103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5395
 
Introduced , by Rep. Anna Moeller
 
SYNOPSIS AS INTRODUCED:

5 ILCS 100/5-45.55 new
215 ILCS 124/3
215 ILCS 124/5
215 ILCS 124/10
215 ILCS 124/15
215 ILCS 124/20
215 ILCS 124/25
215 ILCS 124/30
215 ILCS 124/35 new
215 ILCS 124/40 new
215 ILCS 124/50 new
215 ILCS 134/20
215 ILCS 134/25
 Amends the Network Adequacy and Transparency Act. Adds definitions. Provides that 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. Provides that 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. Makes changes to provisions concerning network adequacy, notice of nonrenewal or termination, transition of services, network transparency, administration and enforcement, provider requirements, and provider directory information. Amends the Managed Care Reform and Patient Rights Act. Makes changes to provisions concerning notice of nonrenewal or termination and transition of services. Amends the Illinois Administrative Procedure Act to authorize the Department of Insurance to adopt emergency rules implementing federal standards for provider ratios, time and distance, or appointment wait times when such standards apply to health insurance coverage regulated by the Department of Insurance and are more stringent than the State standards extant at the time the final federal standards are published. Amends the Illinois Administrative Procedure Act to make a conforming change. Effective immediately. 


LRB103 37071 RPS 67189 b


 
 
A BILL FOR
 
HB5395LRB103 37071 RPS 67189 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 5. The Illinois Administrative Procedure Act is 
5amended by adding Section 5-45.55 as follows:

6 (5 ILCS 100/5-45.55 new)
7 Sec. 5-45.55. Emergency rulemaking; Network Adequacy and 
8Transparency Act. To provide for the expeditious and timely 
9implementation of the Network Adequacy and Transparency Act, 
10emergency rules implementing federal standards for provider 
11ratios, travel time and distance, and appointment wait times 
12if such standards apply to health insurance coverage regulated 
13by the Department of Insurance and are more stringent than the 
14State standards extant at the time the final federal standards 
15are published may be adopted in accordance with Section 5-45 
16by the Department of Insurance. The adoption of emergency 
17rules authorized by Section 5-45 and this Section is deemed to 
18be necessary for the public interest, safety, and welfare.
19 This Section is repealed one year after the effective date 
20of this amendatory Act of the 103rd General Assembly.

21 Section 15. The Network Adequacy and Transparency Act is 
22amended by changing Sections 3, 5, 10, 15, 20, 25, and 30 and 
 
 
HB5395- 2 -LRB103 37071 RPS 67189 b


1by adding Sections 35, 40, and 50 as follows:

2 (215 ILCS 124/3)
3 Sec. 3. Applicability of Act. This Act applies to an 
4individual or group policy of accident and health insurance 
5coverage with a network plan amended, delivered, issued, or 
6renewed in this State on or after January 1, 2019. This Act 
7does not apply to an individual or group policy for excepted 
8benefits or short-term, limited-duration health insurance 
9coverage dental or vision insurance or a limited health 
10service organization with a network plan amended, delivered, 
11issued, or renewed in this State on or after January 1, 2019, 
12except to the extent that federal law establishes network 
13adequacy and transparency standards for stand-alone dental 
14plans, which the Department shall enforce. 
15(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)

16 (215 ILCS 124/5)
17 Sec. 5. Definitions. In this Act:
18 "Authorized representative" means a person to whom a 
19beneficiary has given express written consent to represent the 
20beneficiary; a person authorized by law to provide substituted 
21consent for a beneficiary; or the beneficiary's treating 
22provider only when the beneficiary or his or her family member 
23is unable to provide consent.
24 "Beneficiary" means an individual, an enrollee, an 
 
 
HB5395- 3 -LRB103 37071 RPS 67189 b


1insured, a participant, or any other person entitled to 
2reimbursement for covered expenses of or the discounting of 
3provider fees for health care services under a program in 
4which the beneficiary has an incentive to utilize the services 
5of a provider that has entered into an agreement or 
6arrangement with an issuer insurer.
7 "Department" means the Department of Insurance.
8 "Essential community provider" has the meaning ascribed to 
9that term in 45 CFR 156.235.
10 "Excepted benefits" has the meaning ascribed to that term 
11in 42 U.S.C. 300gg-91(c). 
12 "Exchange" has the meaning ascribed to that term in 45 CFR 
13155.20. 
14 "Director" means the Director of Insurance.
15 "Family caregiver" means a relative, partner, friend, or 
16neighbor who has a significant relationship with the patient 
17and administers or assists the patient with activities of 
18daily living, instrumental activities of daily living, or 
19other medical or nursing tasks for the quality and welfare of 
20that patient. 
21 "Group health plan" has the meaning ascribed to that term 
22in Section 5 of the Illinois Health Insurance Portability and 
23Accountability Act.
24 "Health insurance coverage" has the meaning ascribed to 
25that term in Section 5 of the Illinois Health Insurance 
26Portability and Accountability Act. "Health insurance 
 
 
HB5395- 4 -LRB103 37071 RPS 67189 b


1coverage" does not include any coverage or benefits under 
2Medicare or under the medical assistance program established 
3under Article V of the Illinois Public Aid Code. 
4 "Issuer" means a "health insurance issuer" as defined in 
5Section 5 of the Illinois Health Insurance Portability and 
6Accountability Act. 
7 "Insurer" means any entity that offers individual or group 
8accident and health insurance, including, but not limited to, 
9health maintenance organizations, preferred provider 
10organizations, exclusive provider organizations, and other 
11plan structures requiring network participation, excluding the 
12medical assistance program under the Illinois Public Aid Code, 
13the State employees group health insurance program, workers 
14compensation insurance, and pharmacy benefit managers.
15 "Material change" means a significant reduction in the 
16number of providers available in a network plan, including, 
17but not limited to, a reduction of 10% or more in a specific 
18type of providers within any county, the removal of a major 
19health system that causes a network to be significantly 
20different within any county from the network when the 
21beneficiary purchased the network plan, or any change that 
22would cause the network to no longer satisfy the requirements 
23of this Act or the Department's rules for network adequacy and 
24transparency.
25 "Network" means the group or groups of preferred providers 
26providing services to a network plan.
 
 
HB5395- 5 -LRB103 37071 RPS 67189 b


1 "Network plan" means an individual or group policy of 
2accident and health insurance coverage that either requires a 
3covered person to use or creates incentives, including 
4financial incentives, for a covered person to use providers 
5managed, owned, under contract with, or employed by the issuer 
6or by a third party contracted to arrange, contract for, or 
7administer such provider-related incentives for the issuer 
8insurer.
9 "Ongoing course of treatment" means (1) treatment for a 
10life-threatening condition, which is a disease or condition 
11for which likelihood of death is probable unless the course of 
12the disease or condition is interrupted; (2) treatment for a 
13serious acute condition, defined as a disease or condition 
14requiring complex ongoing care that the covered person is 
15currently receiving, such as chemotherapy, radiation therapy, 
16or post-operative visits, or a serious and complex condition 
17as defined under 42 U.S.C. 300gg-113(b)(2); (3) a course of 
18treatment for a health condition that a treating provider 
19attests that discontinuing care by that provider would worsen 
20the condition or interfere with anticipated outcomes; or (4) 
21the third trimester of pregnancy through the post-partum 
22period; (5) undergoing a course of institutional or inpatient 
23care from the provider within the meaning of 42 U.S.C. 
24300gg-113(b)(1)(B); (6) being scheduled to undergo nonelective 
25surgery from the provider, including receipt of preoperative 
26or postoperative care from such provider with respect to such 
 
 
HB5395- 6 -LRB103 37071 RPS 67189 b


1a surgery; (7) being determined to be terminally ill, as 
2determined under 42 U.S.C. 1395x(dd)(3)(A), and receiving 
3treatment for such illness from such provider; or (8) any 
4other treatment of a condition or disease that requires 
5repeated health care services pursuant to a plan of treatment 
6by a provider because of the potential for changes in the 
7therapeutic regimen.
8 "Preferred provider" means any provider who has entered, 
9either directly or indirectly, into an agreement with an 
10employer or risk-bearing entity relating to health care 
11services that may be rendered to beneficiaries under a network 
12plan.
13 "Providers" means physicians licensed to practice medicine 
14in all its branches, other health care professionals, 
15hospitals, or other health care institutions or facilities 
16that provide health care services.
17 "Short-term, limited-duration health insurance coverage" 
18has the meaning ascribed to that term in Section 5 of the 
19Short-Term, Limited-Duration Health Insurance Coverage Act.
20 "Stand-alone dental plan" has the meaning ascribed to that 
21term in 45 CFR 156.400. 
22 "Telehealth" has the meaning given to that term in Section 
23356z.22 of the Illinois Insurance Code.
24 "Telemedicine" has the meaning given to that term in 
25Section 49.5 of the Medical Practice Act of 1987.
26 "Tiered network" means a network that identifies and 
 
 
HB5395- 7 -LRB103 37071 RPS 67189 b


1groups some or all types of provider and facilities into 
2specific groups to which different provider reimbursement, 
3covered person cost-sharing or provider access requirements, 
4or any combination thereof, apply for the same services.
5 "Woman's principal health care provider" means a physician 
6licensed to practice medicine in all of its branches 
7specializing in obstetrics, gynecology, or family practice.
8(Source: P.A. 102-92, eff. 7-9-21; 102-813, eff. 5-13-22.)

9 (215 ILCS 124/10)
10 Sec. 10. Network adequacy.
11 (a) Before issuing, delivering, or renewing a network 
12plan, an issuer An insurer providing a network plan shall file 
13a description of all of the following with the Director:
14  (1) The written policies and procedures for adding 
15 providers to meet patient needs based on increases in the 
16 number of beneficiaries, changes in the 
17 patient-to-provider ratio, changes in medical and health 
18 care capabilities, and increased demand for services.
19  (2) The written policies and procedures for making 
20 referrals within and outside the network.
21  (3) The written policies and procedures on how the 
22 network plan will provide 24-hour, 7-day per week access 
23 to network-affiliated primary care, emergency services, 
24 and women's principal health care providers.
25 An issuer insurer shall not prohibit a preferred provider 
 
 
HB5395- 8 -LRB103 37071 RPS 67189 b


1from discussing any specific or all treatment options with 
2beneficiaries irrespective of the insurer's position on those 
3treatment options or from advocating on behalf of 
4beneficiaries within the utilization review, grievance, or 
5appeals processes established by the issuer insurer in 
6accordance with any rights or remedies available under 
7applicable State or federal law.
8 (b) Before issuing, delivering, or renewing a network 
9plan, an issuer Insurers must file for review a description of 
10the services to be offered through a network plan. The 
11description shall include all of the following:
12  (1) A geographic map of the area proposed to be served 
13 by the plan by county service area and zip code, including 
14 marked locations for preferred providers.
15  (2) As deemed necessary by the Department, the names, 
16 addresses, phone numbers, and specialties of the providers 
17 who have entered into preferred provider agreements under 
18 the network plan.
19  (3) The number of beneficiaries anticipated to be 
20 covered by the network plan.
21  (4) An Internet website and toll-free telephone number 
22 for beneficiaries and prospective beneficiaries to access 
23 current and accurate lists of preferred providers in each 
24 plan, additional information about the plan, as well as 
25 any other information required by Department rule.
26  (5) A description of how health care services to be 
 
 
HB5395- 9 -LRB103 37071 RPS 67189 b


1 rendered under the network plan are reasonably accessible 
2 and available to beneficiaries. The description shall 
3 address all of the following:
4   (A) the type of health care services to be 
5 provided by the network plan;
6   (B) the ratio of physicians and other providers to 
7 beneficiaries, by specialty and including primary care 
8 physicians and facility-based physicians when 
9 applicable under the contract, necessary to meet the 
10 health care needs and service demands of the currently 
11 enrolled population; 
12   (C) the travel and distance standards for plan 
13 beneficiaries in county service areas; and
14   (D) a description of how the use of telemedicine, 
15 telehealth, or mobile care services may be used to 
16 partially meet the network adequacy standards, if 
17 applicable.
18  (6) A provision ensuring that whenever a beneficiary 
19 has made a good faith effort, as evidenced by accessing 
20 the provider directory, calling the network plan, and 
21 calling the provider, to utilize preferred providers for a 
22 covered service and it is determined the insurer does not 
23 have the appropriate preferred providers due to 
24 insufficient number, type, unreasonable travel distance or 
25 delay, or preferred providers refusing to provide a 
26 covered service because it is contrary to the conscience 
 
 
HB5395- 10 -LRB103 37071 RPS 67189 b


1 of the preferred providers, as protected by the Health 
2 Care Right of Conscience Act, the issuer insurer shall 
3 ensure, directly or indirectly, by terms contained in the 
4 payer contract, that the beneficiary will be provided the 
5 covered service at no greater cost to the beneficiary than 
6 if the service had been provided by a preferred provider. 
7 This paragraph (6) does not apply to: (A) a beneficiary 
8 who willfully chooses to access a non-preferred provider 
9 for health care services available through the panel of 
10 preferred providers, or (B) a beneficiary enrolled in a 
11 health maintenance organization. In these circumstances, 
12 the contractual requirements for non-preferred provider 
13 reimbursements shall apply unless Section 356z.3a of the 
14 Illinois Insurance Code requires otherwise. In no event 
15 shall a beneficiary who receives care at a participating 
16 health care facility be required to search for 
17 participating providers under the circumstances described 
18 in subsection (b) or (b-5) of Section 356z.3a of the 
19 Illinois Insurance Code except under the circumstances 
20 described in paragraph (2) of subsection (b-5).
21  (7) A provision that the beneficiary shall receive 
22 emergency care coverage such that payment for this 
23 coverage is not dependent upon whether the emergency 
24 services are performed by a preferred or non-preferred 
25 provider and the coverage shall be at the same benefit 
26 level as if the service or treatment had been rendered by a 
 
 
HB5395- 11 -LRB103 37071 RPS 67189 b


1 preferred provider. For purposes of this paragraph (7), 
2 "the same benefit level" means that the beneficiary is 
3 provided the covered service at no greater cost to the 
4 beneficiary than if the service had been provided by a 
5 preferred provider. This provision shall be consistent 
6 with Section 356z.3a of the Illinois Insurance Code.
7  (8) A limitation that, if the plan provides that the 
8 beneficiary will incur a penalty for failing to 
9 pre-certify inpatient hospital treatment, the penalty may 
10 not exceed $1,000 per occurrence in addition to the plan 
11 cost sharing provisions.
12  (9) For a network plan to be offered through the 
13 Exchange in the individual or small group market, as well 
14 as any off-Exchange mirror of such a network plan, 
15 evidence that the network plan includes essential 
16 community providers in accordance with rules established 
17 by the Exchange that will operate in this State for the 
18 applicable plan year. 
19 (c) The issuer network plan shall demonstrate to the 
20Director a minimum ratio of providers to plan beneficiaries as 
21required by the Department for each network plan.
22  (1) The minimum ratio of physicians or other providers 
23 to plan beneficiaries shall be established annually by the 
24 Department in consultation with the Department of Public 
25 Health based upon the guidance from the federal Centers 
26 for Medicare and Medicaid Services. The Department shall 
 
 
HB5395- 12 -LRB103 37071 RPS 67189 b


1 not establish ratios for vision or dental providers who 
2 provide services under dental-specific or vision-specific 
3 benefits, except to the extent provided under federal law 
4 for stand-alone dental plans. The Department shall 
5 consider establishing ratios for the following physicians 
6 or other providers:
7   (A) Primary Care;
8   (B) Pediatrics;
9   (C) Cardiology;
10   (D) Gastroenterology;
11   (E) General Surgery;
12   (F) Neurology;
13   (G) OB/GYN;
14   (H) Oncology/Radiation;
15   (I) Ophthalmology;
16   (J) Urology;
17   (K) Behavioral Health;
18   (L) Allergy/Immunology;
19   (M) Chiropractic;
20   (N) Dermatology;
21   (O) Endocrinology;
22   (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
23   (Q) Infectious Disease;
24   (R) Nephrology;
25   (S) Neurosurgery;
26   (T) Orthopedic Surgery;
 
 
HB5395- 13 -LRB103 37071 RPS 67189 b


1   (U) Physiatry/Rehabilitative;
2   (V) Plastic Surgery;
3   (W) Pulmonary;
4   (X) Rheumatology;
5   (Y) Anesthesiology;
6   (Z) Pain Medicine;
7   (AA) Pediatric Specialty Services;
8   (BB) Outpatient Dialysis; and
9   (CC) HIV.
10  (2) The Director shall establish a process for the 
11 review of the adequacy of these standards, along with an 
12 assessment of additional specialties to be included in the 
13 list under this subsection (c).
14  (3) Notwithstanding any other law or rule, the minimum 
15 ratio for each provider type shall be no less than any such 
16 ratio established for qualified health plans in 
17 Federally-Facilitated Exchanges by federal law or by the 
18 federal Centers for Medicare and Medicaid Services, even 
19 if the network plan is issued in the large group market or 
20 is otherwise not issued through an exchange. Federal 
21 standards for stand-alone dental plans shall only apply to 
22 such network plans. In the absence of an applicable 
23 Department rule, the federal standards shall apply for the 
24 time period specified in the federal law, regulation, or 
25 guidance. If the Centers for Medicare and Medicaid 
26 Services establish standards that are more stringent than 
 
 
HB5395- 14 -LRB103 37071 RPS 67189 b


1 the standards in effect under any Department rule, the 
2 Department may amend its rules to conform to the more 
3 stringent federal standards. 
4 (d) The network plan shall demonstrate to the Director 
5maximum travel and distance standards and appointment wait 
6time standards for plan beneficiaries, which shall be 
7established annually by the Department in consultation with 
8the Department of Public Health based upon the guidance from 
9the federal Centers for Medicare and Medicaid Services. These 
10standards shall consist of the maximum minutes or miles to be 
11traveled by a plan beneficiary for each county type, such as 
12large counties, metro counties, or rural counties as defined 
13by Department rule.
14 The maximum travel time and distance standards must 
15include standards for each physician and other provider 
16category listed for which ratios have been established.
17 The Director shall establish a process for the review of 
18the adequacy of these standards along with an assessment of 
19additional specialties to be included in the list under this 
20subsection (d).
21 Notwithstanding any other law or Department rule, the 
22maximum travel time and distance standards and appointment 
23wait time standards shall be no greater than any such 
24standards established for qualified health plans in 
25Federally-Facilitated Exchanges by federal law or by the 
26federal Centers for Medicare and Medicaid Services, even if 
 
 
HB5395- 15 -LRB103 37071 RPS 67189 b


1the network plan is issued in the large group market or is 
2otherwise not issued through an exchange. Federal standards 
3for stand-alone dental plans shall only apply to such network 
4plans. In the absence of an applicable Department rule, the 
5federal standards shall apply for the time period specified in 
6the federal law, regulation, or guidance. If the Centers for 
7Medicare and Medicaid Services establish standards that are 
8more stringent than the standards in effect under any 
9Department rule, the Department may amend its rules to conform 
10to the more stringent federal standards. 
11 If the federal area designations for the maximum time or 
12distance or appointment wait time standards required are 
13changed by the most recent Letter to Issuers in the 
14Federally-facilitated Marketplaces, the Department shall post 
15on its website notice of such changes and may amend its rules 
16to conform to those designations if the Director deems 
17appropriate. 
18 (d-5)(1) Every issuer insurer shall ensure that 
19beneficiaries have timely and proximate access to treatment 
20for mental, emotional, nervous, or substance use disorders or 
21conditions in accordance with the provisions of paragraph (4) 
22of subsection (a) of Section 370c of the Illinois Insurance 
23Code. Issuers Insurers shall use a comparable process, 
24strategy, evidentiary standard, and other factors in the 
25development and application of the network adequacy standards 
26for timely and proximate access to treatment for mental, 
 
 
HB5395- 16 -LRB103 37071 RPS 67189 b


1emotional, nervous, or substance use disorders or conditions 
2and those for the access to treatment for medical and surgical 
3conditions. As such, the network adequacy standards for timely 
4and proximate access shall equally be applied to treatment 
5facilities and providers for mental, emotional, nervous, or 
6substance use disorders or conditions and specialists 
7providing medical or surgical benefits pursuant to the parity 
8requirements of Section 370c.1 of the Illinois Insurance Code 
9and the federal Paul Wellstone and Pete Domenici Mental Health 
10Parity and Addiction Equity Act of 2008. Notwithstanding the 
11foregoing, the network adequacy standards for timely and 
12proximate access to treatment for mental, emotional, nervous, 
13or substance use disorders or conditions shall, at a minimum, 
14satisfy the following requirements:
15  (A) For beneficiaries residing in the metropolitan 
16 counties of Cook, DuPage, Kane, Lake, McHenry, and Will, 
17 network adequacy standards for timely and proximate access 
18 to treatment for mental, emotional, nervous, or substance 
19 use disorders or conditions means a beneficiary shall not 
20 have to travel longer than 30 minutes or 30 miles from the 
21 beneficiary's residence to receive outpatient treatment 
22 for mental, emotional, nervous, or substance use disorders 
23 or conditions. Beneficiaries shall not be required to wait 
24 longer than 10 business days between requesting an initial 
25 appointment and being seen by the facility or provider of 
26 mental, emotional, nervous, or substance use disorders or 
 
 
HB5395- 17 -LRB103 37071 RPS 67189 b


1 conditions for outpatient treatment or to wait longer than 
2 20 business days between requesting a repeat or follow-up 
3 appointment and being seen by the facility or provider of 
4 mental, emotional, nervous, or substance use disorders or 
5 conditions for outpatient treatment; however, subject to 
6 the protections of paragraph (3) of this subsection, a 
7 network plan shall not be held responsible if the 
8 beneficiary or provider voluntarily chooses to schedule an 
9 appointment outside of these required time frames.
10  (B) For beneficiaries residing in Illinois counties 
11 other than those counties listed in subparagraph (A) of 
12 this paragraph, network adequacy standards for timely and 
13 proximate access to treatment for mental, emotional, 
14 nervous, or substance use disorders or conditions means a 
15 beneficiary shall not have to travel longer than 60 
16 minutes or 60 miles from the beneficiary's residence to 
17 receive outpatient treatment for mental, emotional, 
18 nervous, or substance use disorders or conditions. 
19 Beneficiaries shall not be required to wait longer than 10 
20 business days between requesting an initial appointment 
21 and being seen by the facility or provider of mental, 
22 emotional, nervous, or substance use disorders or 
23 conditions for outpatient treatment or to wait longer than 
24 20 business days between requesting a repeat or follow-up 
25 appointment and being seen by the facility or provider of 
26 mental, emotional, nervous, or substance use disorders or 
 
 
HB5395- 18 -LRB103 37071 RPS 67189 b


1 conditions for outpatient treatment; however, subject to 
2 the protections of paragraph (3) of this subsection, a 
3 network plan shall not be held responsible if the 
4 beneficiary or provider voluntarily chooses to schedule an 
5 appointment outside of these required time frames.
6 (2) For beneficiaries residing in all Illinois counties, 
7network adequacy standards for timely and proximate access to 
8treatment for mental, emotional, nervous, or substance use 
9disorders or conditions means a beneficiary shall not have to 
10travel longer than 60 minutes or 60 miles from the 
11beneficiary's residence to receive inpatient or residential 
12treatment for mental, emotional, nervous, or substance use 
13disorders or conditions.
14 (3) If there is no in-network facility or provider 
15available for a beneficiary to receive timely and proximate 
16access to treatment for mental, emotional, nervous, or 
17substance use disorders or conditions in accordance with the 
18network adequacy standards outlined in this subsection, the 
19issuer insurer shall provide necessary exceptions to its 
20network to ensure admission and treatment with a provider or 
21at a treatment facility in accordance with the network 
22adequacy standards in this subsection. 
23 (4) If the federal Centers for Medicare and Medicaid 
24Services establishes or law requires more stringent standards 
25for qualified health plans in the Federally-Facilitated 
26Exchanges, the federal standards shall control for all network 
 
 
HB5395- 19 -LRB103 37071 RPS 67189 b


1plans for the time period specified in the federal law, 
2regulation, or guidance, even if the network plan is issued in 
3the large group market, is issued through a different type of 
4Exchange, or is otherwise not issued through an Exchange. 
5 (e) Except for network plans solely offered as a group 
6health plan, these ratio and time and distance standards apply 
7to the lowest cost-sharing tier of any tiered network.
8 (f) The network plan may consider use of other health care 
9service delivery options, such as telemedicine or telehealth, 
10mobile clinics, and centers of excellence, or other ways of 
11delivering care to partially meet the requirements set under 
12this Section.
13 (g) Except for the requirements set forth in subsection 
14(d-5), issuers insurers who are not able to comply with the 
15provider ratios and time and distance or appointment wait time 
16standards established under this Act or federal law by the 
17Department may request an exception to these requirements from 
18the Department. The Department may grant an exception in the 
19following circumstances:
20  (1) if no providers or facilities meet the specific 
21 time and distance standard in a specific service area and 
22 the issuer insurer (i) discloses information on the 
23 distance and travel time points that beneficiaries would 
24 have to travel beyond the required criterion to reach the 
25 next closest contracted provider outside of the service 
26 area and (ii) provides contact information, including 
 
 
HB5395- 20 -LRB103 37071 RPS 67189 b


1 names, addresses, and phone numbers for the next closest 
2 contracted provider or facility;
3  (2) if patterns of care in the service area do not 
4 support the need for the requested number of provider or 
5 facility type and the issuer insurer provides data on 
6 local patterns of care, such as claims data, referral 
7 patterns, or local provider interviews, indicating where 
8 the beneficiaries currently seek this type of care or 
9 where the physicians currently refer beneficiaries, or 
10 both; or
11  (3) other circumstances deemed appropriate by the 
12 Department consistent with the requirements of this Act.
13 (h) Issuers Insurers are required to report to the 
14Director any material change to an approved network plan 
15within 15 days after the change occurs and any change that 
16would result in failure to meet the requirements of this Act. 
17The issuer shall submit a revised version of the portions of 
18the network adequacy filing affected by the material change, 
19as determined by the Director by rule, and the issuer shall 
20attach versions with the changes indicated for each document 
21that was revised from the previous version of the filing. Upon 
22notice from the issuer insurer, the Director shall reevaluate 
23the network plan's compliance with the network adequacy and 
24transparency standards of this Act. For every day past 15 days 
25that the issuer fails to submit a revised network adequacy 
26filing to the Director, the Director may order a fine of $1,000 
 
 
HB5395- 21 -LRB103 37071 RPS 67189 b


1per day. 
2 (i) If a network plan is inadequate under this Act with 
3respect to a provider type in a county, and if the network plan 
4does not have an approved exception for that provider type in 
5that county pursuant to subsection (g), an issuer shall 
6process out-of-network claims for covered health care services 
7received from that provider type within that county at the 
8in-network benefit level and shall retroactively adjudicate 
9and reimburse beneficiaries to achieve that objective if their 
10claims were processed at the out-of-network level contrary to 
11this subsection. 
12 (j) If the Director determines that a network is 
13inadequate in any county and no exception has been granted 
14under subsection (g) and the issuer does not have a process in 
15place to comply with subsection (d-5), the Director may 
16prohibit the network plan from being issued or renewed within 
17that county until the Director determines that the network is 
18adequate apart from processes and exceptions described in 
19subsections (d-5) and (g). Nothing in this subsection shall be 
20construed to terminate any beneficiary's health insurance 
21coverage under a network plan before the expiration of the 
22beneficiary's policy period if the Director makes a 
23determination under this subsection after the issuance or 
24renewal of the beneficiary's policy or certificate because of 
25a material change. Policies or certificates issued or renewed 
26in violation of this subsection may subject the issuer to a 
 
 
HB5395- 22 -LRB103 37071 RPS 67189 b


1civil penalty of $1,000 per policy. 
2(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; 
3102-1117, eff. 1-13-23.)

4 (215 ILCS 124/15)
5 Sec. 15. Notice of nonrenewal or termination. 
6 (a) A network plan must give at least 60 days' notice of 
7nonrenewal or termination of a provider to the provider and to 
8the beneficiaries served by the provider. The notice shall 
9include a name and address to which a beneficiary or provider 
10may direct comments and concerns regarding the nonrenewal or 
11termination and the telephone number maintained by the 
12Department for consumer complaints. Immediate written notice 
13may be provided without 60 days' notice when a provider's 
14license has been disciplined by a State licensing board or 
15when the network plan reasonably believes direct imminent 
16physical harm to patients under the provider's providers care 
17may occur. The notice to the beneficiary shall provide the 
18individual with an opportunity to notify the issuer of the 
19individual's need for transitional care. 
20 (b) Primary care providers must notify active affected 
21patients of nonrenewal or termination of the provider from the 
22network plan, except in the case of incapacitation.
23(Source: P.A. 100-502, eff. 9-15-17.)

24 (215 ILCS 124/20)
 
 
HB5395- 23 -LRB103 37071 RPS 67189 b


1 Sec. 20. Transition of services.
2 (a) A network plan shall provide for continuity of care 
3for its beneficiaries as follows:
4  (1) If a beneficiary's physician or hospital provider 
5 leaves the network plan's network of providers for reasons 
6 other than termination of a contract in situations 
7 involving imminent harm to a patient or a final 
8 disciplinary action by a State licensing board and the 
9 provider remains within the network plan's service area, 
10 if benefits provided under such network plan with respect 
11 to such provider or facility are terminated because of a 
12 change in the terms of the participation of such provider 
13 or facility in such plan, or if a contract between a group 
14 health plan and a health insurance issuer offering a 
15 network plan in connection with the group health plan is 
16 terminated and results in a loss of benefits provided 
17 under such plan with respect to such provider, then the 
18 network plan shall permit the beneficiary to continue an 
19 ongoing course of treatment with that provider during a 
20 transitional period for the following duration:
21   (A) 90 days from the date of the notice to the 
22 beneficiary of the provider's disaffiliation from the 
23 network plan if the beneficiary has an ongoing course 
24 of treatment; or
25   (B) if the beneficiary has entered the third 
26 trimester of pregnancy at the time of the provider's 
 
 
HB5395- 24 -LRB103 37071 RPS 67189 b


1 disaffiliation, a period that includes the provision 
2 of post-partum care directly related to the delivery.
3  (2) Notwithstanding the provisions of paragraph (1) of 
4 this subsection (a), such care shall be authorized by the 
5 network plan during the transitional period in accordance 
6 with the following:
7   (A) the provider receives continued reimbursement 
8 from the network plan at the rates and terms and 
9 conditions applicable under the terminated contract 
10 prior to the start of the transitional period;
11   (B) the provider adheres to the network plan's 
12 quality assurance requirements, including provision to 
13 the network plan of necessary medical information 
14 related to such care; and
15   (C) the provider otherwise adheres to the network 
16 plan's policies and procedures, including, but not 
17 limited to, procedures regarding referrals and 
18 obtaining preauthorizations for treatment.
19  (3) The provisions of this Section governing health 
20 care provided during the transition period do not apply if 
21 the beneficiary has successfully transitioned to another 
22 provider participating in the network plan, if the 
23 beneficiary has already met or exceeded the benefit 
24 limitations of the plan, or if the care provided is not 
25 medically necessary.
26 (b) A network plan shall provide for continuity of care 
 
 
HB5395- 25 -LRB103 37071 RPS 67189 b


1for new beneficiaries as follows:
2  (1) If a new beneficiary whose provider is not a 
3 member of the network plan's provider network, but is 
4 within the network plan's service area, enrolls in the 
5 network plan, the network plan shall permit the 
6 beneficiary to continue an ongoing course of treatment 
7 with the beneficiary's current physician during a 
8 transitional period:
9   (A) of 90 days from the effective date of 
10 enrollment if the beneficiary has an ongoing course of 
11 treatment; or
12   (B) if the beneficiary has entered the third 
13 trimester of pregnancy at the effective date of 
14 enrollment, that includes the provision of post-partum 
15 care directly related to the delivery.
16  (2) If a beneficiary, or a beneficiary's authorized 
17 representative, elects in writing to continue to receive 
18 care from such provider pursuant to paragraph (1) of this 
19 subsection (b), such care shall be authorized by the 
20 network plan for the transitional period in accordance 
21 with the following:
22   (A) the provider receives reimbursement from the 
23 network plan at rates established by the network plan;
24   (B) the provider adheres to the network plan's 
25 quality assurance requirements, including provision to 
26 the network plan of necessary medical information 
 
 
HB5395- 26 -LRB103 37071 RPS 67189 b


1 related to such care; and
2   (C) the provider otherwise adheres to the network 
3 plan's policies and procedures, including, but not 
4 limited to, procedures regarding referrals and 
5 obtaining preauthorization for treatment.
6  (3) The provisions of this Section governing health 
7 care provided during the transition period do not apply if 
8 the beneficiary has successfully transitioned to another 
9 provider participating in the network plan, if the 
10 beneficiary has already met or exceeded the benefit 
11 limitations of the plan, or if the care provided is not 
12 medically necessary.
13 (c) In no event shall this Section be construed to require 
14a network plan to provide coverage for benefits not otherwise 
15covered or to diminish or impair preexisting condition 
16limitations contained in the beneficiary's contract.
17 (d) A provider shall comply with the requirements of 42 
18U.S.C. 300gg-138. 
19(Source: P.A. 100-502, eff. 9-15-17.)

20 (215 ILCS 124/25)
21 Sec. 25. Network transparency.
22 (a) A network plan shall post electronically an 
23up-to-date, accurate, and complete provider directory for each 
24of its network plans, with the information and search 
25functions, as described in this Section.
 
 
HB5395- 27 -LRB103 37071 RPS 67189 b


1  (1) In making the directory available electronically, 
2 the network plans shall ensure that the general public is 
3 able to view all of the current providers for a plan 
4 through a clearly identifiable link or tab and without 
5 creating or accessing an account or entering a policy or 
6 contract number.
7  (2) The network plan shall update the online provider 
8 directory at least monthly. An issuer's failure to update 
9 a network plan's directory shall subject the issuer to a 
10 civil penalty of $5,000 per month. Providers shall notify 
11 the network plan electronically or in writing of any 
12 changes to their information as listed in the provider 
13 directory, including the information required in 
14 subparagraph (K) of paragraph (1) of subsection (b). If a 
15 provider is no longer accepting new patients, the provider 
16 must give notice to the issuer within 10 business days 
17 after deciding to cease accepting new patients, or within 
18 10 business days after the effective date of this 
19 amendatory Act of the 103rd General Assembly, whichever is 
20 later. The network plan shall update its online provider 
21 directory in a manner consistent with the information 
22 provided by the provider within 2 10 business days after 
23 being notified of the change by the provider. Nothing in 
24 this paragraph (2) shall void any contractual relationship 
25 between the provider and the plan.
26  (3) At least once every 90 days, the The network plan 
 
 
HB5395- 28 -LRB103 37071 RPS 67189 b


1 shall audit each periodically at least 25% of its print 
2 and online provider directories for accuracy, make any 
3 corrections necessary, and retain documentation of the 
4 audit. The network plan shall submit the audit to the 
5 Director upon request. As part of these audits, the 
6 network plan shall contact any provider in its network 
7 that has not submitted a claim to the plan or otherwise 
8 communicated his or her intent to continue participation 
9 in the plan's network. The audits shall comply with 42 
10 U.S.C. 300gg-115(a)(2), except that "provider directory 
11 information" shall include all information required to be 
12 included in a provider directory pursuant to this Act. 
13  (4) A network plan shall provide a print copy of a 
14 current provider directory or a print copy of the 
15 requested directory information upon request of a 
16 beneficiary or a prospective beneficiary. Print copies 
17 must be updated quarterly and an errata that reflects 
18 changes in the provider network must be updated quarterly.
19  (5) For each network plan, a network plan shall 
20 include, in plain language in both the electronic and 
21 print directory, the following general information:
22   (A) in plain language, a description of the 
23 criteria the plan has used to build its provider 
24 network;
25   (B) if applicable, in plain language, a 
26 description of the criteria the issuer insurer or 
 
 
HB5395- 29 -LRB103 37071 RPS 67189 b


1 network plan has used to create tiered networks;
2   (C) if applicable, in plain language, how the 
3 network plan designates the different provider tiers 
4 or levels in the network and identifies for each 
5 specific provider, hospital, or other type of facility 
6 in the network which tier each is placed, for example, 
7 by name, symbols, or grouping, in order for a 
8 beneficiary-covered person or a prospective 
9 beneficiary-covered person to be able to identify the 
10 provider tier; and
11   (D) if applicable, a notation that authorization 
12 or referral may be required to access some providers.
13  (6) A network plan shall make it clear for both its 
14 electronic and print directories what provider directory 
15 applies to which network plan, such as including the 
16 specific name of the network plan as marketed and issued 
17 in this State. The network plan shall include in both its 
18 electronic and print directories a customer service email 
19 address and telephone number or electronic link that 
20 beneficiaries or the general public may use to notify the 
21 network plan of inaccurate provider directory information 
22 and contact information for the Department's Office of 
23 Consumer Health Insurance.
24  (7) A provider directory, whether in electronic or 
25 print format, shall accommodate the communication needs of 
26 individuals with disabilities, and include a link to or 
 
 
HB5395- 30 -LRB103 37071 RPS 67189 b


1 information regarding available assistance for persons 
2 with limited English proficiency.
3 (b) For each network plan, a network plan shall make 
4available through an electronic provider directory the 
5following information in a searchable format:
6  (1) for health care professionals:
7   (A) name;
8   (B) gender;
9   (C) participating office locations;
10   (D) specialty, if applicable;
11   (E) medical group affiliations, if applicable;
12   (F) facility affiliations, if applicable;
13   (G) participating facility affiliations, if 
14 applicable;
15   (H) languages spoken other than English, if 
16 applicable;
17   (I) whether accepting new patients;
18   (J) board certifications, if applicable; and
19   (K) use of telehealth or telemedicine, including, 
20 but not limited to:
21    (i) whether the provider offers the use of 
22 telehealth or telemedicine to deliver services to 
23 patients for whom it would be clinically 
24 appropriate;
25    (ii) what modalities are used and what types 
26 of services may be provided via telehealth or 
 
 
HB5395- 31 -LRB103 37071 RPS 67189 b


1 telemedicine; and
2    (iii) whether the provider has the ability and 
3 willingness to include in a telehealth or 
4 telemedicine encounter a family caregiver who is 
5 in a separate location than the patient if the 
6 patient wishes and provides his or her consent; 
7 and 
8   (L) whether patients can make an appointment to 
9 visit the health care professional. 
10  (2) for hospitals:
11   (A) hospital name;
12   (B) hospital type (such as acute, rehabilitation, 
13 children's, or cancer);
14   (C) participating hospital location; and
15   (D) hospital accreditation status; and
16  (3) for facilities, other than hospitals, by type:
17   (A) facility name;
18   (B) facility type;
19   (C) types of services performed; and
20   (D) participating facility location or locations.
21 (c) For the electronic provider directories, for each 
22network plan, a network plan shall make available all of the 
23following information in addition to the searchable 
24information required in this Section:
25  (1) for health care professionals:
26   (A) contact information, including both a 
 
 
HB5395- 32 -LRB103 37071 RPS 67189 b


1 telephone number and digital contact information if 
2 the provider has supplied digital contact information; 
3 and
4   (B) languages spoken other than English by 
5 clinical staff, if applicable;
6  (2) for hospitals, telephone number and digital 
7 contact information; and
8  (3) for facilities other than hospitals, telephone 
9 number.
10 (d) The issuer insurer or network plan shall make 
11available in print, upon request, the following provider 
12directory information for the applicable network plan:
13  (1) for health care professionals:
14   (A) name;
15   (B) contact information, including a telephone 
16 number and digital contact information if the provider 
17 has supplied digital contact information;
18   (C) participating office location or locations;
19   (D) specialty, if applicable;
20   (E) languages spoken other than English, if 
21 applicable;
22   (F) whether accepting new patients; and
23   (G) use of telehealth or telemedicine, including, 
24 but not limited to:
25    (i) whether the provider offers the use of 
26 telehealth or telemedicine to deliver services to 
 
 
HB5395- 33 -LRB103 37071 RPS 67189 b


1 patients for whom it would be clinically 
2 appropriate;
3    (ii) what modalities are used and what types 
4 of services may be provided via telehealth or 
5 telemedicine; and
6    (iii) whether the provider has the ability and 
7 willingness to include in a telehealth or 
8 telemedicine encounter a family caregiver who is 
9 in a separate location than the patient if the 
10 patient wishes and provides his or her consent; 
11 and 
12   (H) whether patients can make an appointment to 
13 visit the health care professional. 
14  (2) for hospitals:
15   (A) hospital name;
16   (B) hospital type (such as acute, rehabilitation, 
17 children's, or cancer); and
18   (C) participating hospital location, and telephone 
19 number, and digital contact information; and
20  (3) for facilities, other than hospitals, by type:
21   (A) facility name;
22   (B) facility type;
23   (C) types of services performed; and
24   (D) participating facility location or locations, 
25 and telephone numbers, and digital contact information 
26 for each location.
 
 
HB5395- 34 -LRB103 37071 RPS 67189 b


1 (e) The network plan shall include a disclosure in the 
2print format provider directory that the information included 
3in the directory is accurate as of the date of printing and 
4that beneficiaries or prospective beneficiaries should consult 
5the issuer's insurer's electronic provider directory on its 
6website and contact the provider. The network plan shall also 
7include a telephone number in the print format provider 
8directory for a customer service representative where the 
9beneficiary can obtain current provider directory information.
10 (f) The Director may conduct periodic audits of the 
11accuracy of provider directories. A network plan shall not be 
12subject to any fines or penalties for information required in 
13this Section that a provider submits that is inaccurate or 
14incomplete. 
15 (g) To the extent not otherwise provided in this Act, an 
16issuer shall comply with the requirements of 42 U.S.C. 
17300gg-115, except that "provider directory information" shall 
18include all information required to be included in a provider 
19directory pursuant to this Section.
20 (h) This Section applies to network plans not otherwise 
21exempt under Section 3, including stand-alone dental plans. 
22(Source: P.A. 102-92, eff. 7-9-21; revised 9-26-23.)

23 (215 ILCS 124/30)
24 Sec. 30. Administration and enforcement. 
25 (a) Issuers Insurers, as defined in this Act, have a 
 
 
HB5395- 35 -LRB103 37071 RPS 67189 b


1continuing obligation to comply with the requirements of this 
2Act. Other than the duties specifically created in this Act, 
3nothing in this Act is intended to preclude, prevent, or 
4require the adoption, modification, or termination of any 
5utilization management, quality management, or claims 
6processing methodologies of an issuer insurer.
7 (b) Nothing in this Act precludes, prevents, or requires 
8the adoption, modification, or termination of any network plan 
9term, benefit, coverage or eligibility provision, or payment 
10methodology.
11 (c) The Director shall enforce the provisions of this Act 
12pursuant to the enforcement powers granted to it by law.
13 (d) The Department shall adopt rules to enforce compliance 
14with this Act to the extent necessary.
15 (e) In accordance with Section 5-45 of the Illinois 
16Administrative Procedure Act, the Department may adopt 
17emergency rules to implement federal standards for provider 
18ratios, travel time and distance, and appointment wait times 
19if such standards apply to health insurance coverage regulated 
20by the Department and are more stringent than the State 
21standards extant at the time the final federal standards are 
22published. 
23(Source: P.A. 100-502, eff. 9-15-17.)

24 (215 ILCS 124/35 new)
25 Sec. 35. Provider requirements. Providers shall comply 
 
 
HB5395- 36 -LRB103 37071 RPS 67189 b


1with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations 
2promulgated thereunder, as well as Section 20 and paragraph 
3(2) of subsection (a) of Section 25 of this Act, except that 
4"provider directory information" includes all information 
5required to be included in a provider directory pursuant to 
6Section 25 of this Act. To the extent a provider is licensed by 
7the Department of Financial and Professional Regulation or by 
8the Department of Public Health, that agency shall have the 
9authority to investigate, examine, process complaints, issue 
10subpoenas, examine witnesses under oath, issue a fine, or take 
11disciplinary action against the provider's license for 
12violations of these requirements in accordance with the 
13provider's applicable licensing statute.

14 (215 ILCS 124/40 new)
15 Sec. 40. Confidentiality.
16 (a) All records in the custody or possession of the 
17Department are presumed to be open to public inspection or 
18copying unless exempt from disclosure by Section 7 or 7.5 of 
19the Freedom of Information Act. Except as otherwise provided 
20in this Section or other applicable law, the filings required 
21under this Act shall be open to public inspection or copying.
22 (b) The following information shall not be deemed 
23confidential:
24  (1) actual or projected ratios of providers to 
25 beneficiaries;
 
 
HB5395- 37 -LRB103 37071 RPS 67189 b


1  (2) actual or projected time and distance between 
2 network providers and beneficiaries or actual or projected 
3 waiting times for a beneficiary to see a network provider;
4  (3) geographic maps of network providers;
5  (4) requests for exceptions under subsection (g) of 
6 Section 10, except with respect to any discussion of 
7 ongoing or planned contractual negotiations with providers 
8 that the issuer requests to be treated as confidential;
9  (5) provider directories and provider lists; and
10  (6) insurer or Department statements of determination 
11 as to whether a network plan has satisfied the Act's 
12 requirements regarding the information described in this 
13 subsection.
14 (c) An issuer's work papers and reports on the results of a 
15self-audit of its provider directories shall remain 
16confidential unless expressly waived by the insurer or unless 
17deemed public information under federal law.
18 (d) The filings required under Section 10 of this Act 
19shall be confidential while they remain under the Department's 
20review but shall become open to public inspection and copying 
21upon completion of the review, except as provided in this 
22Section or under other applicable law.
23 (e) Nothing in this Section shall supersede the statutory 
24requirement that work papers obtained during a market conduct 
25examination be deemed confidential.

 
 
HB5395- 38 -LRB103 37071 RPS 67189 b


1 (215 ILCS 124/50 new)
2 Sec. 50. Funds for enforcement. Moneys from fines and 
3penalties collected from issuers for violations of this Act 
4shall be deposited into the Insurance Producer Administration 
5Fund for appropriation by the General Assembly to the 
6Department to be used for providing financial support of the 
7Department's enforcement of this Act.

8 Section 20. The Managed Care Reform and Patient Rights Act 
9is amended by changing Sections 20 and 25 as follows:

10 (215 ILCS 134/20)
11 Sec. 20. Notice of nonrenewal or termination. A health 
12care plan must give at least 60 days notice of nonrenewal or 
13termination of a health care provider to the health care 
14provider and to the enrollees served by the health care 
15provider. The notice shall include a name and address to which 
16an enrollee or health care provider may direct comments and 
17concerns regarding the nonrenewal or termination. Immediate 
18written notice may be provided without 60 days notice when a 
19health care provider's license has been disciplined by a State 
20licensing board. The notice to the enrollee shall provide the 
21individual with an opportunity to notify the health care plan 
22of the individual's need for transitional care. 
23(Source: P.A. 91-617, eff. 1-1-00.)

 
 
HB5395- 39 -LRB103 37071 RPS 67189 b


1 (215 ILCS 134/25)
2 Sec. 25. Transition of services. 
3 (a) A health care plan shall provide for continuity of 
4care for its enrollees as follows:
5  (1) If an enrollee's health care provider physician 
6 leaves the health care plan's network of health care 
7 providers for reasons other than termination of a contract 
8 in situations involving imminent harm to a patient or a 
9 final disciplinary action by a State licensing board and 
10 the provider physician remains within the health care 
11 plan's service area, or if benefits provided under such 
12 health care plan with respect to such provider are 
13 terminated because of a change in the terms of the 
14 participation of such provider in such plan, or if a 
15 contract between a group health plan, as defined in 
16 Section 5 of the Illinois Health Insurance Portability and 
17 Accountability Act, and a health care plan offered in 
18 connection with the group health plan is terminated and 
19 results in a loss of benefits provided under such plan 
20 with respect to such provider, the health care plan shall 
21 permit the enrollee to continue an ongoing course of 
22 treatment with that provider physician during a 
23 transitional period:
24   (A) of 90 days from the date of the notice of 
25 provider's physician's termination from the health 
26 care plan to the enrollee of the provider's 
 
 
HB5395- 40 -LRB103 37071 RPS 67189 b


1 physician's disaffiliation from the health care plan 
2 if the enrollee has an ongoing course of treatment; or
3   (B) if the enrollee has entered the third 
4 trimester of pregnancy at the time of the provider's 
5 physician's disaffiliation, that includes the 
6 provision of post-partum care directly related to the 
7 delivery.
8  (2) Notwithstanding the provisions in item (1) of this 
9 subsection, such care shall be authorized by the health 
10 care plan during the transitional period only if the 
11 provider physician agrees:
12   (A) to continue to accept reimbursement from the 
13 health care plan at the rates applicable prior to the 
14 start of the transitional period;
15   (B) to adhere to the health care plan's quality 
16 assurance requirements and to provide to the health 
17 care plan necessary medical information related to 
18 such care; and
19   (C) to otherwise adhere to the health care plan's 
20 policies and procedures, including but not limited to 
21 procedures regarding referrals and obtaining 
22 preauthorizations for treatment.
23  (3) During an enrollee's plan year, a health care plan 
24 shall not remove a drug from its formulary or negatively 
25 change its preferred or cost-tier sharing unless, at least 
26 60 days before making the formulary change, the health 
 
 
HB5395- 41 -LRB103 37071 RPS 67189 b


1 care plan:
2   (A) provides general notification of the change in 
3 its formulary to current and prospective enrollees;
4   (B) directly notifies enrollees currently 
5 receiving coverage for the drug, including information 
6 on the specific drugs involved and the steps they may 
7 take to request coverage determinations and 
8 exceptions, including a statement that a certification 
9 of medical necessity by the enrollee's prescribing 
10 provider will result in continuation of coverage at 
11 the existing level; and
12   (C) directly notifies by first class mail and 
13 through an electronic transmission, if available, the 
14 prescribing provider of all health care plan enrollees 
15 currently prescribed the drug affected by the proposed 
16 change; the notice shall include a one-page form by 
17 which the prescribing provider can notify the health 
18 care plan by first class mail that coverage of the drug 
19 for the enrollee is medically necessary.
20  The notification in paragraph (C) may direct the 
21 prescribing provider to an electronic portal through which 
22 the prescribing provider may electronically file a 
23 certification to the health care plan that coverage of the 
24 drug for the enrollee is medically necessary. The 
25 prescribing provider may make a secure electronic 
26 signature beside the words "certification of medical 
 
 
HB5395- 42 -LRB103 37071 RPS 67189 b


1 necessity", and this certification shall authorize 
2 continuation of coverage for the drug.
3  If the prescribing provider certifies to the health 
4 care plan either in writing or electronically that the 
5 drug is medically necessary for the enrollee as provided 
6 in paragraph (C), a health care plan shall authorize 
7 coverage for the drug prescribed based solely on the 
8 prescribing provider's assertion that coverage is 
9 medically necessary, and the health care plan is 
10 prohibited from making modifications to the coverage 
11 related to the covered drug, including, but not limited 
12 to: 
13   (i) increasing the out-of-pocket costs for the 
14 covered drug;
15   (ii) moving the covered drug to a more restrictive 
16 tier; or 
17   (iii) denying an enrollee coverage of the drug for 
18 which the enrollee has been previously approved for 
19 coverage by the health care plan. 
20  Nothing in this item (3) prevents a health care plan 
21 from removing a drug from its formulary or denying an 
22 enrollee coverage if the United States Food and Drug 
23 Administration has issued a statement about the drug that 
24 calls into question the clinical safety of the drug, the 
25 drug manufacturer has notified the United States Food and 
26 Drug Administration of a manufacturing discontinuance or 
 
 
HB5395- 43 -LRB103 37071 RPS 67189 b


1 potential discontinuance of the drug as required by 
2 Section 506C of the Federal Food, Drug, and Cosmetic Act, 
3 as codified in 21 U.S.C. 356c, or the drug manufacturer 
4 has removed the drug from the market. 
5  Nothing in this item (3) prohibits a health care plan, 
6 by contract, written policy or procedure, or any other 
7 agreement or course of conduct, from requiring a 
8 pharmacist to effect substitutions of prescription drugs 
9 consistent with Section 19.5 of the Pharmacy Practice Act, 
10 under which a pharmacist may substitute an interchangeable 
11 biologic for a prescribed biologic product, and Section 25 
12 of the Pharmacy Practice Act, under which a pharmacist may 
13 select a generic drug determined to be therapeutically 
14 equivalent by the United States Food and Drug 
15 Administration and in accordance with the Illinois Food, 
16 Drug and Cosmetic Act. 
17  This item (3) applies to a policy or contract that is 
18 amended, delivered, issued, or renewed on or after January 
19 1, 2019. This item (3) does not apply to a health plan as 
20 defined in the State Employees Group Insurance Act of 1971 
21 or medical assistance under Article V of the Illinois 
22 Public Aid Code. 
23 (b) A health care plan shall provide for continuity of 
24care for new enrollees as follows:
25  (1) If a new enrollee whose physician is not a member 
26 of the health care plan's provider network, but is within 
 
 
HB5395- 44 -LRB103 37071 RPS 67189 b


1 the health care plan's service area, enrolls in the health 
2 care plan, the health care plan shall permit the enrollee 
3 to continue an ongoing course of treatment with the 
4 enrollee's current physician during a transitional period:
5   (A) of 90 days from the effective date of 
6 enrollment if the enrollee has an ongoing course of 
7 treatment; or
8   (B) if the enrollee 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 an enrollee elects to continue to receive care 
13 from such physician pursuant to item (1) of this 
14 subsection, such care shall be authorized by the health 
15 care plan for the transitional period only if the 
16 physician agrees:
17   (A) to accept reimbursement from the health care 
18 plan at rates established by the health care plan; 
19 such rates shall be the level of reimbursement 
20 applicable to similar physicians within the health 
21 care plan for such services;
22   (B) to adhere to the health care plan's quality 
23 assurance requirements and to provide to the health 
24 care plan necessary medical information related to 
25 such care; and
26   (C) to otherwise adhere to the health care plan's 
 
 
HB5395- 45 -LRB103 37071 RPS 67189 b


1 policies and procedures including, but not limited to 
2 procedures regarding referrals and obtaining 
3 preauthorization for treatment.
4 (c) In no event shall this Section be construed to require 
5a health care plan to provide coverage for benefits not 
6otherwise covered or to diminish or impair preexisting 
7condition limitations contained in the enrollee's contract. In 
8no event shall this Section be construed to prohibit the 
9addition of prescription drugs to a health care plan's list of 
10covered drugs during the coverage year. 
11 (d) In this Section, "ongoing course of treatment" has the 
12meaning ascribed to that term in Section 5 of the Network 
13Adequacy and Transparency Act. 
14(Source: P.A. 100-1052, eff. 8-24-18.)

15 Section 95. No acceleration or delay. Where this Act makes 
16changes in a statute that is represented in this Act by text 
17that is not yet or no longer in effect (for example, a Section 
18represented by multiple versions), the use of that text does 
19not accelerate or delay the taking effect of (i) the changes 
20made by this Act or (ii) provisions derived from any other 
21Public Act.