Illinois Administrative Code › Title 50 - INSURANCE › Part 2051 - PREFERRED PROVIDER PROGRAMS › Section 2051.310 - Health Care Preferred Provider Program Administrator Network Availability and Adequacy Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a)
			 Administrators and insurers must file a description of the services to be
			 offered through the preferred provider program. WC PPPs are exempt from the
			 requirements of this Section, but must instead comply with the requirements of
			 Section
			 2051.315.
			 The description shall include:
1) The method
			 of marketing the program;
2) A
			 geographic map of the area proposed to be served by the program by county and
			 zip code, including marked locations for preferred providers;
3) The names, addresses and specialties of
			 the providers who have entered into preferred provider agreements under the
			 program;
4) The number of
			 beneficiaries anticipated to be covered by the providers listed in subsection
			 (a)(3);
5) An Internet website and
			 toll-free telephone number for beneficiaries and prospective beneficiaries to
			 access regarding up-to-date lists of preferred providers, additional
			 information about the DHCSP, as well as any other information necessary to
			 conform to this Part. A plan shall identify specific providers in a
			 beneficiary's area, confirm specific provider participation or provide a
			 listing of preferred providers by mail. Preferred provider lists requested by
			 phone must be sent within 3 working days. The up-to-date provider list applies
			 to all providers that have entered arrangements to provide services under the
			 program either directly, or indirectly through another administrator.
			 Administrators' and insurers' Internet website addresses shall be prominently
			 displayed on all advertisements, marketing materials, brochures, benefit cards
			 and identification cards; and
6) A
			 description of how health care services to be rendered under the preferred
			 provider program are reasonably accessible and available to beneficiaries.
			 Standards shall address:
A) The type of
			 health care services to be provided by the administrator;
B) The ratio of providers to beneficiaries,
			 by specialty and including primary care physicians when applicable under the
			 contract, necessary to meet the health care needs and service demands of the
			 currently enrolled population;
C)
			 The greatest distance or time that the beneficiary may be required to travel to
			 access:
i) Preferred provider hospital
			 services when applicable under the contract;
ii) Primary care physician and woman's
			 principal health care provider services when applicable under the
			 contract;
iii) Any applicable
			 health care service providers;
D) Written policies and procedures for
			 determining when the program is closed to new providers desiring to enter into
			 preferred provider arrangements;
E)
			 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;
F) The
			 provision of 24 hour, 7 day per week access to network affiliated primary care
			 and woman's principal health care providers. This subsection (a)(6)(F) does not
			 apply to administrators offering only a DHCSP;
G) The procedures for making referrals within
			 and outside the network. This subsection (a)(6)(G) does not apply to
			 administrators offering only a DHCSP;
H) A provision ensuring that whenever a
			 beneficiary has made a good faith effort to utilize preferred providers for a
			 covered service and it is determined the administrator does not have the
			 appropriate preferred providers due to insufficient number, type or distance,
			 the administrator shall ensure, directly or indirectly, by terms contained in
			 the payor 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 subsection (a)(6)(H) does not apply to a beneficiary
			 who willfully chooses to access a non-preferred provider for health care
			 services available through the administrator's panel of participating
			 providers. In these circumstances, the contractual requirements for
			 non-preferred provider reimbursements will apply. This subsection (a)(6)(H)
			 does not apply to administrators offering only a DHCSP;
I) The procedures for paying benefits when
			 particular physician specialties are not represented within the provider
			 network, or the services of such providers are not available at the time care
			 is sought. In any case in which a beneficiary has made a good faith effort to
			 utilize network providers, by satisfying contractual obligation specified in
			 the benefit contract or certificate, for a covered service and the
			 administrator does not have the appropriate preferred specialty providers
			 (including but not limited to radiologists, anesthesiologists, pathologists and
			 emergency room physicians) under contract due to the inability of the
			 administrator to contract with the specialists, or due to the insufficient
			 number or type of, or travel distance to, specialists, the administrator shall
			 ensure 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 subsection (a)(6)(I) does not apply to a beneficiary who
			 willfully chooses to access a non-preferred provider for health care services
			 available through the administrator's panel of participating providers. In
			 these circumstances, the contractual requirements for non-preferred provider
			 reimbursements will apply. This subsection (a)(6)(I) does not apply to
			 administrators offering only a DHCSP;
J) A provision that the beneficiary shall
			 receive emergency care coverage such that payment for this coverage is not
			 dependent upon whether the 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 subsection (a)(6)(J), "the same benefit level" means 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
			 subsection (a)(6)(J) does not apply to administrators offering only a
			 DHCSP;
K) 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;
L) Efforts to address
			 the needs of beneficiaries with limited English proficiency and literacy and/or
			 diverse cultural and ethnic backgrounds, and to comply with the Americans With
			 Disabilities Act of 1990;
M) A
			 sample beneficiary identification card in conformity with the Uniform Health
			 Care Service Benefits Information Card Act [215 ILCS 139 ], and the Uniform
			 Prescription Drug Information Card Act [215 ILCS 138 ] when pharmaceutical
			 services are provided as part of the program's health care services;
N) When a gatekeeper option is included as
			 part of the program, a requirement that the administrator make a good faith
			 effort to provide written notice of termination of the gatekeeper to all
			 beneficiaries who are patients seen on a regular basis by the gatekeeper whose
			 contract is terminating. In a gatekeeper option, when a contract termination
			 involves a primary care physician, all beneficiaries who are patients of that
			 primary care physician shall also be notified. This subsection (a)(6)(N) does
			 not apply to administrators offering only a DHCSP.