HB 3796

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Full Text of HB3796
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	HB3796 - 104th General Assembly
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		HB3796 Enrolled		LRB104 09757 BAB 19823 b
1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Network Adequacy and Transparency Act is
5amended by changing Section 20 as follows:
6    (215 ILCS 124/20)
7    Sec. 20. Transition of services.
8    (a) A network plan shall provide for continuity of care
9for its beneficiaries as follows:
10        (1) If a beneficiary's provider leaves the network
11    plan's network of providers for reasons other than
12    termination of a contract in situations involving imminent
13    harm to a patient or a final disciplinary action by a State
14    licensing board and the provider remains within the
15    network plan's service area, if benefits provided under
16    such network plan with respect to such provider or
17    facility are terminated because of a change in the terms
18    of the participation of such provider or facility in such
19    plan, or if a contract between a group health plan and a
20    health insurance issuer offering a network plan in
21    connection with the group health plan is terminated and
22    results in a loss of benefits provided under such plan
23    with respect to such provider, then the network plan shall
		HB3796 Enrolled	- 2 -	LRB104 09757 BAB 19823 b
1    permit the beneficiary to continue an ongoing course of
2    treatment with that provider during a transitional period
3    for the following duration:
4            (A) 90 days from the date of the notice to the
5        beneficiary of the provider's disaffiliation from the
6        network plan if the beneficiary has an ongoing course
7        of treatment;
8            (A-5) 90 days from the date of the notice to the 
9        beneficiary of the provider's disaffiliation from the 
10        network plan if the beneficiary has a confirmed 
11        appointment and the provider attests that the 
12        appointment was scheduled prior to the date of 
13        notification; or
14            (B) if the beneficiary has entered the third
15        trimester of pregnancy at the time of the provider's
16        disaffiliation, a period that includes the provision
17        of post-partum care directly related to the delivery.
18        (2) Notwithstanding the provisions of paragraph (1) of
19    this subsection (a), such care shall be authorized by the
20    network plan during the transitional period in accordance
21    with the following:
22            (A) the provider receives continued reimbursement
23        from the network plan at the rates and terms and
24        conditions applicable under the terminated contract
25        prior to the start of the transitional period;
26            (B) the provider adheres to the network plan's
		HB3796 Enrolled	- 3 -	LRB104 09757 BAB 19823 b
1        quality assurance requirements, including provision to
2        the network plan of necessary medical information
3        related to such care; and
4            (C) the provider otherwise adheres to the network
5        plan's policies and procedures, including, but not
6        limited to, procedures regarding referrals and
7        obtaining preauthorizations for treatment.
8        (3) The provisions of this Section governing health
9    care provided during the transition period do not apply if
10    the beneficiary has successfully transitioned to another
11    provider participating in the network plan, if the
12    beneficiary has already met or exceeded the benefit
13    limitations of the plan, or if the care provided is not
14    medically necessary.
15        (4) The provisions of this Section governing health 
16    care provided during the transition period do not apply if 
17    the provider or the beneficiary, as set forth in item 
18    (A-5) of paragraph (1) of subsection (a), reschedules an 
19    appointment or schedules any follow up appointments after 
20    90 days from the date of notice provided in Section 15.
21    (b) A network plan shall provide for continuity of care
22for new beneficiaries as follows:
23        (1) If a new beneficiary whose provider is not a
24    member of the network plan's provider network, but is
25    within the network plan's service area, enrolls in the
26    network plan, the network plan shall permit the
		HB3796 Enrolled	- 4 -	LRB104 09757 BAB 19823 b
1    beneficiary to continue an ongoing course of treatment
2    with the beneficiary's current physician during a
3    transitional period:
4            (A) of 90 days from the effective date of
5        enrollment if the beneficiary has an ongoing course of
6        treatment;
7            (A-5) of 90 days from the effective date of 
8        enrollment if the beneficiary has a confirmed 
9        appointment and the current provider attests that the 
10        appointment was scheduled prior to the effective date 
11        of enrollment; or
12            (B) if the beneficiary has entered the third
13        trimester of pregnancy at the effective date of
14        enrollment, that includes the provision of post-partum
15        care directly related to the delivery.
16        (2) If a beneficiary, or a beneficiary's authorized
17    representative, elects in writing to continue to receive
18    care from such provider pursuant to paragraph (1) of this
19    subsection (b), such care shall be authorized by the
20    network plan for the transitional period in accordance
21    with the following:
22            (A) the provider receives reimbursement from the
23        network plan at rates established by the network plan;
24            (B) the provider adheres to the network plan's
25        quality assurance requirements, including provision to
26        the network plan of necessary medical information
		HB3796 Enrolled	- 5 -	LRB104 09757 BAB 19823 b
1        related to such care; and
2            (C) the provider otherwise adheres to the network
3        plan's policies and procedures, including, but not
4        limited to, procedures regarding referrals and
5        obtaining preauthorization for treatment.
6        (3) The provisions of this Section governing health
7    care provided during the transition period do not apply if
8    the beneficiary has successfully transitioned to another
9    provider participating in the network plan, if the
10    beneficiary has already met or exceeded the benefit
11    limitations of the plan, or if the care provided is not
12    medically necessary.
13        (4) The provisions of this subsection governing health 
14    care provided during the transition period do not apply if 
15    the provider or the beneficiary, as set forth in item 
16    (A-5) of paragraph (1) of subsection (b), reschedules an 
17    appointment or schedules any follow up appointments after 
18    90 days from the effective date of enrollment.
19    (c) In no event shall this Section be construed to require
20a network plan to provide coverage for benefits not otherwise
21covered or to diminish or impair preexisting condition
22limitations contained in the beneficiary's contract.
23    (d) A provider shall comply with the requirements of 42
24U.S.C. 300gg-138.
25(Source: P.A. 103-650, eff. 1-1-25.)
26    Section 99. Effective date. This Act takes effect January
		HB3796 Enrolled	- 6 -	LRB104 09757 BAB 19823 b
11, 2027.