Bill Text: IL HB0311 | 2017-2018 | 100th General Assembly | Engrossed


Bill Title: Creates the Network Adequacy and Transparency Act. Provides that administrators and insurers, prior to going to market, must file with the Department of Insurance for review and approval a description of the services to be offered through a network plan, with certain criteria included in the description. Provides that the network plan shall demonstrate to the Department, prior to approval, a minimum ratio of full-time equivalent providers to plan beneficiaries and maximum travel and distance standards for plan beneficiaries, which shall be established annually by the Department based upon specified sources. Provides that the Department shall conduct quarterly audits of network plans to verify compliance with network adequacy standards. Establishes certain notice requirements. Provides that a network plan shall provide for continuity of care for its beneficiaries under certain circumstances and according to certain requirements. Provides that a network plan shall post electronically a current and accurate provider directory and make available in print, upon request, a provider directory subject to certain specifications. Provides that the Department is granted specific authority to issue a cease and desist order against, fine, or otherwise penalize any insurer or administrator for violations of any provision of the Act. Makes other changes. Effective January 1, 2018.

Spectrum: Moderate Partisan Bill (Democrat 61-18)

Status: (Engrossed) 2017-04-28 - Added as Alternate Co-Sponsor Sen. Cristina Castro [HB0311 Detail]

Download: Illinois-2017-HB0311-Engrossed.html



HB0311 EngrossedLRB100 05356 RPS 15367 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5Network Adequacy and Transparency Act.
6 Section 3. Applicability of Act.This Act applies to an
7individual or group policy of accident and health insurance
8with a network plan amended, delivered, issued, or renewed in
9this State on or after January 1, 2019.
10 Section 5. Definitions. In this Act:
11 "Authorized representative" means a person to whom a
12beneficiary has given express written consent to represent the
13beneficiary; a person authorized by law to provide substituted
14consent for a beneficiary; or the beneficiary's treating
15provider only when the beneficiary or his or her family member
16is unable to provide consent.
17 "Beneficiary" means an individual, an enrollee, an
18insured, a participant, or any other person entitled to
19reimbursement for covered expenses of or the discounting of
20provider fees for health care services under a program in which
21the beneficiary has an incentive to utilize the services of a
22provider that has entered into an agreement or arrangement with

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1an insurer.
2 "Department" means the Department of Insurance.
3 "Director" means the Director of Insurance.
4 "Insurer" means any entity that offers individual or group
5accident and health insurance, including, but not limited to,
6health maintenance organizations, preferred provider
7organizations, exclusive provider organizations, and other
8plan structures requiring network participation, excluding the
9medical assistance program under the Illinois Public Aid Code,
10the State employees group health insurance program, workers
11compensation insurance, and pharmacy benefit managers.
12 "Material change" means a significant reduction in the
13number of providers available in a network plan, including, but
14not limited to, a reduction of 10% or more in a specific type
15of providers, the removal of a major health system that causes
16a network to be significantly different from the network when
17the beneficiary purchased the network plan, or any change that
18would cause the network to no longer satisfy the requirements
19of this Act or the Department's rules for network adequacy and
20transparency.
21 "Network" means the group or groups of preferred providers
22providing services to a network plan.
23 "Network plan" means an individual or group policy of
24accident and health insurance that either requires a covered
25person to use or creates incentives, including financial
26incentives, for a covered person to use providers managed,

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1owned, under contract with, or employed by the insurer.
2 "Ongoing course of treatment" means (1) treatment for a
3life-threatening condition, which is a disease or condition for
4which likelihood of death is probable unless the course of the
5disease or condition is interrupted; (2) treatment for a
6serious acute condition, defined as a disease or condition
7requiring complex ongoing care that the covered person is
8currently receiving, such as chemotherapy, radiation therapy,
9or post-operative visits; (3) a course of treatment for a
10health condition that a treating provider attests that
11discontinuing care by that provider would worsen the condition
12or interfere with anticipated outcomes; or (4) the third
13trimester of pregnancy through the post-partum period.
14 "Preferred provider" means any provider who has entered,
15either directly or indirectly, into an agreement with an
16employer or risk-bearing entity relating to health care
17services that may be rendered to beneficiaries under a network
18plan.
19 "Providers" means physicians licensed to practice medicine
20in all its branches, other health care professionals,
21hospitals, or other health care institutions that provide
22health care services.
23 "Telehealth" has the meaning given to that term in Section
24356z.22 of the Illinois Insurance Code.
25 "Telemedicine" has the meaning given to that term in
26Section 49.5 of the Medical Practice Act of 1987.

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1 "Tiered network" means a network that identifies and groups
2some or all types of provider and facilities into specific
3groups to which different provider reimbursement, covered
4person cost-sharing or provider access requirements, or any
5combination thereof, apply for the same services.
6 "Woman's principal health care provider" means a physician
7licensed to practice medicine in all of its branches
8specializing in obstetrics, gynecology, or family practice.
9 Section 10. Network adequacy.
10 (a) An insurer providing a network plan shall file a
11description of all of the following with the Director:
12 (1) The written policies and procedures for adding
13 providers to meet patient needs based on increases in the
14 number of beneficiaries, changes in the
15 patient-to-provider ratio, changes in medical and health
16 care capabilities, and increased demand for services.
17 (2) The written policies and procedures for making
18 referrals within and outside the network.
19 (3) The written policies and procedures on how the
20 network plan will provide 24-hour, 7-day per week access to
21 network-affiliated primary care, emergency services, and
22 woman's principal health care providers.
23 An insurer shall not prohibit a preferred provider from
24discussing any specific or all treatment options with
25beneficiaries irrespective of the insurer's position on those

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1treatment options or from advocating on behalf of beneficiaries
2within the utilization review, grievance, or appeals processes
3established by the insurer in accordance with any rights or
4remedies available under applicable State or federal law.
5 (b) Insurers must file for review a description of the
6services to be offered through a network plan. The description
7shall include all of the following:
8 (1) A geographic map of the area proposed to be served
9 by the plan by county service area and zip code, including
10 marked locations for preferred providers.
11 (2) As deemed necessary by the Department, the names,
12 addresses, phone numbers, and specialties of the providers
13 who have entered into preferred provider agreements under
14 the network plan.
15 (3) The number of beneficiaries anticipated to be
16 covered by the network plan.
17 (4) An Internet website and toll-free telephone number
18 for beneficiaries and prospective beneficiaries to access
19 current and accurate lists of preferred providers,
20 additional information about the plan, as well as any other
21 information required by Department rule.
22 (5) A description of how health care services to be
23 rendered under the network plan are reasonably accessible
24 and available to beneficiaries. The description shall
25 address all of the following:
26 (A) the type of health care services to be provided

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1 by the network plan;
2 (B) the ratio of physicians and other providers to
3 beneficiaries, by specialty and including primary care
4 physicians and facility-based physicians when
5 applicable under the contract, necessary to meet the
6 health care needs and service demands of the currently
7 enrolled population;
8 (C) the travel and distance standards for plan
9 beneficiaries in county service areas; and
10 (D) a description of how the use of telemedicine,
11 telehealth, or mobile care services may be used to
12 partially meet the network adequacy standards, if
13 applicable.
14 (6) A provision ensuring that whenever a beneficiary
15 has made a good faith effort, as evidenced by accessing the
16 provider directory, calling the network plan, and calling
17 the provider, to utilize preferred providers for a covered
18 service and it is determined the insurer does not have the
19 appropriate preferred providers due to insufficient
20 number, type, or unreasonable travel distance or delay, the
21 insurer shall ensure, directly or indirectly, by terms
22 contained in the payer contract, that the beneficiary will
23 be provided the covered service at no greater cost to the
24 beneficiary than if the service had been provided by a
25 preferred provider. This paragraph (6) does not apply to:
26 (A) a beneficiary who willfully chooses to access a

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1 non-preferred provider for health care services available
2 through the panel of preferred providers, or (B) a
3 beneficiary enrolled in a health maintenance organization.
4 In these circumstances, the contractual requirements for
5 non-preferred provider reimbursements shall apply.
6 (7) A provision that the beneficiary shall receive
7 emergency care coverage such that payment for this coverage
8 is not dependent upon whether the emergency services are
9 performed by a preferred or non-preferred provider and the
10 coverage shall be at the same benefit level as if the
11 service or treatment had been rendered by a preferred
12 provider. For purposes of this paragraph (7), "the same
13 benefit level" means that the beneficiary is provided the
14 covered service at no greater cost to the beneficiary than
15 if the service had been provided by a preferred provider.
16 (8) A limitation that, if the plan provides that the
17 beneficiary will incur a penalty for failing to pre-certify
18 inpatient hospital treatment, the penalty may not exceed
19 $1,000 per occurrence in addition to the plan cost sharing
20 provisions.
21 (c) The network plan shall demonstrate to the Director a
22minimum ratio of providers to plan beneficiaries as required by
23the Department.
24 (1) The ratio of physicians or other providers to plan
25 beneficiaries shall be established annually by the
26 Department in consultation with the Department of Public

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1 Health based upon the guidance from the federal Centers for
2 Medicare and Medicaid Services. The Department shall
3 consider establishing ratios for the following physicians
4 or other providers:
5 (A) Primary Care;
6 (B) Pediatrics;
7 (C) Cardiology;
8 (D) Gastroenterology;
9 (E) General Surgery;
10 (F) Neurology;
11 (G) OB/GYN;
12 (H) Oncology/Radiation;
13 (I) Ophthalmology;
14 (J) Urology;
15 (K) Behavioral Health;
16 (L) Allergy/Immunology;
17 (M) Chiropractic;
18 (N) Dermatology;
19 (O) Endocrinology;
20 (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
21 (Q) Infectious Disease;
22 (R) Nephrology;
23 (S) Neurosurgery;
24 (T) Orthopedic Surgery;
25 (U) Physiatry/Rehabilitative;
26 (V) Plastic Surgery;

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1 (W) Pulmonary;
2 (X) Rheumatology;
3 (Y) Anesthesiology;
4 (Z) Pain Medicine;
5 (AA) Pediatric Specialty Services;
6 (BB) Outpatient Dialysis; and
7 (CC) HIV.
8 (2) The Director shall establish a process for the
9 review of the adequacy of these standards, along with an
10 assessment of additional specialties to be included in the
11 list under this subsection (c).
12 (d) The network plan shall demonstrate to the Director
13maximum travel and distance standards for plan beneficiaries,
14which shall be established annually by the Department in
15consultation with the Department of Public Health based upon
16the guidance from the federal Centers for Medicare and Medicaid
17Services. These standards shall consist of the maximum minutes
18or miles to be traveled by a plan beneficiary for each county
19type, such as large counties, metro counties, or rural counties
20as defined by Department rule.
21 The maximum travel time and distance standards must include
22standards for each physician and other provider category listed
23for which ratios have been established.
24 The Director shall establish a process for the review of
25the adequacy of these standards along with an assessment of
26additional specialties to be included in the list under this

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1subsection (d).
2 (e) Except for network plans solely offered as a group
3health plan, these ratio and time and distance standards apply
4to the lowest cost-sharing tier of any tiered network.
5 (f) The network plan shall demonstrate sufficient
6inpatient services, including, but not limited to, services of
7preferred providers who specialize in emergency medicine,
8anesthesiology, pathology, and radiology.
9 (g) The network plan may consider use of other health care
10service delivery options, such as telemedicine or telehealth,
11mobile clinics, and centers of excellence, or other ways of
12delivering care to partially meet the requirements set under
13this Section.
14 (h) Insurers who are not able to comply with the provider
15ratios and time and distance standards established by the
16Department may request an exception to these requirements from
17the Department. The Department may grant an exception in the
18following circumstances:
19 (1) if no providers or facilities meet the specific
20 time and distance standard in a specific service area and
21 the insurer (i) discloses information on the distance and
22 travel time points that beneficiaries would have to travel
23 beyond the required criterion to reach the next closest
24 contracted provider outside of the service area and (ii)
25 provides contact information, including names, addresses,
26 and phone numbers for the next closest contracted provider

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1 or facility;
2 (2) if patterns of care in the service area do not
3 support the need for the requested number of provider or
4 facility type and the insurer provides data on local
5 patterns of care, such as claims data, referral patterns,
6 or local provider interviews, indicating where the
7 beneficiaries currently seek this type of care or where the
8 physicians currently refer beneficiaries, or both; or
9 (3) other circumstances deemed appropriate by the
10 Department consistent with the requirements of this Act.
11 (i) Insurers are required to report to the Director any
12material change to an approved network plan within 15 days
13after the change occurs and any change that would result in
14failure to meet the requirements of this Act. Upon notice from
15the insurer, the Director shall reevaluate the network plan's
16compliance with the network adequacy and transparency
17standards of this Act.
18 Section 15. Notice of nonrenewal or termination.
19(a) A network plan must give at least 60 days' notice of
20nonrenewal or termination of a provider to the provider and to
21the beneficiaries served by the provider. The notice shall
22include a name and address to which a beneficiary or provider
23may direct comments and concerns regarding the nonrenewal or
24termination and the telephone number maintained by the
25Department for consumer complaints. Immediate written notice

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1may be provided without 60 days' notice when a provider's
2license has been disciplined by a State licensing board or when
3the network plan reasonably believes direct imminent physical
4harm to patients under the providers care may occur.
5 Section 20. Transition of services.
6 (a) A network plan shall provide for continuity of care for
7its beneficiaries as follows:
8 (1) If a beneficiary's physician or hospital provider
9 leaves the network plan's network of providers for reasons
10 other than termination of a contract in situations
11 involving imminent harm to a patient or a final
12 disciplinary action by a State licensing board and the
13 provider remains within the network plan's service area,
14 the network plan shall permit the beneficiary to continue
15 an ongoing course of treatment with that provider during a
16 transitional period for the following duration:
17 (A) 90 days from the date of the notice to the
18 beneficiary of the provider's disaffiliation from the
19 network plan if the beneficiary has an ongoing course
20 of treatment; or
21 (B) if the beneficiary has entered the third
22 trimester of pregnancy at the time of the provider's
23 disaffiliation, a period that includes the provision
24 of post-partum care directly related to the delivery.
25 (2) Notwithstanding the provisions of paragraph (1) of

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1 this subsection (a), such care shall be authorized by the
2 network plan during the transitional period in accordance
3 with the following:
4 (A) the provider receives continued reimbursement
5 from the network plan at the rates and terms and
6 conditions applicable under the terminated contract
7 prior to the start of the transitional period;
8 (B) the provider adheres to the network plan's
9 quality assurance requirements, including provision to
10 the network plan of necessary medical information
11 related to such care; and
12 (C) the provider otherwise adheres to the network
13 plan's policies and procedures, including, but not
14 limited to, procedures regarding referrals and
15 obtaining preauthorizations for treatment.
16 (3) The provisions of this Section governing health
17 care provided during the transition period do not apply if
18 the beneficiary has successfully transitioned to another
19 provider participating in the network plan, if the
20 beneficiary has already met or exceeded the benefit
21 limitations of the plan, or if the care provided is not
22 medically necessary.
23 (b) A network plan shall provide for continuity of care for
24new beneficiaries as follows:
25 (1) If a new beneficiary whose provider is not a member
26 of the network plan's provider network, but is within the

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1 network plan's service area, enrolls in the network plan,
2 the network plan shall permit the beneficiary to continue
3 an ongoing course of treatment with the beneficiary's
4 current physician during a transitional period:
5 (A) of 90 days from the effective date of
6 enrollment if the beneficiary has an ongoing course of
7 treatment; or
8 (B) if the beneficiary has entered the third
9 trimester of pregnancy at the effective date of
10 enrollment, that includes the provision of post-partum
11 care directly related to the delivery.
12 (2) If a beneficiary, or a beneficiary's authorized
13 representative, elects in writing to continue to receive
14 care from such provider pursuant to paragraph (1) of this
15 subsection (b), such care shall be authorized by the
16 network plan for the transitional period in accordance with
17 the following:
18 (A) the provider receives reimbursement from the
19 network plan at rates established by the network plan;
20 (B) the provider adheres to the network plan's
21 quality assurance requirements, including provision to
22 the network plan of necessary medical information
23 related to such care; and
24 (C) the provider otherwise adheres to the network
25 plan's policies and procedures, including, but not
26 limited to, procedures regarding referrals and

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1 obtaining preauthorization for treatment.
2 (3) The provisions of this Section governing health
3 care provided during the transition period do not apply if
4 the beneficiary has successfully transitioned to another
5 provider participating in the network plan, if the
6 beneficiary has already met or exceeded the benefit
7 limitations of the plan, or if the care provided is not
8 medically necessary.
9 (c) In no event shall this Section be construed to require
10a network plan to provide coverage for benefits not otherwise
11covered or to diminish or impair preexisting condition
12limitations contained in the beneficiary's contract.
13 Section 25. Network transparency.
14 (a) A network plan shall post electronically an up-to-date,
15accurate, and complete provider directory for each of its
16network plans, with the information and search functions, as
17described in this Section.
18 (1) In making the directory available electronically,
19 the network plans shall ensure that the general public is
20 able to view all of the current providers for a plan
21 through a clearly identifiable link or tab and without
22 creating or accessing an account or entering a policy or
23 contract number.
24 (2) The network plan shall update the online provider
25 directory at least monthly. Providers shall notify the

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1 network plan electronically or in writing of any changes to
2 their information as listed in the provider directory. The
3 network plan shall update its online provider directory in
4 a manner consistent with the information provided by the
5 provider within 10 business days after being notified of
6 the change by the provider. Nothing in this paragraph (2)
7 shall void any contractual relationship between the
8 provider and the plan.
9 (3) The network plan shall audit periodically at least
10 25% of its provider directories for accuracy, make any
11 corrections necessary, and retain documentation of the
12 audit. The network plan shall submit the audit to the
13 Director upon request. As part of these audits, the network
14 plan shall contact any provider in its network that has not
15 submitted a claim to the plan or otherwise communicated his
16 or her intent to continue participation in the plan's
17 network.
18 (4) A network plan shall provide a print copy of a
19 current provider directory or a print copy of the requested
20 directory information upon request of a beneficiary or a
21 prospective beneficiary. Print copies must be updated
22 quarterly and an errata that reflects changes in the
23 provider network must be updated quarterly.
24 (5) For each network plan, a network plan shall
25 include, in plain language in both the electronic and print
26 directory, the following general information:

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1 (A) in plain language, a description of the
2 criteria the plan has used to build its provider
3 network;
4 (B) if applicable, in plain language, a
5 description of the criteria the insurer or network plan
6 has used to create tiered networks;
7 (C) if applicable, in plain language, how the
8 network plan designates the different provider tiers
9 or levels in the network and identifies for each
10 specific provider, hospital, or other type of facility
11 in the network which tier each is placed, for example,
12 by name, symbols, or grouping, in order for a
13 beneficiary-covered person or a prospective
14 beneficiary-covered person to be able to identify the
15 provider tier; and
16 (D) if applicable, a notation that authorization
17 or referral may be required to access some providers.
18 (6) A network plan shall make it clear for both its
19 electronic and print directories what provider directory
20 applies to which network plan, such as including the
21 specific name of the network plan as marketed and issued in
22 this State. The network plan shall include in both its
23 electronic and print directories a customer service email
24 address and telephone number or electronic link that
25 beneficiaries or the general public may use to notify the
26 network plan of inaccurate provider directory information

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1 and contact information for the Department's Office of
2 Consumer Health Insurance.
3 (7) A provider directory, whether in electronic or
4 print format, shall accommodate the communication needs of
5 individuals with disabilities, and include a link to or
6 information regarding available assistance for persons
7 with limited English proficiency.
8 (b) For each network plan, a network plan shall make
9available through an electronic provider directory the
10following information in a searchable format:
11 (1) for health care professionals:
12 (A) name;
13 (B) gender;
14 (C) participating office locations;
15 (D) specialty, if applicable;
16 (E) medical group affiliations, if applicable;
17 (F) facility affiliations, if applicable;
18 (G) participating facility affiliations, if
19 applicable;
20 (H) languages spoken other than English, if
21 applicable;
22 (I) whether accepting new patients; and
23 (J) board certifications, if applicable.
24 (2) for hospitals:
25 (A) hospital name;
26 (B) hospital type (such as acute, rehabilitation,

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1 children's, or cancer);
2 (C) participating hospital location; and
3 (D) hospital accreditation status; and
4 (3) for facilities, other than hospitals, by type:
5 (A) facility name;
6 (B) facility type;
7 (C) types of services performed; and
8 (D) participating facility location or locations.
9 (c) For the electronic provider directories, for each
10network plan, a network plan shall make available all of the
11following information in addition to the searchable
12information required in this Section:
13 (1) for health care professionals:
14 (A) contact information; and
15 (B) languages spoken other than English by
16 clinical staff, if applicable;
17 (2) for hospitals, telephone number; and
18 (3) for facilities other than hospitals, telephone
19 number.
20 (d) The insurer or network plan shall make available in
21print, upon request, the following provider directory
22information for the applicable network plan:
23 (1) for health care professionals:
24 (A) name;
25 (B) contact information;
26 (C) participating office location or locations;

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1 (D) specialty, if applicable;
2 (E) languages spoken other than English, if
3 applicable; and
4 (F) whether accepting new patients.
5 (2) for hospitals:
6 (A) hospital name;
7 (B) hospital type (such as acute, rehabilitation,
8 children's, or cancer); and
9 (C) participating hospital location and telephone
10 number; and
11 (3) for facilities, other than hospitals, by type:
12 (A) facility name;
13 (B) facility type;
14 (C) types of services performed; and
15 (D) participating facility location or locations
16 and telephone numbers.
17 (e) The network plan shall include a disclosure in the
18print format provider directory that the information included
19in the directory is accurate as of the date of printing and
20that beneficiaries or prospective beneficiaries should consult
21the insurer's electronic provider directory on its website and
22contact the provider. The network plan shall also include a
23telephone number in the print format provider directory for a
24customer service representative where the beneficiary can
25obtain current provider directory information.
26 (f) The Director may conduct periodic audits of the

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1accuracy of provider directories.
2 Section 30. Facility nonparticipating provider
3transparency.Prior to providing a non-emergency outpatient
4procedure to a beneficiary in an in-network facility or during
5the admission or as soon as practicable thereafter, the
6hospital must provide an insured patient with written notice
7that:
8 (1) the patient may receive separate bills for services
9 provided by health care professionals affiliated with the
10 hospital;
11 (2) if applicable, some hospital staff members may not
12 be participating providers in the same insurance plans and
13 networks as the hospital;
14 (3) if applicable, the patient may have a greater
15 financial responsibility for services provided by health
16 care professionals at the hospital who are not under
17 contract with the patient's health care plan; and
18 (4) questions about coverage or benefit levels should
19 be directed to the patient's health care plan and the
20 patient's certificate of coverage.
21 Section 35. Administration and enforcement.
22 (a) Insurers, as defined in this Act, have a continuing
23obligation to comply with the requirements of this Act. Other
24than the duties specifically created in this Act, nothing in

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1this Act is intended to preclude, prevent, or require the
2adoption, modification, or termination of any utilization
3management, quality management, or claims processing
4methodologies of an insurer.
5 (b) Nothing in this Act precludes, prevents, or requires
6the adoption, modification, or termination of any network plan
7term, benefit, coverage or eligibility provision, or payment
8methodology.
9 (c) The Director shall enforce the provisions of this Act
10pursuant to the enforcement powers granted to it by law.
11 (d) The Department shall adopt rules to enforce compliance
12with this Act to the extent necessary.
13 Section 99. Effective date. This Act takes effect upon
14becoming law.
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