Payment issues with health insurance companies continue to cause headaches for physicians and their practices, the result of which continues to threaten the economic sustainability of healthcare. Access
Access to quality patient care is often disrupted due to barriers caused by health insurance companies, roadblocks that ultimately threaten the care Illinois patients’ need.
ISMS has worked to streamline onerous prior authorization requests and ensure transparency from insurance companies.
- Network Adequacy & Transparency Act: ISMS crafted law which ensures the adequacy, accessibility and transparency of health care network plans.
- Prevented Prescription Drug Formulary Disruptions: ISMS helped enact legislation that will prevent insurance companies from modifying an enrollee’s drug formulary coverage after the enrollee is already locked into a health plan for the year.
- Right-to-Shop: ISMS blocked legislation that would encourage patients to focus exclusively on cost when seeking medical care, with complete disregard for physician experience, expertise or other factors related to quality of care, amongst other harmful provisions.
- Drug Pricing: ISMS stopped legislation by insurers that would have coerced patients to choose the lowest-cost healthcare option by offering financial incentives.
To see ISMS’ specific work on more insurance related issues, please view the end of session legislative reports.
Currently Tracked Bills
Insurance Coverage for Reconstructive Services: HB 1384 (Sponsor: Rep. Kelly M. Cassidy, Sen. Meg Loughran Cappel) - House Bill 1384 provides that a group or individual policy of accident and health insurance may not deny coverage for medically necessary reconstructive services intended to restore physical appearance. This is particularly valuable to those who have experienced domestic abuse. It also ensures that medically necessary reconstructive services intended to restore physical appearance must be covered under the medical assistance program for persons who are otherwise eligible for assistance. This bill passed both chambers and awaits action by the governor.
Adequate Networks and Hospital-Based Specialists: HB 2580 (Sponsor: Rep. William E Hauter) - House Bill 2580 amends the Network Adequacy and Transparency Act to include a list of physician specialties that must be considered by the Department of Insurance when assessing the adequacy of a health plan’s network of healthcare professionals and hospital-based medical specialists. This includes pathologists, anesthesiologists, emergency medicine, radiologists and neonatologists. The insurance industry in strongly opposed to this bill. House Bill 2580 has been referred to the House Rules Committee
Insurance Rates: HB 2581 (Sponsor: Rep. William E Hauter) - House Bill 2581 provides that for any claim submitted to arbitration, the health insurance issuer must pay the healthcare professional or facility at least the current Medicare reimbursement rate pending the resolution of the arbitration. This bill remains in the House.
Provide Claims by Batching: HB 3030 (Sponsors: Rep. Bob Morgan, Sen. Julie Morrison) - This bill would allow out-of-network physicians to batch claims when seeking arbitration for underpayment of services. Currently, physicians seeking arbitration can only do so on a per claim basis, which is cost prohibitive. House Bill 3030 passed both chambers and now awaits action by the governor
Insurance Coverage and Deductible Year: SB 92 (Sponsor: Sen. Laura Fine) - Senate Bill 92 provides that the Department of Insurance issue rules to establish specific standards which may cover, but are not be limited to, alignment of an accident and health insurance policy's coverage year and deductible year for the purpose of determining patient out-of-pocket cost-sharing limits. The insurance industry opposed this bill, which remains in the Senate.
Strengthening the Network Adequacy and Transparency Act (NAT Act)
On March 21, 2023, the Joint Committee on Administrative Rules approved the Illinois Department of Insurance (DOI)’s final rule to support compliance with and enforcement of the Network Adequacy and Transparency Act (NAT Act). ISMS had encouraged the Department to develop rules to ensure that the provisions in the Act are consistent with their legislative intent. In particular, we stressed the importance of using the rulemaking process to strengthen protections related to provider ratio,time, and distance standards; plan reporting of network changes; assure continuity of care for patients during network transitions; and maintain the accuracy of provider directories.
The Rule approved today reflects extensive input from ISMS:
- Specifies that time and distance standards are those established in the 2023 Letter to Insurers in Federally-Facilitated Marketplaces, issued by the Centers for Medicare and Medicaid Services, and clarifies how distance and time are to be estimated.
The law requires the DOI, in consultation with the Department of Public Health, to establish time and distance standards annually, based on CMS guidance The Rule specifically ties the time and distance standards to the published 2023 CMS guidance to Marketplace issuers. The DOI has indicated that it intends to issue updated rules annually, which will reaffirm or revise the basis for the time and distance standards, including considering the latest published Guidance from CMS. Also, the Rule finalized on March 21 specifies that these time and distance standards must be demonstrated for each county in a plan’s service area.
- Specifies that plans seeking an exception to the time and distance standards submit specific information to the DOI via the Network Adequacy Exception Form, which can be found on the DOI website.
The law allows for an exceptions process for plans that “are not able to comply” with the time and distance standards. Potential exceptions include there being no healthcare professionals that meet the specific parameters, but the plan can document availability of the “next closest” healthcare professionals, or patterns of care the service area does not support the inclusion of particular provider types. The Rule specifies that, in the case of plans requesting to rely on the “next closest” providers, plans “shall state whether there are any providers or facilities that would satisfy the time and distance standards if they were contracted for use with the network plan and shall identify any such providers or facilities.”
- Codifies specific provider ratios for most provider types listed in the NAT Act.
The law gives the DOI discretion in selecting specialties for which it will establish ratios, and discretion in setting those ratios. The Rule establishes specific ratios for all but six of the 28 specialists listed in the law as ones for the DOI to “consider.”
- Requires material changes to be submitted via a revised version of the most recent network adequacy filing, indicating the changes for each document that was revised from the previous version of the filing.
The law requires plans to submit material changes to the DOI but does not specify how the notification should be made or what details need to be included. The approved Rule formalizes and increases transparency of this notification requirement by requiring plans to submit the revisions via an updated network adequacy filing, with relevant changes highlighted.
- Requires plans to file annual reports describing the verification process established to ensure accuracy of provider directories. In addition, plans are required to audit each of their print and online directories for each network plan no less than twice per year, and to submit these audits as an attachment to the annual filing describing the verification process.
The law requires plans to maintain updated directories and to conduct their own audits “periodically,” the results of which should be submitted to the DOI upon request. The Rule requires plans to file reports with the DOI annually, and to attached copies of self-audits, which plans are required to conduct at least twice a year.
- Requires plans to submit to the DOI sample correspondence to beneficiaries and providers regarding network changes. Specifies information that must be included in letters to patients including the availability of transitional services, a description of who qualifies for transitional services and the insurer’s formal procedure for a beneficiary to request transitional services.
The law requires plans to notify providers and beneficiaries of non-renewal or termination of a provider at least 60 days before the end date. The law also requires plans to provide for a 90-day transition of care for certain patients being served by providers who leave the network. The Rule defines the information that must be included in the non-renewal/termination notice, including detailed information about a patient’s potential transitional care rights under the law.
In February 2023, the DOI established a Network Adequacy Unit with staff specifically dedicated to network adequacy and transparency issues., which will significantly increase the Department’s capacity to respond to complaints and review filings, as well as devise efficient regulatory processes under the NAT Act. The new Unit will also continually monitor the efficiency and effectiveness of network adequacy regulations, and may recommend appropriate adjustments via future rule-makings, which the Department plans to undertake annually.