Public Act 104-0175
 
HB1331 EnrolledLRB104 07370 BAB 17410 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois, 
represented in the General Assembly:
 
    Section 5. The Network Adequacy and Transparency Act is 
amended by changing Section 10 as follows:
 
    (215 ILCS 124/10)
    (Text of Section from P.A. 103-650)
    Sec. 10. Network adequacy.
    (a) Before issuing, delivering, or renewing a network 
plan, an issuer providing a network plan shall file a 
description of all of the following with the Director:
        (1) The written policies and procedures for adding 
    providers to meet patient needs based on increases in the 
    number of beneficiaries, changes in the 
    patient-to-provider ratio, changes in medical and health 
    care capabilities, and increased demand for services.
        (2) The written policies and procedures for making 
    referrals within and outside the network.
        (3) The written policies and procedures on how the 
    network plan will provide 24-hour, 7-day per week access 
    to network-affiliated primary care, emergency services, 
    and women's principal health care providers.
    An issuer shall not prohibit a preferred provider from 
discussing any specific or all treatment options with 
beneficiaries irrespective of the insurer's position on those 
treatment options or from advocating on behalf of 
beneficiaries within the utilization review, grievance, or 
appeals processes established by the issuer in accordance with 
any rights or remedies available under applicable State or 
federal law.
    (b) Before issuing, delivering, or renewing a network 
plan, an issuer must file for review a description of the 
services to be offered through a network plan. The description 
shall include all of the following:
        (1) A geographic map of the area proposed to be served 
    by the plan by county service area and zip code, including 
    marked locations for preferred providers.
        (2) As deemed necessary by the Department, the names, 
    addresses, phone numbers, and specialties of the providers 
    who have entered into preferred provider agreements under 
    the network plan.
        (3) The number of beneficiaries anticipated to be 
    covered by the network plan.
        (4) An Internet website and toll-free telephone number 
    for beneficiaries and prospective beneficiaries to access 
    current and accurate lists of preferred providers in each 
    plan, additional information about the plan, as well as 
    any other information required by Department rule.
        (5) A description of how health care services to be 
    rendered under the network plan are reasonably accessible 
    and available to beneficiaries. The description shall 
    address all of the following:
            (A) the type of health care services to be 
        provided by the network plan;
            (B) the ratio of physicians and other providers to 
        beneficiaries, by specialty and including primary care 
        physicians and facility-based physicians when 
        applicable under the contract, necessary to meet the 
        health care needs and service demands of the currently 
        enrolled population; 
            (C) the travel and distance standards for plan 
        beneficiaries in county service areas; and
            (D) a description of how the use of telemedicine, 
        telehealth, or mobile care services may be used to 
        partially meet the network adequacy standards, if 
        applicable.
        (6) A provision ensuring that whenever a beneficiary 
    has made a good faith effort, as evidenced by accessing 
    the provider directory, calling the network plan, and 
    calling the provider, to utilize preferred providers for a 
    covered service and it is determined the insurer does not 
    have the appropriate preferred providers due to 
    insufficient number, type, unreasonable travel distance or 
    delay, or preferred providers refusing to provide a 
    covered service because it is contrary to the conscience 
    of the preferred providers, as protected by the Health 
    Care Right of Conscience Act, the issuer shall ensure, 
    directly or indirectly, by terms contained in the payer 
    contract, that the beneficiary will be provided the 
    covered service at no greater cost to the beneficiary than 
    if the service had been provided by a preferred provider. 
    This paragraph (6) does not apply to: (A) a beneficiary 
    who willfully chooses to access a non-preferred provider 
    for health care services available through the panel of 
    preferred providers, or (B) a beneficiary enrolled in a 
    health maintenance organization. In these circumstances, 
    the contractual requirements for non-preferred provider 
    reimbursements shall apply unless Section 356z.3a of the 
    Illinois Insurance Code requires otherwise. In no event 
    shall a beneficiary who receives care at a participating 
    health care facility be required to search for 
    participating providers under the circumstances described 
    in subsection (b) or (b-5) of Section 356z.3a of the 
    Illinois Insurance Code except under the circumstances 
    described in paragraph (2) of subsection (b-5).
        (7) A provision that the beneficiary shall receive 
    emergency care coverage such that payment for this 
    coverage is not dependent upon whether the emergency 
    services are performed by a preferred or non-preferred 
    provider and the coverage shall be at the same benefit 
    level as if the service or treatment had been rendered by a 
    preferred provider. For purposes of this paragraph (7), 
    "the same benefit level" means that the beneficiary is 
    provided the covered service at no greater cost to the 
    beneficiary than if the service had been provided by a 
    preferred provider. This provision shall be consistent 
    with Section 356z.3a of the Illinois Insurance Code.
        (8) A limitation that, if the plan provides that the 
    beneficiary will incur a penalty for failing to 
    pre-certify inpatient hospital treatment, the penalty may 
    not exceed $1,000 per occurrence in addition to the plan 
    cost sharing provisions.
        (9) For a network plan to be offered through the 
    Exchange in the individual or small group market, as well 
    as any off-Exchange mirror of such a network plan, 
    evidence that the network plan includes essential 
    community providers in accordance with rules established 
    by the Exchange that will operate in this State for the 
    applicable plan year. 
    (c) The issuer shall demonstrate to the Director a minimum 
ratio of providers to plan beneficiaries as required by the 
Department for each network plan.
        (1) The minimum ratio of physicians or other providers 
    to plan beneficiaries shall be established by the 
    Department in consultation with the Department of Public 
    Health based upon the guidance from the federal Centers 
    for Medicare and Medicaid Services. The Department shall 
    not establish ratios for vision or dental providers who 
    provide services under dental-specific or vision-specific 
    benefits, except to the extent provided under federal law 
    for stand-alone dental plans. The Department shall 
    consider establishing ratios for the following physicians 
    or other providers:
            (A) Primary Care;
            (B) Pediatrics;
            (C) Cardiology;
            (D) Gastroenterology;
            (E) General Surgery;
            (F) Neurology;
            (G) OB/GYN;
            (H) Oncology/Radiation;
            (I) Ophthalmology;
            (J) Urology;
            (K) Behavioral Health;
            (L) Allergy/Immunology;
            (M) Chiropractic;
            (N) Dermatology;
            (O) Endocrinology;
            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
            (Q) Infectious Disease;
            (R) Nephrology;
            (S) Neurosurgery;
            (T) Orthopedic Surgery;
            (U) Physiatry/Rehabilitative;
            (V) Plastic Surgery;
            (W) Pulmonary;
            (X) Rheumatology;
            (Y) Anesthesiology;
            (Z) Pain Medicine;
            (AA) Pediatric Specialty Services;
            (BB) Outpatient Dialysis; and
            (CC) HIV; and .
            (DD) Genetic Medicine and Genetic Counseling. 
        (2) The Director shall establish a process for the 
    review of the adequacy of these standards, along with an 
    assessment of additional specialties to be included in the 
    list under this subsection (c).
        (3) Notwithstanding any other law or rule, the minimum 
    ratio for each provider type shall be no less than any such 
    ratio established for qualified health plans in 
    Federally-Facilitated Exchanges by federal law or by the 
    federal Centers for Medicare and Medicaid Services, even 
    if the network plan is issued in the large group market or 
    is otherwise not issued through an exchange. Federal 
    standards for stand-alone dental plans shall only apply to 
    such network plans. In the absence of an applicable 
    Department rule, the federal standards shall apply for the 
    time period specified in the federal law, regulation, or 
    guidance. If the Centers for Medicare and Medicaid 
    Services establish standards that are more stringent than 
    the standards in effect under any Department rule, the 
    Department may amend its rules to conform to the more 
    stringent federal standards. 
    (d) The network plan shall demonstrate to the Director 
maximum travel and distance standards and appointment wait 
time standards for plan beneficiaries, which shall be 
established by the Department in consultation with the 
Department of Public Health based upon the guidance from the 
federal Centers for Medicare and Medicaid Services. These 
standards shall consist of the maximum minutes or miles to be 
traveled by a plan beneficiary for each county type, such as 
large counties, metro counties, or rural counties as defined 
by Department rule.
    The maximum travel time and distance standards must 
include standards for each physician and other provider 
category listed for which ratios have been established.
    The Director shall establish a process for the review of 
the adequacy of these standards along with an assessment of 
additional specialties to be included in the list under this 
subsection (d).
    Notwithstanding any other law or Department rule, the 
maximum travel time and distance standards and appointment 
wait time standards shall be no greater than any such 
standards established for qualified health plans in 
Federally-Facilitated Exchanges by federal law or by the 
federal Centers for Medicare and Medicaid Services, even if 
the network plan is issued in the large group market or is 
otherwise not issued through an exchange. Federal standards 
for stand-alone dental plans shall only apply to such network 
plans. In the absence of an applicable Department rule, the 
federal standards shall apply for the time period specified in 
the federal law, regulation, or guidance. If the Centers for 
Medicare and Medicaid Services establish standards that are 
more stringent than the standards in effect under any 
Department rule, the Department may amend its rules to conform 
to the more stringent federal standards. 
    If the federal area designations for the maximum time or 
distance or appointment wait time standards required are 
changed by the most recent Letter to Issuers in the 
Federally-facilitated Marketplaces, the Department shall post 
on its website notice of such changes and may amend its rules 
to conform to those designations if the Director deems 
appropriate. 
    (d-5)(1) Every issuer shall ensure that beneficiaries have 
timely and proximate access to treatment for mental, 
emotional, nervous, or substance use disorders or conditions 
in accordance with the provisions of paragraph (4) of 
subsection (a) of Section 370c of the Illinois Insurance Code. 
Issuers shall use a comparable process, strategy, evidentiary 
standard, and other factors in the development and application 
of the network adequacy standards for timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions and those for the access 
to treatment for medical and surgical conditions. As such, the 
network adequacy standards for timely and proximate access 
shall equally be applied to treatment facilities and providers 
for mental, emotional, nervous, or substance use disorders or 
conditions and specialists providing medical or surgical 
benefits pursuant to the parity requirements of Section 370c.1 
of the Illinois Insurance Code and the federal Paul Wellstone 
and Pete Domenici Mental Health Parity and Addiction Equity 
Act of 2008. Notwithstanding the foregoing, the network 
adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions shall, at a minimum, satisfy the 
following requirements:
        (A) For beneficiaries residing in the metropolitan 
    counties of Cook, DuPage, Kane, Lake, McHenry, and Will, 
    network adequacy standards for timely and proximate access 
    to treatment for mental, emotional, nervous, or substance 
    use disorders or conditions means a beneficiary shall not 
    have to travel longer than 30 minutes or 30 miles from the 
    beneficiary's residence to receive outpatient treatment 
    for mental, emotional, nervous, or substance use disorders 
    or conditions. Beneficiaries shall not be required to wait 
    longer than 10 business days between requesting an initial 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
        (B) For beneficiaries residing in Illinois counties 
    other than those counties listed in subparagraph (A) of 
    this paragraph, network adequacy standards for timely and 
    proximate access to treatment for mental, emotional, 
    nervous, or substance use disorders or conditions means a 
    beneficiary shall not have to travel longer than 60 
    minutes or 60 miles from the beneficiary's residence to 
    receive outpatient treatment for mental, emotional, 
    nervous, or substance use disorders or conditions. 
    Beneficiaries shall not be required to wait longer than 10 
    business days between requesting an initial appointment 
    and being seen by the facility or provider of mental, 
    emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
    (2) For beneficiaries residing in all Illinois counties, 
network adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions means a beneficiary shall not have to 
travel longer than 60 minutes or 60 miles from the 
beneficiary's residence to receive inpatient or residential 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions.
    (3) If there is no in-network facility or provider 
available for a beneficiary to receive timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions in accordance with the 
network adequacy standards outlined in this subsection, the 
issuer shall provide necessary exceptions to its network to 
ensure admission and treatment with a provider or at a 
treatment facility in accordance with the network adequacy 
standards in this subsection. 
    (4) If the federal Centers for Medicare and Medicaid 
Services establishes or law requires more stringent standards 
for qualified health plans in the Federally-Facilitated 
Exchanges, the federal standards shall control for all network 
plans for the time period specified in the federal law, 
regulation, or guidance, even if the network plan is issued in 
the large group market, is issued through a different type of 
Exchange, or is otherwise not issued through an Exchange. 
    (e) Except for network plans solely offered as a group 
health plan, these ratio and time and distance standards apply 
to the lowest cost-sharing tier of any tiered network.
    (f) The network plan may consider use of other health care 
service delivery options, such as telemedicine or telehealth, 
mobile clinics, and centers of excellence, or other ways of 
delivering care to partially meet the requirements set under 
this Section.
    (g) Except for the requirements set forth in subsection 
(d-5), issuers who are not able to comply with the provider 
ratios and time and distance or appointment wait time 
standards established under this Act or federal law may 
request an exception to these requirements from the 
Department. The Department may grant an exception in the 
following circumstances:
        (1) if no providers or facilities meet the specific 
    time and distance standard in a specific service area and 
    the issuer (i) discloses information on the distance and 
    travel time points that beneficiaries would have to travel 
    beyond the required criterion to reach the next closest 
    contracted provider outside of the service area and (ii) 
    provides contact information, including names, addresses, 
    and phone numbers for the next closest contracted provider 
    or facility;
        (2) if patterns of care in the service area do not 
    support the need for the requested number of provider or 
    facility type and the issuer provides data on local 
    patterns of care, such as claims data, referral patterns, 
    or local provider interviews, indicating where the 
    beneficiaries currently seek this type of care or where 
    the physicians currently refer beneficiaries, or both; or
        (3) other circumstances deemed appropriate by the 
    Department consistent with the requirements of this Act.
    (h) Issuers are required to report to the Director any 
material change to an approved network plan within 15 business 
days after the change occurs and any change that would result 
in failure to meet the requirements of this Act. The issuer 
shall submit a revised version of the portions of the network 
adequacy filing affected by the material change, as determined 
by the Director by rule, and the issuer shall attach versions 
with the changes indicated for each document that was revised 
from the previous version of the filing. Upon notice from the 
issuer, the Director shall reevaluate the network plan's 
compliance with the network adequacy and transparency 
standards of this Act. For every day past 15 business days that 
the issuer fails to submit a revised network adequacy filing 
to the Director, the Director may order a fine of $5,000 per 
day. 
    (i) If a network plan is inadequate under this Act with 
respect to a provider type in a county, and if the network plan 
does not have an approved exception for that provider type in 
that county pursuant to subsection (g), an issuer shall cover 
out-of-network claims for covered health care services 
received from that provider type within that county at the 
in-network benefit level and shall retroactively adjudicate 
and reimburse beneficiaries to achieve that objective if their 
claims were processed at the out-of-network level contrary to 
this subsection. Nothing in this subsection shall be construed 
to supersede Section 356z.3a of the Illinois Insurance Code. 
    (j) If the Director determines that a network is 
inadequate in any county and no exception has been granted 
under subsection (g) and the issuer does not have a process in 
place to comply with subsection (d-5), the Director may 
prohibit the network plan from being issued or renewed within 
that county until the Director determines that the network is 
adequate apart from processes and exceptions described in 
subsections (d-5) and (g). Nothing in this subsection shall be 
construed to terminate any beneficiary's health insurance 
coverage under a network plan before the expiration of the 
beneficiary's policy period if the Director makes a 
determination under this subsection after the issuance or 
renewal of the beneficiary's policy or certificate because of 
a material change. Policies or certificates issued or renewed 
in violation of this subsection may subject the issuer to a 
civil penalty of $5,000 per policy. 
    (k) For the Department to enforce any new or modified 
federal standard before the Department adopts the standard by 
rule, the Department must, no later than May 15 before the 
start of the plan year, give public notice to the affected 
health insurance issuers through a bulletin. 
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; 
102-1117, eff. 1-13-23; 103-650, eff. 1-1-25.)
 
    (Text of Section from P.A. 103-656)
    Sec. 10. Network adequacy.
    (a) An insurer providing a network plan shall file a 
description of all of the following with the Director:
        (1) The written policies and procedures for adding 
    providers to meet patient needs based on increases in the 
    number of beneficiaries, changes in the 
    patient-to-provider ratio, changes in medical and health 
    care capabilities, and increased demand for services.
        (2) The written policies and procedures for making 
    referrals within and outside the network.
        (3) The written policies and procedures on how the 
    network plan will provide 24-hour, 7-day per week access 
    to network-affiliated primary care, emergency services, 
    and women's principal health care providers.
    An insurer shall not prohibit a preferred provider from 
discussing any specific or all treatment options with 
beneficiaries irrespective of the insurer's position on those 
treatment options or from advocating on behalf of 
beneficiaries within the utilization review, grievance, or 
appeals processes established by the insurer in accordance 
with any rights or remedies available under applicable State 
or federal law.
    (b) Insurers must file for review a description of the 
services to be offered through a network plan. The description 
shall include all of the following:
        (1) A geographic map of the area proposed to be served 
    by the plan by county service area and zip code, including 
    marked locations for preferred providers.
        (2) As deemed necessary by the Department, the names, 
    addresses, phone numbers, and specialties of the providers 
    who have entered into preferred provider agreements under 
    the network plan.
        (3) The number of beneficiaries anticipated to be 
    covered by the network plan.
        (4) An Internet website and toll-free telephone number 
    for beneficiaries and prospective beneficiaries to access 
    current and accurate lists of preferred providers, 
    additional information about the plan, as well as any 
    other information required by Department rule.
        (5) A description of how health care services to be 
    rendered under the network plan are reasonably accessible 
    and available to beneficiaries. The description shall 
    address all of the following:
            (A) the type of health care services to be 
        provided by the network plan;
            (B) the ratio of physicians and other providers to 
        beneficiaries, by specialty and including primary care 
        physicians and facility-based physicians when 
        applicable under the contract, necessary to meet the 
        health care needs and service demands of the currently 
        enrolled population; 
            (C) the travel and distance standards for plan 
        beneficiaries in county service areas; and
            (D) a description of how the use of telemedicine, 
        telehealth, or mobile care services may be used to 
        partially meet the network adequacy standards, if 
        applicable.
        (6) A provision ensuring that whenever a beneficiary 
    has made a good faith effort, as evidenced by accessing 
    the provider directory, calling the network plan, and 
    calling the provider, to utilize preferred providers for a 
    covered service and it is determined the insurer does not 
    have the appropriate preferred providers due to 
    insufficient number, type, unreasonable travel distance or 
    delay, or preferred providers refusing to provide a 
    covered service because it is contrary to the conscience 
    of the preferred providers, as protected by the Health 
    Care Right of Conscience Act, the insurer shall ensure, 
    directly or indirectly, by terms contained in the payer 
    contract, that the beneficiary will be provided the 
    covered service at no greater cost to the beneficiary than 
    if the service had been provided by a preferred provider. 
    This paragraph (6) does not apply to: (A) a beneficiary 
    who willfully chooses to access a non-preferred provider 
    for health care services available through the panel of 
    preferred providers, or (B) a beneficiary enrolled in a 
    health maintenance organization. In these circumstances, 
    the contractual requirements for non-preferred provider 
    reimbursements shall apply unless Section 356z.3a of the 
    Illinois Insurance Code requires otherwise. In no event 
    shall a beneficiary who receives care at a participating 
    health care facility be required to search for 
    participating providers under the circumstances described 
    in subsection (b) or (b-5) of Section 356z.3a of the 
    Illinois Insurance Code except under the circumstances 
    described in paragraph (2) of subsection (b-5).
        (7) A provision that the beneficiary shall receive 
    emergency care coverage such that payment for this 
    coverage is not dependent upon whether the emergency 
    services are performed by a preferred or non-preferred 
    provider and the coverage shall be at the same benefit 
    level as if the service or treatment had been rendered by a 
    preferred provider. For purposes of this paragraph (7), 
    "the same benefit level" means that the beneficiary is 
    provided the covered service at no greater cost to the 
    beneficiary than if the service had been provided by a 
    preferred provider. This provision shall be consistent 
    with Section 356z.3a of the Illinois Insurance Code.
        (8) A limitation that complies with subsections (d) 
    and (e) of Section 55 of the Prior Authorization Reform 
    Act.
    (c) The network plan shall demonstrate to the Director a 
minimum ratio of providers to plan beneficiaries as required 
by the Department.
        (1) The ratio of physicians or other providers to plan 
    beneficiaries shall be established annually by the 
    Department in consultation with the Department of Public 
    Health based upon the guidance from the federal Centers 
    for Medicare and Medicaid Services. The Department shall 
    not establish ratios for vision or dental providers who 
    provide services under dental-specific or vision-specific 
    benefits. The Department shall consider establishing 
    ratios for the following physicians or other providers:
            (A) Primary Care;
            (B) Pediatrics;
            (C) Cardiology;
            (D) Gastroenterology;
            (E) General Surgery;
            (F) Neurology;
            (G) OB/GYN;
            (H) Oncology/Radiation;
            (I) Ophthalmology;
            (J) Urology;
            (K) Behavioral Health;
            (L) Allergy/Immunology;
            (M) Chiropractic;
            (N) Dermatology;
            (O) Endocrinology;
            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
            (Q) Infectious Disease;
            (R) Nephrology;
            (S) Neurosurgery;
            (T) Orthopedic Surgery;
            (U) Physiatry/Rehabilitative;
            (V) Plastic Surgery;
            (W) Pulmonary;
            (X) Rheumatology;
            (Y) Anesthesiology;
            (Z) Pain Medicine;
            (AA) Pediatric Specialty Services;
            (BB) Outpatient Dialysis; and
            (CC) HIV; and .
            (DD) Genetic Medicine and Genetic Counseling. 
        (2) The Director shall establish a process for the 
    review of the adequacy of these standards, along with an 
    assessment of additional specialties to be included in the 
    list under this subsection (c).
    (d) The network plan shall demonstrate to the Director 
maximum travel and distance standards for plan beneficiaries, 
which shall be established annually by the Department in 
consultation with the Department of Public Health based upon 
the guidance from the federal Centers for Medicare and 
Medicaid Services. These standards shall consist of the 
maximum minutes or miles to be traveled by a plan beneficiary 
for each county type, such as large counties, metro counties, 
or rural counties as defined by Department rule.
    The maximum travel time and distance standards must 
include standards for each physician and other provider 
category listed for which ratios have been established.
    The Director shall establish a process for the review of 
the adequacy of these standards along with an assessment of 
additional specialties to be included in the list under this 
subsection (d).
    (d-5)(1) Every insurer shall ensure that beneficiaries 
have timely and proximate access to treatment for mental, 
emotional, nervous, or substance use disorders or conditions 
in accordance with the provisions of paragraph (4) of 
subsection (a) of Section 370c of the Illinois Insurance Code. 
Insurers shall use a comparable process, strategy, evidentiary 
standard, and other factors in the development and application 
of the network adequacy standards for timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions and those for the access 
to treatment for medical and surgical conditions. As such, the 
network adequacy standards for timely and proximate access 
shall equally be applied to treatment facilities and providers 
for mental, emotional, nervous, or substance use disorders or 
conditions and specialists providing medical or surgical 
benefits pursuant to the parity requirements of Section 370c.1 
of the Illinois Insurance Code and the federal Paul Wellstone 
and Pete Domenici Mental Health Parity and Addiction Equity 
Act of 2008. Notwithstanding the foregoing, the network 
adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions shall, at a minimum, satisfy the 
following requirements:
        (A) For beneficiaries residing in the metropolitan 
    counties of Cook, DuPage, Kane, Lake, McHenry, and Will, 
    network adequacy standards for timely and proximate access 
    to treatment for mental, emotional, nervous, or substance 
    use disorders or conditions means a beneficiary shall not 
    have to travel longer than 30 minutes or 30 miles from the 
    beneficiary's residence to receive outpatient treatment 
    for mental, emotional, nervous, or substance use disorders 
    or conditions. Beneficiaries shall not be required to wait 
    longer than 10 business days between requesting an initial 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
        (B) For beneficiaries residing in Illinois counties 
    other than those counties listed in subparagraph (A) of 
    this paragraph, network adequacy standards for timely and 
    proximate access to treatment for mental, emotional, 
    nervous, or substance use disorders or conditions means a 
    beneficiary shall not have to travel longer than 60 
    minutes or 60 miles from the beneficiary's residence to 
    receive outpatient treatment for mental, emotional, 
    nervous, or substance use disorders or conditions. 
    Beneficiaries shall not be required to wait longer than 10 
    business days between requesting an initial appointment 
    and being seen by the facility or provider of mental, 
    emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
    (2) For beneficiaries residing in all Illinois counties, 
network adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions means a beneficiary shall not have to 
travel longer than 60 minutes or 60 miles from the 
beneficiary's residence to receive inpatient or residential 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions.
    (3) If there is no in-network facility or provider 
available for a beneficiary to receive timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions in accordance with the 
network adequacy standards outlined in this subsection, the 
insurer shall provide necessary exceptions to its network to 
ensure admission and treatment with a provider or at a 
treatment facility in accordance with the network adequacy 
standards in this subsection. 
    (e) Except for network plans solely offered as a group 
health plan, these ratio and time and distance standards apply 
to the lowest cost-sharing tier of any tiered network.
    (f) The network plan may consider use of other health care 
service delivery options, such as telemedicine or telehealth, 
mobile clinics, and centers of excellence, or other ways of 
delivering care to partially meet the requirements set under 
this Section.
    (g) Except for the requirements set forth in subsection 
(d-5), insurers who are not able to comply with the provider 
ratios and time and distance standards established by the 
Department may request an exception to these requirements from 
the Department. The Department may grant an exception in the 
following circumstances:
        (1) if no providers or facilities meet the specific 
    time and distance standard in a specific service area and 
    the insurer (i) discloses information on the distance and 
    travel time points that beneficiaries would have to travel 
    beyond the required criterion to reach the next closest 
    contracted provider outside of the service area and (ii) 
    provides contact information, including names, addresses, 
    and phone numbers for the next closest contracted provider 
    or facility;
        (2) if patterns of care in the service area do not 
    support the need for the requested number of provider or 
    facility type and the insurer provides data on local 
    patterns of care, such as claims data, referral patterns, 
    or local provider interviews, indicating where the 
    beneficiaries currently seek this type of care or where 
    the physicians currently refer beneficiaries, or both; or
        (3) other circumstances deemed appropriate by the 
    Department consistent with the requirements of this Act.
    (h) Insurers are required to report to the Director any 
material change to an approved network plan within 15 days 
after the change occurs and any change that would result in 
failure to meet the requirements of this Act. Upon notice from 
the insurer, the Director shall reevaluate the network plan's 
compliance with the network adequacy and transparency 
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; 
102-1117, eff. 1-13-23; 103-656, eff. 1-1-25.)
 
    (Text of Section from P.A. 103-718)
    Sec. 10. Network adequacy.
    (a) An insurer providing a network plan shall file a 
description of all of the following with the Director:
        (1) The written policies and procedures for adding 
    providers to meet patient needs based on increases in the 
    number of beneficiaries, changes in the 
    patient-to-provider ratio, changes in medical and health 
    care capabilities, and increased demand for services.
        (2) The written policies and procedures for making 
    referrals within and outside the network.
        (3) The written policies and procedures on how the 
    network plan will provide 24-hour, 7-day per week access 
    to network-affiliated primary care, emergency services, 
    and obstetrical and gynecological health care 
    professionals.
    An insurer shall not prohibit a preferred provider from 
discussing any specific or all treatment options with 
beneficiaries irrespective of the insurer's position on those 
treatment options or from advocating on behalf of 
beneficiaries within the utilization review, grievance, or 
appeals processes established by the insurer in accordance 
with any rights or remedies available under applicable State 
or federal law.
    (b) Insurers must file for review a description of the 
services to be offered through a network plan. The description 
shall include all of the following:
        (1) A geographic map of the area proposed to be served 
    by the plan by county service area and zip code, including 
    marked locations for preferred providers.
        (2) As deemed necessary by the Department, the names, 
    addresses, phone numbers, and specialties of the providers 
    who have entered into preferred provider agreements under 
    the network plan.
        (3) The number of beneficiaries anticipated to be 
    covered by the network plan.
        (4) An Internet website and toll-free telephone number 
    for beneficiaries and prospective beneficiaries to access 
    current and accurate lists of preferred providers, 
    additional information about the plan, as well as any 
    other information required by Department rule.
        (5) A description of how health care services to be 
    rendered under the network plan are reasonably accessible 
    and available to beneficiaries. The description shall 
    address all of the following:
            (A) the type of health care services to be 
        provided by the network plan;
            (B) the ratio of physicians and other providers to 
        beneficiaries, by specialty and including primary care 
        physicians and facility-based physicians when 
        applicable under the contract, necessary to meet the 
        health care needs and service demands of the currently 
        enrolled population; 
            (C) the travel and distance standards for plan 
        beneficiaries in county service areas; and
            (D) a description of how the use of telemedicine, 
        telehealth, or mobile care services may be used to 
        partially meet the network adequacy standards, if 
        applicable.
        (6) A provision ensuring that whenever a beneficiary 
    has made a good faith effort, as evidenced by accessing 
    the provider directory, calling the network plan, and 
    calling the provider, to utilize preferred providers for a 
    covered service and it is determined the insurer does not 
    have the appropriate preferred providers due to 
    insufficient number, type, unreasonable travel distance or 
    delay, or preferred providers refusing to provide a 
    covered service because it is contrary to the conscience 
    of the preferred providers, as protected by the Health 
    Care Right of Conscience Act, the insurer shall ensure, 
    directly or indirectly, by terms contained in the payer 
    contract, that the beneficiary will be provided the 
    covered service at no greater cost to the beneficiary than 
    if the service had been provided by a preferred provider. 
    This paragraph (6) does not apply to: (A) a beneficiary 
    who willfully chooses to access a non-preferred provider 
    for health care services available through the panel of 
    preferred providers, or (B) a beneficiary enrolled in a 
    health maintenance organization. In these circumstances, 
    the contractual requirements for non-preferred provider 
    reimbursements shall apply unless Section 356z.3a of the 
    Illinois Insurance Code requires otherwise. In no event 
    shall a beneficiary who receives care at a participating 
    health care facility be required to search for 
    participating providers under the circumstances described 
    in subsection (b) or (b-5) of Section 356z.3a of the 
    Illinois Insurance Code except under the circumstances 
    described in paragraph (2) of subsection (b-5).
        (7) A provision that the beneficiary shall receive 
    emergency care coverage such that payment for this 
    coverage is not dependent upon whether the emergency 
    services are performed by a preferred or non-preferred 
    provider and the coverage shall be at the same benefit 
    level as if the service or treatment had been rendered by a 
    preferred provider. For purposes of this paragraph (7), 
    "the same benefit level" means that the beneficiary is 
    provided the covered service at no greater cost to the 
    beneficiary than if the service had been provided by a 
    preferred provider. This provision shall be consistent 
    with Section 356z.3a of the Illinois Insurance Code.
        (8) A limitation that, if the plan provides that the 
    beneficiary will incur a penalty for failing to 
    pre-certify inpatient hospital treatment, the penalty may 
    not exceed $1,000 per occurrence in addition to the plan 
    cost-sharing provisions.
    (c) The network plan shall demonstrate to the Director a 
minimum ratio of providers to plan beneficiaries as required 
by the Department.
        (1) The ratio of physicians or other providers to plan 
    beneficiaries shall be established annually by the 
    Department in consultation with the Department of Public 
    Health based upon the guidance from the federal Centers 
    for Medicare and Medicaid Services. The Department shall 
    not establish ratios for vision or dental providers who 
    provide services under dental-specific or vision-specific 
    benefits. The Department shall consider establishing 
    ratios for the following physicians or other providers:
            (A) Primary Care;
            (B) Pediatrics;
            (C) Cardiology;
            (D) Gastroenterology;
            (E) General Surgery;
            (F) Neurology;
            (G) OB/GYN;
            (H) Oncology/Radiation;
            (I) Ophthalmology;
            (J) Urology;
            (K) Behavioral Health;
            (L) Allergy/Immunology;
            (M) Chiropractic;
            (N) Dermatology;
            (O) Endocrinology;
            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
            (Q) Infectious Disease;
            (R) Nephrology;
            (S) Neurosurgery;
            (T) Orthopedic Surgery;
            (U) Physiatry/Rehabilitative;
            (V) Plastic Surgery;
            (W) Pulmonary;
            (X) Rheumatology;
            (Y) Anesthesiology;
            (Z) Pain Medicine;
            (AA) Pediatric Specialty Services;
            (BB) Outpatient Dialysis; and
            (CC) HIV; and .
            (DD) Genetic Medicine and Genetic Counseling. 
        (2) The Director shall establish a process for the 
    review of the adequacy of these standards, along with an 
    assessment of additional specialties to be included in the 
    list under this subsection (c).
    (d) The network plan shall demonstrate to the Director 
maximum travel and distance standards for plan beneficiaries, 
which shall be established annually by the Department in 
consultation with the Department of Public Health based upon 
the guidance from the federal Centers for Medicare and 
Medicaid Services. These standards shall consist of the 
maximum minutes or miles to be traveled by a plan beneficiary 
for each county type, such as large counties, metro counties, 
or rural counties as defined by Department rule.
    The maximum travel time and distance standards must 
include standards for each physician and other provider 
category listed for which ratios have been established.
    The Director shall establish a process for the review of 
the adequacy of these standards along with an assessment of 
additional specialties to be included in the list under this 
subsection (d).
    (d-5)(1) Every insurer shall ensure that beneficiaries 
have timely and proximate access to treatment for mental, 
emotional, nervous, or substance use disorders or conditions 
in accordance with the provisions of paragraph (4) of 
subsection (a) of Section 370c of the Illinois Insurance Code. 
Insurers shall use a comparable process, strategy, evidentiary 
standard, and other factors in the development and application 
of the network adequacy standards for timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions and those for the access 
to treatment for medical and surgical conditions. As such, the 
network adequacy standards for timely and proximate access 
shall equally be applied to treatment facilities and providers 
for mental, emotional, nervous, or substance use disorders or 
conditions and specialists providing medical or surgical 
benefits pursuant to the parity requirements of Section 370c.1 
of the Illinois Insurance Code and the federal Paul Wellstone 
and Pete Domenici Mental Health Parity and Addiction Equity 
Act of 2008. Notwithstanding the foregoing, the network 
adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions shall, at a minimum, satisfy the 
following requirements:
        (A) For beneficiaries residing in the metropolitan 
    counties of Cook, DuPage, Kane, Lake, McHenry, and Will, 
    network adequacy standards for timely and proximate access 
    to treatment for mental, emotional, nervous, or substance 
    use disorders or conditions means a beneficiary shall not 
    have to travel longer than 30 minutes or 30 miles from the 
    beneficiary's residence to receive outpatient treatment 
    for mental, emotional, nervous, or substance use disorders 
    or conditions. Beneficiaries shall not be required to wait 
    longer than 10 business days between requesting an initial 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
        (B) For beneficiaries residing in Illinois counties 
    other than those counties listed in subparagraph (A) of 
    this paragraph, network adequacy standards for timely and 
    proximate access to treatment for mental, emotional, 
    nervous, or substance use disorders or conditions means a 
    beneficiary shall not have to travel longer than 60 
    minutes or 60 miles from the beneficiary's residence to 
    receive outpatient treatment for mental, emotional, 
    nervous, or substance use disorders or conditions. 
    Beneficiaries shall not be required to wait longer than 10 
    business days between requesting an initial appointment 
    and being seen by the facility or provider of mental, 
    emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
    (2) For beneficiaries residing in all Illinois counties, 
network adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions means a beneficiary shall not have to 
travel longer than 60 minutes or 60 miles from the 
beneficiary's residence to receive inpatient or residential 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions.
    (3) If there is no in-network facility or provider 
available for a beneficiary to receive timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions in accordance with the 
network adequacy standards outlined in this subsection, the 
insurer shall provide necessary exceptions to its network to 
ensure admission and treatment with a provider or at a 
treatment facility in accordance with the network adequacy 
standards in this subsection. 
    (e) Except for network plans solely offered as a group 
health plan, these ratio and time and distance standards apply 
to the lowest cost-sharing tier of any tiered network.
    (f) The network plan may consider use of other health care 
service delivery options, such as telemedicine or telehealth, 
mobile clinics, and centers of excellence, or other ways of 
delivering care to partially meet the requirements set under 
this Section.
    (g) Except for the requirements set forth in subsection 
(d-5), insurers who are not able to comply with the provider 
ratios and time and distance standards established by the 
Department may request an exception to these requirements from 
the Department. The Department may grant an exception in the 
following circumstances:
        (1) if no providers or facilities meet the specific 
    time and distance standard in a specific service area and 
    the insurer (i) discloses information on the distance and 
    travel time points that beneficiaries would have to travel 
    beyond the required criterion to reach the next closest 
    contracted provider outside of the service area and (ii) 
    provides contact information, including names, addresses, 
    and phone numbers for the next closest contracted provider 
    or facility;
        (2) if patterns of care in the service area do not 
    support the need for the requested number of provider or 
    facility type and the insurer provides data on local 
    patterns of care, such as claims data, referral patterns, 
    or local provider interviews, indicating where the 
    beneficiaries currently seek this type of care or where 
    the physicians currently refer beneficiaries, or both; or
        (3) other circumstances deemed appropriate by the 
    Department consistent with the requirements of this Act.
    (h) Insurers are required to report to the Director any 
material change to an approved network plan within 15 days 
after the change occurs and any change that would result in 
failure to meet the requirements of this Act. Upon notice from 
the insurer, the Director shall reevaluate the network plan's 
compliance with the network adequacy and transparency 
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; 
102-1117, eff. 1-13-23; 103-718, eff. 7-19-24.)
 
    (Text of Section from P.A. 103-777)
    Sec. 10. Network adequacy.
    (a) An insurer providing a network plan shall file a 
description of all of the following with the Director:
        (1) The written policies and procedures for adding 
    providers to meet patient needs based on increases in the 
    number of beneficiaries, changes in the 
    patient-to-provider ratio, changes in medical and health 
    care capabilities, and increased demand for services.
        (2) The written policies and procedures for making 
    referrals within and outside the network.
        (3) The written policies and procedures on how the 
    network plan will provide 24-hour, 7-day per week access 
    to network-affiliated primary care, emergency services, 
    and women's principal health care providers.
    An insurer shall not prohibit a preferred provider from 
discussing any specific or all treatment options with 
beneficiaries irrespective of the insurer's position on those 
treatment options or from advocating on behalf of 
beneficiaries within the utilization review, grievance, or 
appeals processes established by the insurer in accordance 
with any rights or remedies available under applicable State 
or federal law.
    (b) Insurers must file for review a description of the 
services to be offered through a network plan. The description 
shall include all of the following:
        (1) A geographic map of the area proposed to be served 
    by the plan by county service area and zip code, including 
    marked locations for preferred providers.
        (2) As deemed necessary by the Department, the names, 
    addresses, phone numbers, and specialties of the providers 
    who have entered into preferred provider agreements under 
    the network plan.
        (3) The number of beneficiaries anticipated to be 
    covered by the network plan.
        (4) An Internet website and toll-free telephone number 
    for beneficiaries and prospective beneficiaries to access 
    current and accurate lists of preferred providers, 
    additional information about the plan, as well as any 
    other information required by Department rule.
        (5) A description of how health care services to be 
    rendered under the network plan are reasonably accessible 
    and available to beneficiaries. The description shall 
    address all of the following:
            (A) the type of health care services to be 
        provided by the network plan;
            (B) the ratio of physicians and other providers to 
        beneficiaries, by specialty and including primary care 
        physicians and facility-based physicians when 
        applicable under the contract, necessary to meet the 
        health care needs and service demands of the currently 
        enrolled population; 
            (C) the travel and distance standards for plan 
        beneficiaries in county service areas; and
            (D) a description of how the use of telemedicine, 
        telehealth, or mobile care services may be used to 
        partially meet the network adequacy standards, if 
        applicable.
        (6) A provision ensuring that whenever a beneficiary 
    has made a good faith effort, as evidenced by accessing 
    the provider directory, calling the network plan, and 
    calling the provider, to utilize preferred providers for a 
    covered service and it is determined the insurer does not 
    have the appropriate preferred providers due to 
    insufficient number, type, unreasonable travel distance or 
    delay, or preferred providers refusing to provide a 
    covered service because it is contrary to the conscience 
    of the preferred providers, as protected by the Health 
    Care Right of Conscience Act, the insurer shall ensure, 
    directly or indirectly, by terms contained in the payer 
    contract, that the beneficiary will be provided the 
    covered service at no greater cost to the beneficiary than 
    if the service had been provided by a preferred provider. 
    This paragraph (6) does not apply to: (A) a beneficiary 
    who willfully chooses to access a non-preferred provider 
    for health care services available through the panel of 
    preferred providers, or (B) a beneficiary enrolled in a 
    health maintenance organization. In these circumstances, 
    the contractual requirements for non-preferred provider 
    reimbursements shall apply unless Section 356z.3a of the 
    Illinois Insurance Code requires otherwise. In no event 
    shall a beneficiary who receives care at a participating 
    health care facility be required to search for 
    participating providers under the circumstances described 
    in subsection (b) or (b-5) of Section 356z.3a of the 
    Illinois Insurance Code except under the circumstances 
    described in paragraph (2) of subsection (b-5).
        (7) A provision that the beneficiary shall receive 
    emergency care coverage such that payment for this 
    coverage is not dependent upon whether the emergency 
    services are performed by a preferred or non-preferred 
    provider and the coverage shall be at the same benefit 
    level as if the service or treatment had been rendered by a 
    preferred provider. For purposes of this paragraph (7), 
    "the same benefit level" means that the beneficiary is 
    provided the covered service at no greater cost to the 
    beneficiary than if the service had been provided by a 
    preferred provider. This provision shall be consistent 
    with Section 356z.3a of the Illinois Insurance Code.
        (8) A limitation that, if the plan provides that the 
    beneficiary will incur a penalty for failing to 
    pre-certify inpatient hospital treatment, the penalty may 
    not exceed $1,000 per occurrence in addition to the plan 
    cost sharing provisions.
    (c) The network plan shall demonstrate to the Director a 
minimum ratio of providers to plan beneficiaries as required 
by the Department.
        (1) The ratio of physicians or other providers to plan 
    beneficiaries shall be established annually by the 
    Department in consultation with the Department of Public 
    Health based upon the guidance from the federal Centers 
    for Medicare and Medicaid Services. The Department shall 
    not establish ratios for vision or dental providers who 
    provide services under dental-specific or vision-specific 
    benefits, except to the extent provided under federal law 
    for stand-alone dental plans. The Department shall 
    consider establishing ratios for the following physicians 
    or other providers:
            (A) Primary Care;
            (B) Pediatrics;
            (C) Cardiology;
            (D) Gastroenterology;
            (E) General Surgery;
            (F) Neurology;
            (G) OB/GYN;
            (H) Oncology/Radiation;
            (I) Ophthalmology;
            (J) Urology;
            (K) Behavioral Health;
            (L) Allergy/Immunology;
            (M) Chiropractic;
            (N) Dermatology;
            (O) Endocrinology;
            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
            (Q) Infectious Disease;
            (R) Nephrology;
            (S) Neurosurgery;
            (T) Orthopedic Surgery;
            (U) Physiatry/Rehabilitative;
            (V) Plastic Surgery;
            (W) Pulmonary;
            (X) Rheumatology;
            (Y) Anesthesiology;
            (Z) Pain Medicine;
            (AA) Pediatric Specialty Services;
            (BB) Outpatient Dialysis; and
            (CC) HIV; and .
            (DD) Genetic Medicine and Genetic Counseling. 
        (2) The Director shall establish a process for the 
    review of the adequacy of these standards, along with an 
    assessment of additional specialties to be included in the 
    list under this subsection (c).
        (3) If the federal Centers for Medicare and Medicaid 
    Services establishes minimum provider ratios for 
    stand-alone dental plans in the type of exchange in use in 
    this State for a given plan year, the Department shall 
    enforce those standards for stand-alone dental plans for 
    that plan year. 
    (d) The network plan shall demonstrate to the Director 
maximum travel and distance standards for plan beneficiaries, 
which shall be established annually by the Department in 
consultation with the Department of Public Health based upon 
the guidance from the federal Centers for Medicare and 
Medicaid Services. These standards shall consist of the 
maximum minutes or miles to be traveled by a plan beneficiary 
for each county type, such as large counties, metro counties, 
or rural counties as defined by Department rule.
    The maximum travel time and distance standards must 
include standards for each physician and other provider 
category listed for which ratios have been established.
    The Director shall establish a process for the review of 
the adequacy of these standards along with an assessment of 
additional specialties to be included in the list under this 
subsection (d).
    If the federal Centers for Medicare and Medicaid Services 
establishes appointment wait-time standards for qualified 
health plans, including stand-alone dental plans, in the type 
of exchange in use in this State for a given plan year, the 
Department shall enforce those standards for the same types of 
qualified health plans for that plan year. If the federal 
Centers for Medicare and Medicaid Services establishes time 
and distance standards for stand-alone dental plans in the 
type of exchange in use in this State for a given plan year, 
the Department shall enforce those standards for stand-alone 
dental plans for that plan year. 
    (d-5)(1) Every insurer shall ensure that beneficiaries 
have timely and proximate access to treatment for mental, 
emotional, nervous, or substance use disorders or conditions 
in accordance with the provisions of paragraph (4) of 
subsection (a) of Section 370c of the Illinois Insurance Code. 
Insurers shall use a comparable process, strategy, evidentiary 
standard, and other factors in the development and application 
of the network adequacy standards for timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions and those for the access 
to treatment for medical and surgical conditions. As such, the 
network adequacy standards for timely and proximate access 
shall equally be applied to treatment facilities and providers 
for mental, emotional, nervous, or substance use disorders or 
conditions and specialists providing medical or surgical 
benefits pursuant to the parity requirements of Section 370c.1 
of the Illinois Insurance Code and the federal Paul Wellstone 
and Pete Domenici Mental Health Parity and Addiction Equity 
Act of 2008. Notwithstanding the foregoing, the network 
adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions shall, at a minimum, satisfy the 
following requirements:
        (A) For beneficiaries residing in the metropolitan 
    counties of Cook, DuPage, Kane, Lake, McHenry, and Will, 
    network adequacy standards for timely and proximate access 
    to treatment for mental, emotional, nervous, or substance 
    use disorders or conditions means a beneficiary shall not 
    have to travel longer than 30 minutes or 30 miles from the 
    beneficiary's residence to receive outpatient treatment 
    for mental, emotional, nervous, or substance use disorders 
    or conditions. Beneficiaries shall not be required to wait 
    longer than 10 business days between requesting an initial 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
        (B) For beneficiaries residing in Illinois counties 
    other than those counties listed in subparagraph (A) of 
    this paragraph, network adequacy standards for timely and 
    proximate access to treatment for mental, emotional, 
    nervous, or substance use disorders or conditions means a 
    beneficiary shall not have to travel longer than 60 
    minutes or 60 miles from the beneficiary's residence to 
    receive outpatient treatment for mental, emotional, 
    nervous, or substance use disorders or conditions. 
    Beneficiaries shall not be required to wait longer than 10 
    business days between requesting an initial appointment 
    and being seen by the facility or provider of mental, 
    emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
    (2) For beneficiaries residing in all Illinois counties, 
network adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions means a beneficiary shall not have to 
travel longer than 60 minutes or 60 miles from the 
beneficiary's residence to receive inpatient or residential 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions.
    (3) If there is no in-network facility or provider 
available for a beneficiary to receive timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions in accordance with the 
network adequacy standards outlined in this subsection, the 
insurer shall provide necessary exceptions to its network to 
ensure admission and treatment with a provider or at a 
treatment facility in accordance with the network adequacy 
standards in this subsection. 
    (4) If the federal Centers for Medicare and Medicaid 
Services establishes a more stringent standard in any county 
than specified in paragraph (1) or (2) of this subsection 
(d-5) for qualified health plans in the type of exchange in use 
in this State for a given plan year, the federal standard shall 
apply in lieu of the standard in paragraph (1) or (2) of this 
subsection (d-5) for qualified health plans for that plan 
year. 
    (e) Except for network plans solely offered as a group 
health plan, these ratio and time and distance standards apply 
to the lowest cost-sharing tier of any tiered network.
    (f) The network plan may consider use of other health care 
service delivery options, such as telemedicine or telehealth, 
mobile clinics, and centers of excellence, or other ways of 
delivering care to partially meet the requirements set under 
this Section.
    (g) Except for the requirements set forth in subsection 
(d-5), insurers who are not able to comply with the provider 
ratios, time and distance standards, and appointment wait-time 
standards established under this Act or federal law may 
request an exception to these requirements from the 
Department. The Department may grant an exception in the 
following circumstances:
        (1) if no providers or facilities meet the specific 
    time and distance standard in a specific service area and 
    the insurer (i) discloses information on the distance and 
    travel time points that beneficiaries would have to travel 
    beyond the required criterion to reach the next closest 
    contracted provider outside of the service area and (ii) 
    provides contact information, including names, addresses, 
    and phone numbers for the next closest contracted provider 
    or facility;
        (2) if patterns of care in the service area do not 
    support the need for the requested number of provider or 
    facility type and the insurer provides data on local 
    patterns of care, such as claims data, referral patterns, 
    or local provider interviews, indicating where the 
    beneficiaries currently seek this type of care or where 
    the physicians currently refer beneficiaries, or both; or
        (3) other circumstances deemed appropriate by the 
    Department consistent with the requirements of this Act.
    (h) Insurers are required to report to the Director any 
material change to an approved network plan within 15 days 
after the change occurs and any change that would result in 
failure to meet the requirements of this Act. Upon notice from 
the insurer, the Director shall reevaluate the network plan's 
compliance with the network adequacy and transparency 
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; 
102-1117, eff. 1-13-23; 103-777, eff. 1-1-25.)
 
    (Text of Section from P.A. 103-906)
    Sec. 10. Network adequacy.
    (a) An insurer providing a network plan shall file a 
description of all of the following with the Director:
        (1) The written policies and procedures for adding 
    providers to meet patient needs based on increases in the 
    number of beneficiaries, changes in the 
    patient-to-provider ratio, changes in medical and health 
    care capabilities, and increased demand for services.
        (2) The written policies and procedures for making 
    referrals within and outside the network.
        (3) The written policies and procedures on how the 
    network plan will provide 24-hour, 7-day per week access 
    to network-affiliated primary care, emergency services, 
    and women's principal health care providers.
    An insurer shall not prohibit a preferred provider from 
discussing any specific or all treatment options with 
beneficiaries irrespective of the insurer's position on those 
treatment options or from advocating on behalf of 
beneficiaries within the utilization review, grievance, or 
appeals processes established by the insurer in accordance 
with any rights or remedies available under applicable State 
or federal law.
    (b) Insurers must file for review a description of the 
services to be offered through a network plan. The description 
shall include all of the following:
        (1) A geographic map of the area proposed to be served 
    by the plan by county service area and zip code, including 
    marked locations for preferred providers.
        (2) As deemed necessary by the Department, the names, 
    addresses, phone numbers, and specialties of the providers 
    who have entered into preferred provider agreements under 
    the network plan.
        (3) The number of beneficiaries anticipated to be 
    covered by the network plan.
        (4) An Internet website and toll-free telephone number 
    for beneficiaries and prospective beneficiaries to access 
    current and accurate lists of preferred providers, 
    additional information about the plan, as well as any 
    other information required by Department rule.
        (5) A description of how health care services to be 
    rendered under the network plan are reasonably accessible 
    and available to beneficiaries. The description shall 
    address all of the following:
            (A) the type of health care services to be 
        provided by the network plan;
            (B) the ratio of physicians and other providers to 
        beneficiaries, by specialty and including primary care 
        physicians and facility-based physicians when 
        applicable under the contract, necessary to meet the 
        health care needs and service demands of the currently 
        enrolled population; 
            (C) the travel and distance standards for plan 
        beneficiaries in county service areas; and
            (D) a description of how the use of telemedicine, 
        telehealth, or mobile care services may be used to 
        partially meet the network adequacy standards, if 
        applicable.
        (6) A provision ensuring that whenever a beneficiary 
    has made a good faith effort, as evidenced by accessing 
    the provider directory, calling the network plan, and 
    calling the provider, to utilize preferred providers for a 
    covered service and it is determined the insurer does not 
    have the appropriate preferred providers due to 
    insufficient number, type, unreasonable travel distance or 
    delay, or preferred providers refusing to provide a 
    covered service because it is contrary to the conscience 
    of the preferred providers, as protected by the Health 
    Care Right of Conscience Act, the insurer shall ensure, 
    directly or indirectly, by terms contained in the payer 
    contract, that the beneficiary will be provided the 
    covered service at no greater cost to the beneficiary than 
    if the service had been provided by a preferred provider. 
    This paragraph (6) does not apply to: (A) a beneficiary 
    who willfully chooses to access a non-preferred provider 
    for health care services available through the panel of 
    preferred providers, or (B) a beneficiary enrolled in a 
    health maintenance organization. In these circumstances, 
    the contractual requirements for non-preferred provider 
    reimbursements shall apply unless Section 356z.3a of the 
    Illinois Insurance Code requires otherwise. In no event 
    shall a beneficiary who receives care at a participating 
    health care facility be required to search for 
    participating providers under the circumstances described 
    in subsection (b) or (b-5) of Section 356z.3a of the 
    Illinois Insurance Code except under the circumstances 
    described in paragraph (2) of subsection (b-5).
        (7) A provision that the beneficiary shall receive 
    emergency care coverage such that payment for this 
    coverage is not dependent upon whether the emergency 
    services are performed by a preferred or non-preferred 
    provider and the coverage shall be at the same benefit 
    level as if the service or treatment had been rendered by a 
    preferred provider. For purposes of this paragraph (7), 
    "the same benefit level" means that the beneficiary is 
    provided the covered service at no greater cost to the 
    beneficiary than if the service had been provided by a 
    preferred provider. This provision shall be consistent 
    with Section 356z.3a of the Illinois Insurance Code.
        (8) A limitation that, if the plan provides that the 
    beneficiary will incur a penalty for failing to 
    pre-certify inpatient hospital treatment, the penalty may 
    not exceed $1,000 per occurrence in addition to the plan 
    cost sharing provisions.
    (c) The network plan shall demonstrate to the Director a 
minimum ratio of providers to plan beneficiaries as required 
by the Department.
        (1) The ratio of physicians or other providers to plan 
    beneficiaries shall be established annually by the 
    Department in consultation with the Department of Public 
    Health based upon the guidance from the federal Centers 
    for Medicare and Medicaid Services. The Department shall 
    not establish ratios for vision or dental providers who 
    provide services under dental-specific or vision-specific 
    benefits. The Department shall consider establishing 
    ratios for the following physicians or other providers:
            (A) Primary Care;
            (B) Pediatrics;
            (C) Cardiology;
            (D) Gastroenterology;
            (E) General Surgery;
            (F) Neurology;
            (G) OB/GYN;
            (H) Oncology/Radiation;
            (I) Ophthalmology;
            (J) Urology;
            (K) Behavioral Health;
            (L) Allergy/Immunology;
            (M) Chiropractic;
            (N) Dermatology;
            (O) Endocrinology;
            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
            (Q) Infectious Disease;
            (R) Nephrology;
            (S) Neurosurgery;
            (T) Orthopedic Surgery;
            (U) Physiatry/Rehabilitative;
            (V) Plastic Surgery;
            (W) Pulmonary;
            (X) Rheumatology;
            (Y) Anesthesiology;
            (Z) Pain Medicine;
            (AA) Pediatric Specialty Services;
            (BB) Outpatient Dialysis; and
            (CC) HIV; and .
            (DD) Genetic Medicine and Genetic Counseling. 
        (1.5) Beginning January 1, 2026, every insurer shall 
    demonstrate to the Director that each in-network hospital 
    has at least one radiologist, pathologist, 
    anesthesiologist, and emergency room physician as a 
    preferred provider in a network plan. The Department may, 
    by rule, require additional types of hospital-based 
    medical specialists to be included as preferred providers 
    in each in-network hospital in a network plan. 
        (2) The Director shall establish a process for the 
    review of the adequacy of these standards, along with an 
    assessment of additional specialties to be included in the 
    list under this subsection (c).
    (d) The network plan shall demonstrate to the Director 
maximum travel and distance standards for plan beneficiaries, 
which shall be established annually by the Department in 
consultation with the Department of Public Health based upon 
the guidance from the federal Centers for Medicare and 
Medicaid Services. These standards shall consist of the 
maximum minutes or miles to be traveled by a plan beneficiary 
for each county type, such as large counties, metro counties, 
or rural counties as defined by Department rule.
    The maximum travel time and distance standards must 
include standards for each physician and other provider 
category listed for which ratios have been established.
    The Director shall establish a process for the review of 
the adequacy of these standards along with an assessment of 
additional specialties to be included in the list under this 
subsection (d).
    (d-5)(1) Every insurer shall ensure that beneficiaries 
have timely and proximate access to treatment for mental, 
emotional, nervous, or substance use disorders or conditions 
in accordance with the provisions of paragraph (4) of 
subsection (a) of Section 370c of the Illinois Insurance Code. 
Insurers shall use a comparable process, strategy, evidentiary 
standard, and other factors in the development and application 
of the network adequacy standards for timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions and those for the access 
to treatment for medical and surgical conditions. As such, the 
network adequacy standards for timely and proximate access 
shall equally be applied to treatment facilities and providers 
for mental, emotional, nervous, or substance use disorders or 
conditions and specialists providing medical or surgical 
benefits pursuant to the parity requirements of Section 370c.1 
of the Illinois Insurance Code and the federal Paul Wellstone 
and Pete Domenici Mental Health Parity and Addiction Equity 
Act of 2008. Notwithstanding the foregoing, the network 
adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions shall, at a minimum, satisfy the 
following requirements:
        (A) For beneficiaries residing in the metropolitan 
    counties of Cook, DuPage, Kane, Lake, McHenry, and Will, 
    network adequacy standards for timely and proximate access 
    to treatment for mental, emotional, nervous, or substance 
    use disorders or conditions means a beneficiary shall not 
    have to travel longer than 30 minutes or 30 miles from the 
    beneficiary's residence to receive outpatient treatment 
    for mental, emotional, nervous, or substance use disorders 
    or conditions. Beneficiaries shall not be required to wait 
    longer than 10 business days between requesting an initial 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
        (B) For beneficiaries residing in Illinois counties 
    other than those counties listed in subparagraph (A) of 
    this paragraph, network adequacy standards for timely and 
    proximate access to treatment for mental, emotional, 
    nervous, or substance use disorders or conditions means a 
    beneficiary shall not have to travel longer than 60 
    minutes or 60 miles from the beneficiary's residence to 
    receive outpatient treatment for mental, emotional, 
    nervous, or substance use disorders or conditions. 
    Beneficiaries shall not be required to wait longer than 10 
    business days between requesting an initial appointment 
    and being seen by the facility or provider of mental, 
    emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment or to wait longer than 
    20 business days between requesting a repeat or follow-up 
    appointment and being seen by the facility or provider of 
    mental, emotional, nervous, or substance use disorders or 
    conditions for outpatient treatment; however, subject to 
    the protections of paragraph (3) of this subsection, a 
    network plan shall not be held responsible if the 
    beneficiary or provider voluntarily chooses to schedule an 
    appointment outside of these required time frames.
    (2) For beneficiaries residing in all Illinois counties, 
network adequacy standards for timely and proximate access to 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions means a beneficiary shall not have to 
travel longer than 60 minutes or 60 miles from the 
beneficiary's residence to receive inpatient or residential 
treatment for mental, emotional, nervous, or substance use 
disorders or conditions.
    (3) If there is no in-network facility or provider 
available for a beneficiary to receive timely and proximate 
access to treatment for mental, emotional, nervous, or 
substance use disorders or conditions in accordance with the 
network adequacy standards outlined in this subsection, the 
insurer shall provide necessary exceptions to its network to 
ensure admission and treatment with a provider or at a 
treatment facility in accordance with the network adequacy 
standards in this subsection. 
    (e) Except for network plans solely offered as a group 
health plan, these ratio and time and distance standards apply 
to the lowest cost-sharing tier of any tiered network.
    (f) The network plan may consider use of other health care 
service delivery options, such as telemedicine or telehealth, 
mobile clinics, and centers of excellence, or other ways of 
delivering care to partially meet the requirements set under 
this Section.
    (g) Except for the requirements set forth in subsection 
(d-5), insurers who are not able to comply with the provider 
ratios and time and distance standards established by the 
Department may request an exception to these requirements from 
the Department. The Department may grant an exception in the 
following circumstances:
        (1) if no providers or facilities meet the specific 
    time and distance standard in a specific service area and 
    the insurer (i) discloses information on the distance and 
    travel time points that beneficiaries would have to travel 
    beyond the required criterion to reach the next closest 
    contracted provider outside of the service area and (ii) 
    provides contact information, including names, addresses, 
    and phone numbers for the next closest contracted provider 
    or facility;
        (2) if patterns of care in the service area do not 
    support the need for the requested number of provider or 
    facility type and the insurer provides data on local 
    patterns of care, such as claims data, referral patterns, 
    or local provider interviews, indicating where the 
    beneficiaries currently seek this type of care or where 
    the physicians currently refer beneficiaries, or both; or
        (3) other circumstances deemed appropriate by the 
    Department consistent with the requirements of this Act.
    (h) Insurers are required to report to the Director any 
material change to an approved network plan within 15 days 
after the change occurs and any change that would result in 
failure to meet the requirements of this Act. Upon notice from 
the insurer, the Director shall reevaluate the network plan's 
compliance with the network adequacy and transparency 
standards of this Act.
(Source: P.A. 102-144, eff. 1-1-22; 102-901, eff. 7-1-22; 
102-1117, eff. 1-13-23; 103-906, eff. 1-1-25.)