartum
individual and the covered pregnant or postpartum
individual's provider have the right to file an expedited
external appeal. An independent review organization shall
make a determination within 72 hours. If the insurer's
determination is upheld and it is determined that
continued inpatient care, detoxification or withdrawal
management, partial hospitalization, intensive outpatient
treatment, or outpatient treatment is not medically
necessary, or if the insurer's determination is not
appealed, the insurer shall remain responsible for
providing benefits for the inpatient care, detoxification
or withdrawal management, partial hospitalization,
intensive outpatient treatment, or outpatient treatment
through the day following the date the determination is
made, and the covered pregnant or postpartum individual
shall only be responsible for any applicable copayment,
deductible, and coinsurance for the stay through that date
as applicable under the policy. The covered pregnant or
postpartum individual shall not be discharged or released
from the inpatient facility, detoxification or withdrawal
management, partial hospitalization, intensive outpatient
treatment, or outpatient treatment until all internal
appeals and independent utilization review organization

10400SB0708sam003 - 21 - LRB104 07006 BAB 26513 a
appeals are exhausted. A decision to reverse an adverse
determination shall comply with the Health Carrier
External Review Act.
(6) Except as otherwise stated in this subsection (b)
and subsection (c), the benefits and cost-sharing shall be
provided to the same extent as for any other medical
condition covered under the policy.
(7) The benefits required by paragraphs (2) and (6) of
this subsection (b) are to be provided to (i) all covered
pregnant or postpartum individuals with a diagnosis of a
mental, emotional, nervous, or substance use disorder or
condition and (ii) all individuals who have experienced a
miscarriage or stillbirth. The presence of additional
related or unrelated diagnoses shall not be a basis to
reduce or deny the benefits required by this subsection
(b).
(8) Insurers shall cover all services for pregnancy,
postpartum, and newborn care that are rendered by
perinatal doulas or licensed certified professional
midwives, including home births, home visits, and support
during labor, abortion, or miscarriage. Coverage shall
include the necessary equipment and medical supplies for a
home birth. For home visits by a perinatal doula, not
counting any home birth, the policy may limit coverage to
16 visits before and 16 visits after a birth, miscarriage,
or abortion, provided that the policy shall not be

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required to cover more than $8,000 for doula visits for
each pregnancy and subsequent postpartum period. As used
in this paragraph (8), "perinatal doula" has the meaning
given in subsection (a) of Section 5-18.5 of the Illinois
Public Aid Code.
(9) Coverage for pregnancy, postpartum, and newborn
care shall include home visits by lactation consultants
and the purchase of breast pumps and breast pump supplies,
including such breast pumps, breast pump supplies,
breastfeeding supplies, and feeding aids as recommended by
the lactation consultant. As used in this paragraph (9),
"lactation consultant" means an International
Board-Certified Lactation Consultant, a certified
lactation specialist with a certification from Lactation
Education Consultants, or a certified lactation counselor
as defined in subsection (a) of Section 5-18.10 of the
Illinois Public Aid Code.
(10) Coverage for postpartum services shall apply for
all covered services rendered within the first 12 months
after the end of pregnancy, subject to any policy
limitation on home visits by a perinatal doula allowed
under paragraph (8) of this subsection (b). Nothing in
this paragraph (10) shall be construed to require a policy
to cover services for an individual who is no longer
insured or enrolled under the policy. If an individual
becomes insured or enrolled under a new policy, the new

10400SB0708sam003 - 23 - LRB104 07006 BAB 26513 a
policy shall cover the individual consistent with the time
period and limitations allowed under this paragraph (10).
This paragraph (10) is subject to the requirements of
Section 25 of the Managed Care Reform and Patient Rights
Act, Section 20 of the Network Adequacy and Transparency
Act, and 42 U.S.C. 300gg-113.
(c) All coverage described in subsection (b), other than
health care services for home births, shall be provided
without cost-sharing, except that, for mental health services,
the cost-sharing prohibition does not apply to inpatient or
residential services, and, for substance use disorder
services, the cost-sharing prohibition applies only to levels
of treatment below and not including Level 3.1 (Clinically
Managed Low-Intensity Residential), as established by the
American Society for Addiction Medicine. This subsection does
not apply to the extent such coverage would disqualify a
high-deductible health plan from eligibility for a health
savings account pursuant to Section 223 of the Internal
Revenue Code.
(Source: P.A. 102-665, eff. 10-8-21; 103-650, eff. 1-1-25;
103-701, eff. 1-1-26; 103-720, eff. 1-1-26; revised 11-26-24.)
(215 ILCS 5/370c) (from Ch. 73, par. 982c)
Sec. 370c. Mental and emotional disorders.
(a)(1) On and after January 1, 2022 (the effective date of
Public Act 102-579), every insurer that amends, delivers,

10400SB0708sam003 - 24 - LRB104 07006 BAB 26513 a
issues, or renews group accident and health policies providing
coverage for hospital or medical treatment or services for
illness on an expense-incurred basis shall provide coverage
for the medically necessary treatment of mental, emotional,
nervous, or substance use disorders or conditions consistent
with the parity requirements of Section 370c.1 of this Code.
(2) Each insured that is covered for mental, emotional,
nervous, or substance use disorders or conditions shall be
free to select the physician licensed to practice medicine in
all its branches, licensed clinical psychologist, licensed
clinical social worker, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Substance
Use Disorder Act of his or her choice to treat such disorders,
and the insurer shall pay the covered charges of such
physician licensed to practice medicine in all its branches,
licensed clinical psychologist, licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act up
to the limits of coverage, provided (i) the disorder or
condition treated is covered by the policy, and (ii) the
physician, licensed psychologist, licensed clinical social
worker, licensed clinical professional counselor, licensed

10400SB0708sam003 - 25 - LRB104 07006 BAB 26513 a
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act is
authorized to provide said services under the statutes of this
State and in accordance with accepted principles of his or her
profession.
(3) Insofar as this Section applies solely to licensed
clinical social workers, licensed clinical professional
counselors, licensed marriage and family therapists, licensed
speech-language pathologists, and other licensed or certified
professionals at programs licensed pursuant to the Substance
Use Disorder Act, those persons who may provide services to
individuals shall do so after the licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act
has informed the patient of the desirability of the patient
conferring with the patient's primary care physician.
(4) "Mental, emotional, nervous, or substance use disorder
or condition" means a condition or disorder that involves a
mental health condition or substance use disorder that falls
under any of the diagnostic categories listed in the mental
and behavioral disorders chapter of the current edition of the
World Health Organization's International Classification of
Disease or that is listed in the most recent version of the

10400SB0708sam003 - 26 - LRB104 07006 BAB 26513 a
American Psychiatric Association's Diagnostic and Statistical
Manual of Mental Disorders. "Mental, emotional, nervous, or
substance use disorder or condition" includes any mental
health condition that occurs during pregnancy or during the
postpartum period and includes, but is not limited to,
postpartum depression.
(5) Medically necessary treatment and medical necessity
determinations shall be interpreted and made in a manner that
is consistent with and pursuant to subsections (h) through (y)
(t).
(b)(1) (Blank).
(2) (Blank).
(2.5) (Blank).
(3) Unless otherwise prohibited by federal law and
consistent with the parity requirements of Section 370c.1 of
this Code, the reimbursing insurer that amends, delivers,
issues, or renews a group or individual policy of accident and
health insurance, a qualified health plan offered through the
health insurance marketplace, or a provider of treatment of
mental, emotional, nervous, or substance use disorders or
conditions shall furnish medical records or other necessary
data that substantiate that initial or continued treatment is
at all times medically necessary. Nothing in this paragraph
(3) supersedes the prohibition on prior authorization
requirements to the extent provided under subsections (g) and
(w) and subparagraph (A) of paragraph (6.5) of this

10400SB0708sam003 - 27 - LRB104 07006 BAB 26513 a
subsection. An insurer shall provide a mechanism for the
timely review by a provider holding the same license and
practicing in the same specialty as the patient's provider,
who is unaffiliated with the insurer, jointly selected by the
patient (or the patient's next of kin or legal representative
if the patient is unable to act for himself or herself), the
patient's provider, and the insurer in the event of a dispute
between the insurer and patient's provider regarding the
medical necessity of a treatment proposed by a patient's
provider. If the reviewing provider determines the treatment
to be medically necessary, the insurer shall provide
reimbursement for the treatment. Future contractual or
employment actions by the insurer regarding the patient's
provider may not be based on the provider's participation in
this procedure. Nothing prevents the insured from agreeing in
writing to continue treatment at his or her expense. When
making a determination of the medical necessity for a
treatment modality for mental, emotional, nervous, or
substance use disorders or conditions, an insurer must make
the determination in a manner that is consistent with the
manner used to make that determination with respect to other
diseases or illnesses covered under the policy, including an
appeals process. Medical necessity determinations for
substance use disorders shall be made in accordance with
appropriate patient placement criteria established by the
American Society of Addiction Medicine. No additional criteria

10400SB0708sam003 - 28 - LRB104 07006 BAB 26513 a
may be used to make medical necessity determinations for
substance use disorders.
(4) A group health benefit plan amended, delivered,
issued, or renewed on or after January 1, 2019 (the effective
date of Public Act 100-1024) or an individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024):
(A) shall provide coverage based upon medical
necessity for the treatment of a mental, emotional,
nervous, or substance use disorder or condition consistent
with the parity requirements of Section 370c.1 of this
Code; provided, however, that in each calendar year
coverage shall not be less than the following:
(i) 45 days of inpatient treatment; and
(ii) beginning on June 26, 2006 (the effective
date of Public Act 94-921), 60 visits for outpatient
treatment including group and individual outpatient
treatment; and
(iii) for plans or policies delivered, issued for
delivery, renewed, or modified after January 1, 2007
(the effective date of Public Act 94-906), 20
additional outpatient visits for speech therapy for
treatment of pervasive developmental disorders that
will be in addition to speech therapy provided

10400SB0708sam003 - 29 - LRB104 07006 BAB 26513 a
pursuant to item (ii) of this subparagraph (A); and
(B) may not include a lifetime limit on the number of
days of inpatient treatment or the number of outpatient
visits covered under the plan.
(C) (Blank).
(5) An issuer of a group health benefit plan or an
individual policy of accident and health insurance or a
qualified health plan offered through the health insurance
marketplace may not count toward the number of outpatient
visits required to be covered under this Section an outpatient
visit for the purpose of medication management and shall cover
the outpatient visits under the same terms and conditions as
it covers outpatient visits for the treatment of physical
illness.
(5.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after September 9, 2015
(the effective date of Public Act 99-480) shall offer coverage
for medically necessary acute treatment services and medically
necessary clinical stabilization services. The treating
provider shall base all treatment recommendations and the
health benefit plan shall base all medical necessity
determinations for substance use disorders in accordance with
the most current edition of the Treatment Criteria for
Addictive, Substance-Related, and Co-Occurring Conditions
established by the American Society of Addiction Medicine. The
treating provider shall base all treatment recommendations and

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the health benefit plan shall base all medical necessity
determinations for medication-assisted treatment in accordance
with the most current Treatment Criteria for Addictive,
Substance-Related, and Co-Occurring Conditions established by
the American Society of Addiction Medicine.
As used in this subsection:
"Acute treatment services" means 24-hour medically
supervised addiction treatment that provides evaluation and
withdrawal management and may include biopsychosocial
assessment, individual and group counseling, psychoeducational
groups, and discharge planning.
"Clinical stabilization services" means 24-hour treatment,
usually following acute treatment services for substance
abuse, which may include intensive education and counseling
regarding the nature of addiction and its consequences,
relapse prevention, outreach to families and significant
others, and aftercare planning for individuals beginning to
engage in recovery from addiction.
"Prior authorization" has the meaning given to that term
in Section 15 of the Prior Authorization Reform Act.
(6) An issuer of a group health benefit plan may provide or
offer coverage required under this Section through a managed
care plan.
(6.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024):

10400SB0708sam003 - 31 - LRB104 07006 BAB 26513 a
(A) shall not impose prior authorization requirements,
including limitations on dosage, other than those
established under the Treatment Criteria for Addictive,
Substance-Related, and Co-Occurring Conditions
established by the American Society of Addiction Medicine,
on a prescription medication approved by the United States
Food and Drug Administration that is prescribed or
administered for the treatment of substance use disorders;
(B) shall not impose any step therapy requirements;
(C) shall place all prescription medications approved
by the United States Food and Drug Administration
prescribed or administered for the treatment of substance
use disorders on, for brand medications, the lowest tier
of the drug formulary developed and maintained by the
individual or group health benefit plan that covers brand
medications and, for generic medications, the lowest tier
of the drug formulary developed and maintained by the
individual or group health benefit plan that covers
generic medications; and
(D) shall not exclude coverage for a prescription
medication approved by the United States Food and Drug
Administration for the treatment of substance use
disorders and any associated counseling or wraparound
services on the grounds that such medications and services
were court ordered.
(7) (Blank).

10400SB0708sam003 - 32 - LRB104 07006 BAB 26513 a
(8) (Blank).
(9) With respect to all mental, emotional, nervous, or
substance use disorders or conditions, coverage for inpatient
treatment shall include coverage for treatment in a
residential treatment center certified or licensed by the
Department of Public Health or the Department of Human
Services.
(c) This Section shall not be interpreted to require
coverage for speech therapy or other habilitative services for
those individuals covered under Section 356z.15 of this Code.
(d) With respect to a group or individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace, the
Department and, with respect to medical assistance, the
Department of Healthcare and Family Services shall each
enforce the requirements of this Section and Sections 356z.23
and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008, 42
U.S.C. 18031(j), and any amendments to, and federal guidance
or regulations issued under, those Acts, including, but not
limited to, final regulations issued under the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 and final regulations applying the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 to Medicaid managed care organizations, the
Children's Health Insurance Program, and alternative benefit

10400SB0708sam003 - 33 - LRB104 07006 BAB 26513 a
plans. Specifically, the Department and the Department of
Healthcare and Family Services shall take action:
(1) proactively ensuring compliance by individual and
group policies, including by requiring that insurers
submit comparative analyses, as set forth in paragraph (6)
of subsection (k) of Section 370c.1, demonstrating how
they design and apply nonquantitative treatment
limitations, both as written and in operation, for mental,
emotional, nervous, or substance use disorder or condition
benefits as compared to how they design and apply
nonquantitative treatment limitations, as written and in
operation, for medical and surgical benefits;
(2) evaluating all consumer or provider complaints
regarding mental, emotional, nervous, or substance use
disorder or condition coverage for possible parity
violations;
(3) performing parity compliance market conduct
examinations or, in the case of the Department of
Healthcare and Family Services, parity compliance audits
of individual and group plans and policies, including, but
not limited to, reviews of:
(A) nonquantitative treatment limitations,
including, but not limited to, prior authorization
requirements, concurrent review, retrospective review,
step therapy, network admission standards,
reimbursement rates, and geographic restrictions;

10400SB0708sam003 - 34 - LRB104 07006 BAB 26513 a
(B) denials of authorization, payment, and
coverage; and
(C) other specific criteria as may be determined
by the Department.
The findings and the conclusions of the parity compliance
market conduct examinations and audits shall be made public.
The Director may adopt rules to effectuate any provisions
of the Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act of 2008 that relate to the business of
insurance.
(e) Availability of plan information.
(1) The criteria for medical necessity determinations
made under a group health plan, an individual policy of
accident and health insurance, or a qualified health plan
offered through the health insurance marketplace with
respect to mental health or substance use disorder
benefits (or health insurance coverage offered in
connection with the plan with respect to such benefits)
must be made available by the plan administrator (or the
health insurance issuer offering such coverage) to any
current or potential participant, beneficiary, or
contracting provider upon request.
(2) The reason for any denial under a group health
benefit plan, an individual policy of accident and health
insurance, or a qualified health plan offered through the
health insurance marketplace (or health insurance coverage

10400SB0708sam003 - 35 - LRB104 07006 BAB 26513 a
offered in connection with such plan or policy) of
reimbursement or payment for services with respect to
mental, emotional, nervous, or substance use disorders or
conditions benefits in the case of any participant or
beneficiary must be made available within a reasonable
time and in a reasonable manner and in readily
understandable language by the plan administrator (or the
health insurance issuer offering such coverage) to the
participant or beneficiary upon request.
(f) As used in this Section, "group policy of accident and
health insurance" and "group health benefit plan" includes (1)
State-regulated employer-sponsored group health insurance
plans written in Illinois or which purport to provide coverage
for a resident of this State; and (2) State, county,
municipal, or school district employee health plans.
References to an insurer include all plans described in this
subsection.
(g) (1) As used in this subsection:
"Benefits", with respect to insurers that are not Medicaid
managed care organizations, means the benefits provided for
treatment services for inpatient and outpatient treatment of
substance use disorders or conditions at American Society of
Addiction Medicine levels of treatment 2.1 (Intensive
Outpatient), 2.5 (High-Intensity Outpatient) (Partial
Hospitalization), 3.1 (Clinically Managed Low-Intensity
Residential), 3.3 (Clinically Managed Population-Specific

10400SB0708sam003 - 36 - LRB104 07006 BAB 26513 a
High-Intensity Residential), 3.5 (Clinically Managed
High-Intensity Residential), and 3.7 (Medically Managed
Residential Monitored Intensive Inpatient) and OMT (Opioid
Maintenance Therapy) services.
"Benefits", with respect to Medicaid managed care
organizations, means the benefits provided for treatment
services for inpatient and outpatient treatment of substance
use disorders or conditions at American Society of Addiction
Medicine levels of treatment 2.1 (Intensive Outpatient), 2.5
(High-Intensity Outpatient) (Partial Hospitalization), 3.5
(Clinically Managed High-Intensity Residential), and 3.7
(Medically Managed Residential Monitored Intensive Inpatient)
and OMT (Opioid Maintenance Therapy) services.
"Substance use disorder treatment provider or facility"
means a licensed physician, licensed psychologist, licensed
psychiatrist, licensed advanced practice registered nurse, or
licensed, certified, or otherwise State-approved facility or
provider of substance use disorder treatment.
(2) A group health insurance policy, an individual health
benefit plan, or qualified health plan that is offered through
the health insurance marketplace, small employer group health
plan, and large employer group health plan that is amended,
delivered, issued, executed, or renewed in this State, or
approved for issuance or renewal in this State, on or after
January 1, 2019 (the effective date of Public Act 100-1023)
shall comply with the requirements of this Section and Section

10400SB0708sam003 - 37 - LRB104 07006 BAB 26513 a
370c.1. The services for the treatment and the ongoing
assessment of the patient's progress in treatment shall follow
the requirements of 77 Ill. Adm. Code 2060.
(3) Prior authorization shall not be utilized for the
benefits under this subsection. Except to the extent
prohibited by Section 370c.1 with respect to treatment
limitations in a benefit classification or subclassification,
the insurer may require the The substance use disorder
treatment provider or facility to shall notify the insurer of
the initiation of treatment. For an insurer that is not a
Medicaid managed care organization, the substance use disorder
treatment provider or facility may be required to give
notification shall occur for the initiation of treatment of
the covered person within 2 business days. For Medicaid
managed care organizations, the substance use disorder
treatment provider or facility may be required to give
notification shall occur in accordance with the protocol set
forth in the provider agreement for initiation of treatment
within 24 hours. If the Medicaid managed care organization is
not capable of accepting the notification in accordance with
the contractual protocol during the 24-hour period following
admission, the substance use disorder treatment provider or
facility shall have one additional business day to provide the
notification to the appropriate managed care organization.
Treatment plans shall be developed in accordance with the
requirements and timeframes established in 77 Ill. Adm. Code

10400SB0708sam003 - 38 - LRB104 07006 BAB 26513 a
2060. No such coverage shall be subject to concurrent review
prior to the applicable notification deadline. If coverage is
denied retrospectively, neither the provider or facility nor
the insurer shall bill, and the covered individual shall not
be liable, for any treatment under this subsection through the
date the adverse determination is issued, other than any
copayment, coinsurance, or deductible for the treatment or
stay through that date as applicable under the policy.
Coverage shall not be retrospectively denied for benefits that
were furnished at a participating substance use disorder
facility prior to the applicable notification deadline except
for the following: If the substance use disorder treatment
provider or facility fails to notify the insurer of the
initiation of treatment in accordance with these provisions,
the insurer may follow its normal prior authorization
processes.
(A) upon reasonable determination that the benefits
were not provided;
(B) upon determination that the patient receiving the
treatment was not an insured, enrollee, or beneficiary
under the policy;
(C) upon material misrepresentation by the patient or
provider. As used in this subparagraph (C), "material"
means a fact or situation that is not merely technical in
nature and results or could result in a substantial change
in the situation;

10400SB0708sam003 - 39 - LRB104 07006 BAB 26513 a
(D) upon determination that a service was excluded
under the terms of coverage. For situations that qualify
under this subparagraph (D), the limitation to billing for
a copayment, coinsurance, or deductible shall not apply;
(E) upon determination that a service was not
medically necessary consistent with subsections (h)
through (n); or
(F) upon determination that the patient did not
consent to the treatment and that there was no court order
mandating the treatment.
(4) For an insurer that is not a Medicaid managed care
organization, if an insurer determines that benefits are no
longer medically necessary, the insurer shall notify the
covered person, the covered person's authorized
representative, if any, and the covered person's health care
provider in writing of the covered person's right to request
an external review pursuant to the Health Carrier External
Review Act. The notification shall occur within 24 hours
following the adverse determination.
Pursuant to the requirements of the Health Carrier
External Review Act, the covered person or the covered
person's authorized representative may request an expedited
external review. An expedited external review may not occur if
the substance use disorder treatment provider or facility
determines that continued treatment is no longer medically
necessary.

10400SB0708sam003 - 40 - LRB104 07006 BAB 26513 a
If an expedited external review request meets the criteria
of the Health Carrier External Review Act, an independent
review organization shall make a final determination of
medical necessity within 72 hours. If an independent review
organization upholds an adverse determination, an insurer
shall remain responsible to provide coverage of benefits
through the day following the determination of the independent
review organization. A decision to reverse an adverse
determination shall comply with the Health Carrier External
Review Act.
(5) The substance use disorder treatment provider or
facility shall provide the insurer with 7 business days'
advance notice of the planned discharge of the patient from
the substance use disorder treatment provider or facility and
notice on the day that the patient is discharged from the
substance use disorder treatment provider or facility.
(6) The benefits required by this subsection shall be
provided to all covered persons with a diagnosis of substance
use disorder or conditions. The presence of additional related
or unrelated diagnoses shall not be a basis to reduce or deny
the benefits required by this subsection.
(7) Nothing in this subsection shall be construed to
require an insurer to provide coverage for any of the benefits
in this subsection.
(8) Any concurrent or retrospective review permitted by
this subsection must be consistent with the utilization review

10400SB0708sam003 - 41 - LRB104 07006 BAB 26513 a
provisions in subsections (h) through (n).
(h) As used in this Section:
"Generally accepted standards of mental, emotional,
nervous, or substance use disorder or condition care" means
standards of care and clinical practice that are generally
recognized by health care providers practicing in relevant
clinical specialties such as psychiatry, psychology, clinical
sociology, social work, addiction medicine and counseling, and
behavioral health treatment. Valid, evidence-based sources
reflecting generally accepted standards of mental, emotional,
nervous, or substance use disorder or condition care include
peer-reviewed scientific studies and medical literature,
recommendations of nonprofit health care provider professional
associations and specialty societies, including, but not
limited to, patient placement criteria and clinical practice
guidelines, recommendations of federal government agencies,
and drug labeling approved by the United States Food and Drug
Administration.
"Medically necessary treatment of mental, emotional,
nervous, or substance use disorders or conditions" means a
service or product addressing the specific needs of that
patient, for the purpose of screening, preventing, diagnosing,
managing, or treating an illness, injury, or condition or its
symptoms and comorbidities, including minimizing the
progression of an illness, injury, or condition or its
symptoms and comorbidities in a manner that is all of the

10400SB0708sam003 - 42 - LRB104 07006 BAB 26513 a
following:
(1) in accordance with the generally accepted
standards of mental, emotional, nervous, or substance use
disorder or condition care;
(2) clinically appropriate in terms of type,
frequency, extent, site, and duration; and
(3) not primarily for the economic benefit of the
insurer, purchaser, or for the convenience of the patient,
treating physician, or other health care provider.
"Utilization review" means either of the following:
(1) prospectively, retrospectively, or concurrently
reviewing and approving, modifying, delaying, or denying,
based in whole or in part on medical necessity, requests
by health care providers, insureds, or their authorized
representatives for coverage of health care services
before, retrospectively, or concurrently with the
provision of health care services to insureds.
(2) evaluating the medical necessity, appropriateness,
level of care, service intensity, efficacy, or efficiency
of health care services, benefits, procedures, or
settings, under any circumstances, to determine whether a
health care service or benefit subject to a medical
necessity coverage requirement in an insurance policy is
covered as medically necessary for an insured.
"Utilization review criteria" means patient placement
criteria or any criteria, standards, protocols, or guidelines

10400SB0708sam003 - 43 - LRB104 07006 BAB 26513 a
used by an insurer to conduct utilization review.
(i)(1) Every insurer that amends, delivers, issues, or
renews a group or individual policy of accident and health
insurance or a qualified health plan offered through the
health insurance marketplace in this State and Medicaid
managed care organizations providing coverage for hospital or
medical treatment on or after January 1, 2023 shall, pursuant
to subsections (h) through (s), provide coverage for medically
necessary treatment of mental, emotional, nervous, or
substance use disorders or conditions.
(2) An insurer shall not set a specific limit on the
duration of benefits or coverage of medically necessary
treatment of mental, emotional, nervous, or substance use
disorders or conditions or limit coverage only to alleviation
of the insured's current symptoms.
(3) All utilization review conducted by the insurer
concerning diagnosis, prevention, and treatment of insureds
diagnosed with mental, emotional, nervous, or substance use
disorders or conditions shall be conducted in accordance with
the requirements of subsections (k) through (w).
(4) An insurer that authorizes a specific type of
treatment by a provider pursuant to this Section shall not
rescind or modify the authorization after that provider
renders the health care service in good faith and pursuant to
this authorization for any reason, including, but not limited
to, the insurer's subsequent cancellation or modification of

10400SB0708sam003 - 44 - LRB104 07006 BAB 26513 a
the insured's or policyholder's contract, or the insured's or
policyholder's eligibility. Nothing in this Section shall
require the insurer to cover a treatment when the
authorization was granted based on a material
misrepresentation by the insured, the policyholder, or the
provider. Nothing in this Section shall require Medicaid
managed care organizations to pay for services if the
individual was not eligible for Medicaid at the time the
service was rendered. Nothing in this Section shall require an
insurer to pay for services if the individual was not the
insurer's enrollee at the time services were rendered. As used
in this paragraph, "material" means a fact or situation that
is not merely technical in nature and results in or could
result in a substantial change in the situation.
(j) An insurer shall not limit benefits or coverage for
medically necessary services on the basis that those services
should be or could be covered by a public entitlement program,
including, but not limited to, special education or an
individualized education program, Medicaid, Medicare,
Supplemental Security Income, or Social Security Disability
Insurance, and shall not include or enforce a contract term
that excludes otherwise covered benefits on the basis that
those services should be or could be covered by a public
entitlement program. Nothing in this subsection shall be
construed to require an insurer to cover benefits that have
been authorized and provided for a covered person by a public

10400SB0708sam003 - 45 - LRB104 07006 BAB 26513 a
entitlement program. Medicaid managed care organizations are
not subject to this subsection.
(k) An insurer shall base any medical necessity
determination or the utilization review criteria that the
insurer, and any entity acting on the insurer's behalf,
applies to determine the medical necessity of health care
services and benefits for the diagnosis, prevention, and
treatment of mental, emotional, nervous, or substance use
disorders or conditions on current generally accepted
standards of mental, emotional, nervous, or substance use
disorder or condition care. All denials and appeals shall be
reviewed by a professional with experience or expertise
comparable to the provider requesting the authorization.
(l) In conducting utilization review of all covered health
care services for the diagnosis, prevention, and treatment of
mental, emotional, and nervous disorders or conditions, an
insurer shall apply the criteria and guidelines set forth in
the most recent version of the treatment criteria developed by
an unaffiliated nonprofit professional association for the
relevant clinical specialty or, for Medicaid managed care
organizations, criteria and guidelines determined by the
Department of Healthcare and Family Services that are
consistent with generally accepted standards of mental,
emotional, nervous or substance use disorder or condition
care. Pursuant to subsection (b), in conducting utilization
review of all covered services and benefits for the diagnosis,

10400SB0708sam003 - 46 - LRB104 07006 BAB 26513 a
prevention, and treatment of substance use disorders an
insurer shall use the most recent edition of the patient
placement criteria established by the American Society of
Addiction Medicine.
(m) In conducting utilization review relating to level of
care placement, continued stay, transfer, discharge, or any
other patient care decisions that are within the scope of the
sources specified in subsection (l), an insurer shall not
apply different, additional, conflicting, or more restrictive
utilization review criteria than the criteria set forth in
those sources. For all level of care placement decisions, the
insurer shall authorize placement at the level of care
consistent with the assessment of the insured using the
relevant patient placement criteria as specified in subsection
(l). If that level of placement is not available, the insurer
shall authorize the next higher level of care. In the event of
disagreement, the insurer shall provide full detail of its
assessment using the relevant criteria as specified in
subsection (l) to the provider of the service and the patient.
If an insurer purchases or licenses utilization review
criteria pursuant to this subsection, the insurer shall verify
and document before use that the criteria were developed in
accordance with subsection (k).
(n) In conducting utilization review that is outside the
scope of the criteria as specified in subsection (l) or
relates to the advancements in technology or in the types or

10400SB0708sam003 - 47 - LRB104 07006 BAB 26513 a
levels of care that are not addressed in the most recent
versions of the sources specified in subsection (l), an
insurer shall conduct utilization review in accordance with
subsection (k).
(o) This Section does not in any way limit the rights of a
patient under the Medical Patient Rights Act.
(p) This Section does not in any way limit early and
periodic screening, diagnostic, and treatment benefits as
defined under 42 U.S.C. 1396d(r).
(q) To ensure the proper use of the criteria described in
subsection (l), every insurer shall do all of the following:
(1) Educate the insurer's staff, including any third
parties contracted with the insurer to review claims,
conduct utilization reviews, or make medical necessity
determinations about the utilization review criteria.
(2) Make the educational program available to other
stakeholders, including the insurer's participating or
contracted providers and potential participants,
beneficiaries, or covered lives. The education program
must be provided at least once a year, in-person or
digitally, or recordings of the education program must be
made available to the aforementioned stakeholders.
(3) Provide, at no cost, the utilization review
criteria and any training material or resources to
providers and insured patients upon request. For
utilization review criteria not concerning level of care

10400SB0708sam003 - 48 - LRB104 07006 BAB 26513 a
placement, continued stay, transfer, discharge, or other
patient care decisions used by the insurer pursuant to
subsection (m), the insurer may place the criteria on a
secure, password-protected website so long as the access
requirements of the website do not unreasonably restrict
access to insureds or their providers. No restrictions
shall be placed upon the insured's or treating provider's
access right to utilization review criteria obtained under
this paragraph at any point in time, including before an
initial request for authorization.
(4) Track, identify, and analyze how the utilization
review criteria are used to certify care, deny care, and
support the appeals process.
(5) Conduct interrater reliability testing to ensure
consistency in utilization review decision making that
covers how medical necessity decisions are made; this
assessment shall cover all aspects of utilization review
as defined in subsection (h).
(6) Run interrater reliability reports about how the
clinical guidelines are used in conjunction with the
utilization review process and parity compliance
activities.
(7) Achieve interrater reliability pass rates of at
least 90% and, if this threshold is not met, immediately
provide for the remediation of poor interrater reliability
and interrater reliability testing for all new staff

10400SB0708sam003 - 49 - LRB104 07006 BAB 26513 a
before they can conduct utilization review without
supervision.
(8) Maintain documentation of interrater reliability
testing and the remediation actions taken for those with
pass rates lower than 90% and submit to the Department of
Insurance or, in the case of Medicaid managed care
organizations, the Department of Healthcare and Family
Services the testing results and a summary of remedial
actions as part of parity compliance reporting set forth
in subsection (k) of Section 370c.1.
(r) This Section applies to all health care services and
benefits for the diagnosis, prevention, and treatment of
mental, emotional, nervous, or substance use disorders or
conditions covered by an insurance policy, including
prescription drugs.
(s) This Section applies to an insurer that amends,
delivers, issues, or renews a group or individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace in this State
providing coverage for hospital or medical treatment and
conducts utilization review as defined in this Section,
including Medicaid managed care organizations, and any entity
or contracting provider that performs utilization review or
utilization management functions on an insurer's behalf.
(t) If the Director determines that an insurer has
violated this Section, the Director may, after appropriate

10400SB0708sam003 - 50 - LRB104 07006 BAB 26513 a
notice and opportunity for hearing, by order, assess a civil
penalty between $1,000 and $5,000 for each violation. Moneys
collected from penalties shall be deposited into the Parity
Advancement Fund established in subsection (i) of Section
370c.1.
(u) An insurer shall not adopt, impose, or enforce terms
in its policies or provider agreements, in writing or in
operation, that undermine, alter, or conflict with the
requirements of this Section.
(v) The provisions of this Section are severable. If any
provision of this Section or its application is held invalid,
that invalidity shall not affect other provisions or
applications that can be given effect without the invalid
provision or application.
(w) Beginning January 1, 2026, coverage for medically
necessary treatment of mental, emotional, or nervous disorders
or conditions for inpatient mental health treatment at
participating hospitals shall comply with the following
requirements:
(1) No Subject to paragraphs (2) and (3) of this
subsection, no policy shall require prior authorization
for outpatient or partial hospitalization services for
treatment of mental, emotional, or nervous disorders or
conditions provided by a physician licensed to practice
medicine in all branches, a licensed clinical
psychologist, a licensed clinical social worker, a

10400SB0708sam003 - 51 - LRB104 07006 BAB 26513 a
licensed clinical professional counselor, a licensed
marriage and family therapist, a licensed speech-language
pathologist, or any other type of licensed, certified, or
legally authorized provider, including trainees working
under the supervision of a licensed health care
professional listed under this subsection, or facility
whose outpatient or partial hospitalization services the
policy covers for treatment of mental, emotional, or
nervous disorders or conditions. Such coverage may be
subject to concurrent and retrospective review consistent
with the utilization review provisions in subsections (h)
through (n) and Section 370c.1. Nothing in this paragraph
(1) supersedes a health maintenance organization's
referral requirement for services from nonparticipating
providers. An insurer may require providers or facilities
to notify the insurer of the initiation of treatment as
specified in this subsection, except to the extent
prohibited by Section 370c.1 with respect to treatment
limitations in a benefit classification or
subclassification. No such coverage shall be subject to
concurrent review for any services furnished before an
applicable notification deadline, subject to the
following: admission for such treatment at any
participating hospital.
(A) In the case of outpatient treatment, for an
insurer that is not a Medicaid managed care

10400SB0708sam003 - 52 - LRB104 07006 BAB 26513 a
organization, the insurer may set a notification
deadline of 2 business days after the initiation of
the covered person's treatment. A Medicaid managed
care organization may set a deadline of 24 hours after
the initiation of treatment. If the Medicaid managed
care organization is not capable of accepting the
notification in accordance with the contractual
protocol within the 24-hour period following
initiation, the treatment provider or facility shall
have one additional business day to provide the
notification to the Medicaid managed care
organization.
(B) In the case of a partial hospitalization
program, for an insurer that is not a Medicaid managed
care organization, the insurer may set a notification
deadline of 48 hours after the initiation of the
covered person's treatment. A Medicaid managed care
organization may set a deadline of 24 hours after the
initiation of treatment. If the Medicaid managed care
organization is not capable of accepting the
notification in accordance with the contractual
protocol during the 24-hour period following
initiation, the treatment provider or facility shall
have one additional business day to provide the
notification to the Medicaid managed care
organization.

10400SB0708sam003 - 53 - LRB104 07006 BAB 26513 a
(2) No policy shall require prior authorization for
inpatient treatment at a hospital for mental, emotional,
or nervous disorders or conditions at a participating
provider. Additionally, no such coverage shall Coverage
provided under this subsection also shall not be subject
to concurrent review for the first 72 hours after
admission, provided that the provider hospital must notify
the insurer of both the admission and the initial
treatment plan within 48 hours of admission. A discharge
plan must be fully developed and continuity services
prepared to meet the patient's needs and the patient's
community preference upon release. Nothing in this
paragraph supersedes a health maintenance organization's
referral requirement for services from nonparticipating
providers upon a patient's discharge from a hospital
Recommended level of care placements identified in the
discharge plan shall comply with generally accepted
standards of care, as defined in subsection (h).
(A) If the provider satisfies the conditions of
paragraph (2), then the insurer shall approve coverage
of the recommended level of care, if applicable, upon
discharge subject to concurrent review.
(B) Nothing in this paragraph supersedes a health
maintenance organization's referral requirement for
services from nonparticipating providers upon a
patient's discharge from a hospital or facility.

10400SB0708sam003 - 54 - LRB104 07006 BAB 26513 a
(C) Concurrent review for such coverage must be
consistent with the utilization review provisions in
subsections (h) through (n).
(D) In this subsection, residential treatment that
is not otherwise identified in the discharge plan is
not inpatient hospitalization.
(3) Treatment provided under this subsection may be
reviewed retrospectively. If coverage is denied
retrospectively, neither the insurer nor the participating
provider hospital shall bill, and the insured shall not be
liable, for any treatment under this subsection through
the date the adverse determination is issued, other than
any copayment, coinsurance, or deductible for the stay
through that date as applicable under the policy. Coverage
shall not be retrospectively denied for the first 72 hours
of admission to inpatient hospitalization for treatment of
mental, emotional, or nervous disorders or conditions, or
before the applicable deadline under paragraph (1) of this
subsection for outpatient treatment or partial
hospitalization programs, treatment at a participating
provider hospital except:
(A) upon reasonable determination that the
inpatient mental health treatment was not provided;
(B) upon determination that the patient receiving
the treatment was not an insured, enrollee, or
beneficiary under the policy;

10400SB0708sam003 - 55 - LRB104 07006 BAB 26513 a
(C) upon material misrepresentation by the patient
or health care provider. In this item (C), "material"
means a fact or situation that is not merely technical
in nature and results or could result in a substantial
change in the situation; or
(D) upon determination that a service was excluded
under the terms of coverage. In that case, the
limitation to billing for a copayment, coinsurance, or
deductible shall not apply; .
(E) for outpatient treatment or partial
hospitalization programs only, upon determination that
a service was not medically necessary consistent with
subsections (h) through (n); or
(F) upon determination that the patient did not
consent to the treatment and that there was no court
order mandating the treatment.
(4) Nothing in this subsection shall be construed to
require a policy to cover any health care service excluded
under the terms of coverage.
This subsection does not apply to coverage for any
prescription or over-the-counter drug.
Nothing in this subsection shall be construed to
require the medical assistance program to reimburse for
services not covered by the medical assistance program as
authorized by the Illinois Public Aid Code or the
Children's Health Insurance Program Act.

10400SB0708sam003 - 56 - LRB104 07006 BAB 26513 a
(x) Notwithstanding any provision of this Section, nothing
shall require the medical assistance program under Article V
of the Illinois Public Aid Code or the Children's Health
Insurance Program Act to violate any applicable federal laws,
regulations, or grant requirements, including requirements for
utilization management, or any State or federal consent
decrees. Nothing in subsection (g) or subsection (w) shall
prevent the Department of Healthcare and Family Services from
requiring a health care provider to use specified level of
care, admission, continued stay, or discharge criteria,
including, but not limited to, those under Section 5-5.23 of
the Illinois Public Aid Code, as long as the Department of
Healthcare and Family Services, subject to applicable federal
laws, regulations, or grant requirements, including
requirements for utilization management, does not require a
health care provider to seek prior authorization or concurrent
review from the Department of Healthcare and Family Services,
a Medicaid managed care organization, or a utilization review
organization under the circumstances expressly prohibited by
subsections (g) and subsection (w). Nothing in this Section
prohibits a health plan, including a Medicaid managed care
organization, from conducting reviews for medical necessity,
clinical appropriateness, safety, fraud, waste, or abuse and
reporting suspected fraud, waste, or abuse according to State
and federal requirements. Nothing in this Section limits the
authority of the Department of Healthcare and Family Services

10400SB0708sam003 - 57 - LRB104 07006 BAB 26513 a
or another State agency, or a Medicaid managed care
organization on the State agency's behalf, to (i) implement or
require programs, services, screenings, assessments, tools, or
reviews to comply with applicable federal law, federal
regulation, federal grant requirements, any State or federal
consent decrees or court orders, or any applicable case law,
such as Olmstead v. L.C., 527 U.S. 581 (1999), or (ii)
administer or require programs, services, screenings,
assessments, tools, or reviews established under State or
federal laws, rules, or regulations in compliance with State
or federal laws, rules, or regulations, including, but not
limited to, the Children's Mental Health Act and the Mental
Health and Developmental Disabilities Administrative Act.
(y) (Blank). Children's Mental Health. Nothing in this
Section shall suspend the screening and assessment
requirements for mental health services for children
participating in the State's medical assistance program as
required in Section 5-5.23 of the Illinois Public Aid Code.
(Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22;
102-813, eff. 5-13-22; 103-426, eff. 8-4-23; 103-650, eff.
1-1-25; 103-1040, eff. 8-9-24; revised 11-26-24.)
Section 10. The Network Adequacy and Transparency Act is
amended by changing Section 10 as follows:
(215 ILCS 124/10)

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(Text of Section from P.A. 103-650)
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 women's principal health care providers.
An issuer 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 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

10400SB0708sam003 - 59 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 60 - LRB104 07006 BAB 26513 a
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 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

10400SB0708sam003 - 61 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 62 - LRB104 07006 BAB 26513 a
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, 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.
(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

10400SB0708sam003 - 63 - LRB104 07006 BAB 26513 a
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;

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(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).
(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.

10400SB0708sam003 - 65 - LRB104 07006 BAB 26513 a
(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

10400SB0708sam003 - 66 - LRB104 07006 BAB 26513 a
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.
(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

10400SB0708sam003 - 67 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 68 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 69 - LRB104 07006 BAB 26513 a
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,

10400SB0708sam003 - 70 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 71 - LRB104 07006 BAB 26513 a
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
after 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.
(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

10400SB0708sam003 - 72 - LRB104 07006 BAB 26513 a
this Section.
(g) Except for the requirements set forth in subsection
(d-5), issuers who are not able to comply with the provider
ratios and time and distance or 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.

10400SB0708sam003 - 73 - LRB104 07006 BAB 26513 a
(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.

10400SB0708sam003 - 74 - LRB104 07006 BAB 26513 a
(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. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22;
102-1117, eff. 1-13-23; 103-650, eff. 1-1-25.)
(Text of Section from P.A. 103-656)
Sec. 10. Network adequacy.

10400SB0708sam003 - 75 - LRB104 07006 BAB 26513 a
(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
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

10400SB0708sam003 - 76 - LRB104 07006 BAB 26513 a
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
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

10400SB0708sam003 - 77 - LRB104 07006 BAB 26513 a
(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 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

10400SB0708sam003 - 78 - LRB104 07006 BAB 26513 a
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)

10400SB0708sam003 - 79 - LRB104 07006 BAB 26513 a
and (e) of Section 55 of the Prior Authorization Reform
Act.
(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. 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;

10400SB0708sam003 - 80 - LRB104 07006 BAB 26513 a
(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).
(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

10400SB0708sam003 - 81 - LRB104 07006 BAB 26513 a
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).
(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

10400SB0708sam003 - 82 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 83 - LRB104 07006 BAB 26513 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,

10400SB0708sam003 - 84 - LRB104 07006 BAB 26513 a
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
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 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

10400SB0708sam003 - 85 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 86 - LRB104 07006 BAB 26513 a
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.
(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), insurers who are not able to comply with the provider
ratios and time and distance standards 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

10400SB0708sam003 - 87 - LRB104 07006 BAB 26513 a
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
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; 103-656, eff. 1-1-25.)
(Text of Section from P.A. 103-718)
Sec. 10. Network adequacy.

10400SB0708sam003 - 88 - LRB104 07006 BAB 26513 a
(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 obstetrical and gynecological health care
professionals.
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
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

10400SB0708sam003 - 89 - LRB104 07006 BAB 26513 a
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
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

10400SB0708sam003 - 90 - LRB104 07006 BAB 26513 a
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 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

10400SB0708sam003 - 91 - LRB104 07006 BAB 26513 a
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.

10400SB0708sam003 - 92 - LRB104 07006 BAB 26513 a
(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. 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;

10400SB0708sam003 - 93 - LRB104 07006 BAB 26513 a
(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).
(d) The network plan shall demonstrate to the Director
maximum travel and distance standards for plan beneficiaries,

10400SB0708sam003 - 94 - LRB104 07006 BAB 26513 a
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).
(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

10400SB0708sam003 - 95 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 96 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 97 - LRB104 07006 BAB 26513 a
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
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 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,

10400SB0708sam003 - 98 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 99 - LRB104 07006 BAB 26513 a
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.
(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), insurers who are not able to comply with the provider
ratios and time and distance standards 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

10400SB0708sam003 - 100 - LRB104 07006 BAB 26513 a
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
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; 103-718, eff. 7-19-24.)

10400SB0708sam003 - 101 - LRB104 07006 BAB 26513 a
(Text of Section from P.A. 103-777)
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
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

10400SB0708sam003 - 102 - LRB104 07006 BAB 26513 a
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
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

10400SB0708sam003 - 103 - LRB104 07006 BAB 26513 a
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 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

10400SB0708sam003 - 104 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 105 - LRB104 07006 BAB 26513 a
preferred provider. This provision shall be consistent
with Section 356z.3a of the Illinois Insurance Code.
(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;

10400SB0708sam003 - 106 - LRB104 07006 BAB 26513 a
(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; and
(CC) HIV.
(2) The Director shall establish a process for the
review of the adequacy of these standards, along with an

10400SB0708sam003 - 107 - LRB104 07006 BAB 26513 a
assessment of additional specialties to be included in the
list under this subsection (c).
(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

10400SB0708sam003 - 108 - LRB104 07006 BAB 26513 a
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 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

10400SB0708sam003 - 109 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 110 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 111 - LRB104 07006 BAB 26513 a
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
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 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.

10400SB0708sam003 - 112 - LRB104 07006 BAB 26513 a
(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.

10400SB0708sam003 - 113 - LRB104 07006 BAB 26513 a
(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 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), insurers 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

10400SB0708sam003 - 114 - LRB104 07006 BAB 26513 a
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
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

10400SB0708sam003 - 115 - LRB104 07006 BAB 26513 a
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; 103-777, eff. 1-1-25.)
(Text of Section from P.A. 103-906)
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

10400SB0708sam003 - 116 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 117 - LRB104 07006 BAB 26513 a
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 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

10400SB0708sam003 - 118 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 119 - LRB104 07006 BAB 26513 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, 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. The Department shall consider establishing
ratios for the following physicians or other providers:
(A) Primary Care;
(B) Pediatrics;
(C) Cardiology;

10400SB0708sam003 - 120 - LRB104 07006 BAB 26513 a
(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; and
(CC) HIV.

10400SB0708sam003 - 121 - LRB104 07006 BAB 26513 a
(1.5) Beginning January 1, 2026, every insurer 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).
(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

10400SB0708sam003 - 122 - LRB104 07006 BAB 26513 a
additional specialties to be included in the list under this
subsection (d).
(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
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

10400SB0708sam003 - 123 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 124 - LRB104 07006 BAB 26513 a
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

10400SB0708sam003 - 125 - LRB104 07006 BAB 26513 a
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 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

10400SB0708sam003 - 126 - LRB104 07006 BAB 26513 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.
(e) Except for network plans solely offered as a group

10400SB0708sam003 - 127 - LRB104 07006 BAB 26513 a
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), insurers who are not able to comply with the provider
ratios and time and distance standards 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,

10400SB0708sam003 - 128 - LRB104 07006 BAB 26513 a
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) 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; 103-906, eff. 1-1-25.)
Section 15. 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)
(Text of Section before amendment by P.A. 103-808)
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, 143.31, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
155.49, 352c, 355.2, 355.3, 355.6, 355.7, 355b, 355c, 356f,

10400SB0708sam003 - 129 - LRB104 07006 BAB 26513 a
356g.5-1, 356m, 356q, 356u.10, 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, 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.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.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
356z.69, 356z.70, 356z.71, 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

10400SB0708sam003 - 130 - LRB104 07006 BAB 26513 a
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
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

10400SB0708sam003 - 131 - LRB104 07006 BAB 26513 a
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
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

10400SB0708sam003 - 132 - LRB104 07006 BAB 26513 a
agreement on competition.
(f) Except for small employer groups as defined in the
Small Employer Rating, Renewability and Portability Health
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

10400SB0708sam003 - 133 - LRB104 07006 BAB 26513 a
or unprofitable experience may be calculated taking into
account the refund period and the immediately preceding 2
plan years.
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;

10400SB0708sam003 - 134 - LRB104 07006 BAB 26513 a
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;
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; 103-605, eff. 7-1-24;
103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)
(Text of Section after amendment by P.A. 103-808)
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, 143.31, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
155.49, 352c, 355.2, 355.3, 355.6, 355.7, 355b, 355c, 356f,
356g, 356g.5-1, 356m, 356q, 356u.10, 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, 356z.15, 356z.17,
356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,

10400SB0708sam003 - 135 - LRB104 07006 BAB 26513 a
356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 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.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
356z.69, 356z.70, 356z.71, 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
1/2 of the Illinois Insurance Code.

10400SB0708sam003 - 136 - LRB104 07006 BAB 26513 a
(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
forma financial statements reflecting projected

10400SB0708sam003 - 137 - LRB104 07006 BAB 26513 a
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
Insurance Act and except for medicare supplement policies as

10400SB0708sam003 - 138 - LRB104 07006 BAB 26513 a
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.
The Health Maintenance Organization shall include a

10400SB0708sam003 - 139 - LRB104 07006 BAB 26513 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;
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.

10400SB0708sam003 - 140 - LRB104 07006 BAB 26513 a
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; 103-605, eff. 7-1-24;
103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised
11-26-24.)
Section 20. The Voluntary Health Services Plans Act is
amended by changing Section 10 as follows:
(215 ILCS 165/10) (from Ch. 32, par. 604)
Sec. 10. Application of Insurance Code provisions. Health
services plan corporations and all persons interested therein
or dealing therewith shall be subject to the provisions of
Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3,
355.7, 355b, 355d, 356g, 356g.5, 356g.5-1, 356m, 356q, 356r,
356t, 356u, 356u.10, 356v, 356w, 356x, 356y, 356z.1, 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, 356z.15, 356z.18,
356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,

10400SB0708sam003 - 141 - LRB104 07006 BAB 26513 a
356z.32, 356z.32a, 356z.33, 356z.40, 356z.41, 356z.46,
356z.47, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59,
356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.71,
364.01, 364.3, 367.2, 368a, 401, 401.1, 402, 403, 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of Section 367 of
the Illinois Insurance Code.
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; 102-203, eff. 1-1-22;
102-306, 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; 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; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-656, eff.
1-1-25; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-753,
eff. 8-2-24; 103-758, eff. 1-1-25; 103-832, eff. 1-1-25;
103-914, eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff.
1-1-25; revised 11-26-24.)
Section 25. The Illinois Public Aid Code is amended by

10400SB0708sam003 - 142 - LRB104 07006 BAB 26513 a
changing Section 5-5.28 as follows:
(305 ILCS 5/5-5.28 new)
Sec. 5-5.28. Rulemaking authority. The Department of
Healthcare and Family Services may adopt rules to implement
the applicable provisions of this amendatory Act of the 104th
General Assembly to managed care organizations, managed care
community networks, and, at the Department's discretion, any
other managed care entity described in subsection (i) of
Section 5-30 of the Illinois Public Aid Code and the medical
assistance fee-for-service program.
Section 95. No acceleration or delay. Where this Act makes
changes in a statute that is represented in this Act by text
that is not yet or no longer in effect (for example, a Section
represented by multiple versions), the use of that text does
not accelerate or delay the taking effect of (i) the changes
made by this Act or (ii) provisions derived from any other
Public Act.
Section 99. Effective date. This Act takes effect January
1, 2026.".