No More Delays! The Illinois Department of Insurance Must Enforce Network Adequacy Now!
March 18, 2022
In 2017, ISMS fought to help enact the Network Adequacy and Transparency Act (NAT Act) to ensure that consumers in a PPO would have timely access to an adequate network of physicians and hospitals. Since its passage, Illinois lawmakers have repeatedly requested that the Illinois Department of Insurance write rules to implement and enforce the many consumer protections in the bill. Yet, as of today, neither rules nor a Legislative Bulletin have been issued to enforce the Act.
In recent weeks, Illinois appears to be experiencing clear violations of the intent of the NAT Act – Public Act 100-0502, including:
- Patients are unable to access appropriate care in a reasonably timely manner
Plans are required to provide “description of how healthcare services to be rendered under the network plan are reasonably accessible and available to beneficiaries,” yet there have been multiple reports that the Springfield Clinic-Blue Cross and Blue Shield of Illinois (BCBSIL) dispute has resulted in significant delays in care due to increased wait times for appointments for patients formerly seeking care at Springfield Clinic. Rules are needed to clarify and strengthen the meaning of “reasonably accessible and available care.”
- A determination from BCBSIL that dropping Springfield Clinic (400 physicians) does not constitute a “material change” in its network and therefore does not need to be reported to DOI.
Insurers are required to report a “material change” in their network to the Illinois Department of Insurance within 15 days of making the change, whereby the network will be reevaluated for adequacy. As defined in the law, "material change" means a significant reduction in the number of healthcare professionals available in a network plan, including a reduction of 10% or more in a specific type of specialty, the removal of a major health system that causes a network to be significantly different from the network when the beneficiary purchased the network plan, or any change that would cause the network to no longer satisfy the requirements of this Act for network adequacy and transparency. Springfield Clinic is one of the largest health systems in the Central Illinois region; at a minimum, removing its physicians from a plan network would constitute a material change on the basis that it “causes a network to be significantly different from the network when the beneficiary purchased the plan.”
- Violations of continuity of care protections for patients
The law provides that network plans ensure continuity of care for enrollees following a change in networks participation. Affected enrollees include patients undergoing an ongoing course of treatment, and patients who are in their third-trimester of pregnancy. Published reports have indicated that patients affected by the Springfield Clinic-BCBSIL dispute have received vague or confusing guidance with respect to whether they are protected by any continuity of care policies, leaving many to anticipate and fear high medical bills associated with necessary services like cancer treatments and pregnancy care.
- Inaccurate and misleading provider directory information
Plans are required to maintain up-to-date and accurate provider directories. Accurate network directory information is a critical component of insuring that plans meet their obligations of having a robust network that ensures “reasonably accessible and available care” for beneficiaries. An extensive investigation by WCIA uncovered significant and frequent errors in published provider directories, including physicians who had moved out of state, aren’t taking new patients, or aren’t reachable at the number provided. Illinois Times published an article covering that Illinois is reviewing whether BCBSIL still has "network-adequacy."
If you have questions, please contact ISMS Senior Vice President of State Legislative Affairs Erin O'Brien by email.