Section 4540.40 Filing Procedures

Section 4540.40  Filing

Procedures

At least annually, an

insurer shall file with the Director the description required under Section 10

of the Act for each network plan before the network plan is issued, delivered,

or renewed in this State.  Each filing shall be submitted through SERFF under

the Supporting Documentation tab as searchable text PDFs unless the applicable

template is an Excel spreadsheet.  Filings must include the following

information:

a)         A complete list of network plan names, associated SERFF

Tracking Numbers, and applicable form numbers that will use the network;

b)         The following network information:

1)

for HMOs, the approval letter from the Illinois Department of Public

Health stating the county or counties, including any partial counties, in which

the insurer has been granted the authority to operate;

2)

for HMOs, a list of the MCOs, including but not limited to individual

practice associations and physician-hospital organizations, used within the

network.  The list must include each MCO’s legal entity name, corporate

address, point of contact at the entity, and point of contact’s phone number

and email address;

3)         for any insurer, a list of all Preferred Provider Program

Administrators (PPPAs), if any, through which the insurer has contracted to

include providers in the plan's network and each PPPA's corresponding Federal

Employer Identification Number (FEIN). An insurer shall verify before filing

that all PPPAs are registered with the Department and in good standing with the

Secretary of State; and

4)         the specific name of the network;

c)         The print and electronic versions of the provider

directories. The directories must include up-to-date, accurate, and complete

provider/facility type, location, and contact information required under

Section 25 of the Act. Providers available by telehealth or telemedicine must

be clearly identified and include information required under the Act

the specific name of the network;

c)         The print and electronic versions of the provider

directories. The directories must include up-to-date, accurate, and complete

provider/facility type, location, and contact information required under

Section 25 of the Act. Providers available by telehealth or telemedicine must

be clearly identified and include information required under the Act. The print

directory, along with the errata, shall be a PDF of the most recent edition

published no more than three months before the date of filing.  Notwithstanding

the above, if the insurer has never offered a network plan with the network

described in the filing, the printed and electronic directories shall include

all preferred providers that, as of the filing date, are under contract,

agreement, or arrangement to service the beneficiaries of the network plan when

it is issued;

d)         Compliance with time and distance standards as follows:

1)         Except as provided in subsection (d)(2), for any network

plan issued, delivered, or renewed on or after January 1, 2023, the filing

required under Section 10 of the Act shall demonstrate compliance with the federal

time and distance standards established in Tables 3.1 and 3.2 of the 2023 Letter

for each county in the service area.  These standards prescribe the maximum

limits of travel in minutes and miles that a beneficiary residing in a given

county type may be expected to undertake to a preferred provider of a given

provider specialty type. The Department will ensure that distance standards are

measured no less stringently than straight-line distance (i.e., “how the crow

flies”) between the beneficiary and the preferred provider, but an insurer may

apply more stringent standards that measure distance based on travel along

existing roads.  Time standards shall be evaluated based on estimated driving

time from the beneficiary to the preferred provider using mapping output data

for travel along existing roads

ntly than straight-line distance (i.e., “how the crow

flies”) between the beneficiary and the preferred provider, but an insurer may

apply more stringent standards that measure distance based on travel along

existing roads.  Time standards shall be evaluated based on estimated driving

time from the beneficiary to the preferred provider using mapping output data

for travel along existing roads.  Measurements of driving time must not be

exclusively based on nor, if an average driving time is used,

disproportionately weighted toward weekends, any day during the week of a

federal or State holiday, or times outside the range of 8 am through 5 pm.

2)         For time and distance standards related to outpatient,

inpatient, or residential treatment for mental, emotional, nervous, or

substance use disorders or conditions, the network plan's compliance with time

and distance standards will be evaluated as follows:

A)        the Department will enforce compliance with Section 10(d-5)

of the Act for all network plans. The insurer shall provide evidence of its

arrangements under which, if the network plan has no preferred provider

available that meets the network adequacy standards of Section 10(d-5) in

relation to a beneficiary, it will make the necessary exemptions to its network

to ensure admission and treatment with a non-preferred provider or facility at

no greater cost to the beneficiary than if the service or treatment had been

provided by a preferred provider; and

B)          nothing in this Part shall be construed to supersede,

exempt, or waive the requirement under 45 CFR 156.230(a)(2) (May 6, 2022) (no

later editions or amendments) that insurers offering QHPs demonstrate

compliance with the quantitative time and distance standards in Tables 3.1 or

3.2 of the 2023 Letter for Outpatient Clinical Behavioral Health, Psychiatry,

and Inpatient or Residential Behavioral Health Facility Services.  The

Department will defer to the U.S

aive the requirement under 45 CFR 156.230(a)(2) (May 6, 2022) (no

later editions or amendments) that insurers offering QHPs demonstrate

compliance with the quantitative time and distance standards in Tables 3.1 or

3.2 of the 2023 Letter for Outpatient Clinical Behavioral Health, Psychiatry,

and Inpatient or Residential Behavioral Health Facility Services.  The

Department will defer to the U.S. Department of Health and Human Services to

enforce those standards for QHPs, including the evaluation of an insurer's

justifications for exceptions.  However, for purposes of subsection (d)(1), an

insurer may elect to demonstrate to the Department that the network plan

actually complies with the federal time and distance standards without an

exception in any county where the federal standards match or exceed the

standards provided in Section 10(d-5) of the Act;

e)         For any network plan to be issued, delivered, amended, or

renewed on or after January 1, 2023, the filing required under Section 10 of

the Act must demonstrate compliance with the following minimum provider ratios.

For health care professionals, the provider ratios below are expressed in terms

of preferred providers to beneficiaries. For facilities, the provider ratios

are expressed in terms of the number of facilities per county:

1)         primary care physician, general practice, family practice,

internal medicine, or primary nurse practitioner − 1:1,000;

2)         allergy/immunology − 1:15,000;

3)         cardiology − 1:10,000;

4)         chiropractic − 1:10,000;

5)         dermatology − 1:10,000;

6)         endocrinology − 1:10,000;

7)         ENT/otolaryngology − 1:15,000;

8)         gastroenterology − 1:10,000;

9)         general surgery − 1:5,000;

10)       gynecology or OB/GYN − 1:2,500;

11)       infectious diseases − 1:15,000;

12)       nephrology − 1:10,000;

13)       neurology − 1:20,000;

14)       oncology/radiation − 1:15,000;

15)       ophthalmology − 1:10,000;

16)       orthopedic surgery − 1:10,000;

17)       physiatry/r

ENT/otolaryngology − 1:15,000;

8)         gastroenterology − 1:10,000;

9)         general surgery − 1:5,000;

10)       gynecology or OB/GYN − 1:2,500;

11)       infectious diseases − 1:15,000;

12)       nephrology − 1:10,000;

13)       neurology − 1:20,000;

14)       oncology/radiation − 1:15,000;

15)       ophthalmology − 1:10,000;

16)       orthopedic surgery − 1:10,000;

17)       physiatry/rehabilitative medicine − 1:15,000;

18)       plastic surgery − 1:20,000;

19)       behavioral health − 1:5,000;

20)       pulmonology − 1:10,000;

21)       rheumatology − 1:10,000;

22)       urology − 1:10,000;

23)       acute inpatient hospital with emergency services available

24 hours a day, 7 days a week – one per county; and

24)       inpatient or residential behavioral health facility −

one per county;

f)         Facilities lists and related exception requests, as

follows:

1)         Insurers must complete and attach the Network Adequacy

County Facilities template found on the Department’s website at https://idoi.illinois.gov/content/dam/soi/en/web/insurance/sites/insurance/companies/documents/network-adequacy-county-facilities.xls,

identifying all contracted acute inpatient hospitals and contracted inpatient

or residential behavioral health facilities for each county in the network. If

an insurer does not have a contracted acute inpatient hospital or a contracted

inpatient or residential behavioral health facility in a county in which the

insurer is marketing the network plan, the county must be marked as NA (not

applicable) or left blank on the template;

2)         For any county that the insurer seeks to include in its

service area that does not have a contracted acute inpatient hospital or a

contracted inpatient or residential behavioral health facility, the insurer

must request an exception under Section 10(g) of the Act using the Network

Adequacy Exception Form (https://idoi.illinois.gov/content/dam/soi/en/web/insurance/sites/insurance/companies/documents/networkadequacyexceptionform.pdf)

o include in its

service area that does not have a contracted acute inpatient hospital or a

contracted inpatient or residential behavioral health facility, the insurer

must request an exception under Section 10(g) of the Act using the Network

Adequacy Exception Form (https://idoi.illinois.gov/content/dam/soi/en/web/insurance/sites/insurance/companies/documents/networkadequacyexceptionform.pdf).

For inpatient or residential behavioral health facilities, an exception may

only be requested with respect to the minimum provider ratio;

g)         Written policies and procedures describing the following

aspects of the network plan:

1)         how the network plan will add preferred providers to meet

patient needs based on increases in the number of beneficiaries, changes in

patient‐to‐provider ratio, changes in medical and health care

capabilities, and increased demand for services;

2)         for HMOs, the referral procedures for providers within and

outside the network; and

3)         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 as set forth in Section

10(a)(3) of the Act;

h)

Geographic maps

of the proposed service area for

the network plans that use the network

by county and

ZIP code,

including marked locations for preferred providers.

(Section 10(b)(1) of

the Act) A separate geographic map with marked locations must be provided for

each provider specialty type for which the Department enforces any time and

distance standards under this Section or Section 10(d-5) of the Act.  Each map

must include all preferred providers under the network plan, including all

contracted network groups, except that, for network plans with tiered networks

that are not solely offered as group health plans, the map must only include

preferred providers from the lowest cost-sharing tier

epartment enforces any time and

distance standards under this Section or Section 10(d-5) of the Act.  Each map

must include all preferred providers under the network plan, including all

contracted network groups, except that, for network plans with tiered networks

that are not solely offered as group health plans, the map must only include

preferred providers from the lowest cost-sharing tier.  Each map must display

all preferred providers of the provider specialty type with a dot point

indicator marking the specific location of each preferred provider of that type

and must highlight the areas that are covered by circles whose radii originate

from each preferred provider's dot using both the time and the distance

standards for the applicable provider specialty type in the county type or

types that the preferred provider will serve.  The map may omit overlapping

boundary lines among two or more circles;

i)          A list of all preferred providers, identified by

specialty type, for each network to be submitted via the Illinois Network

Adequacy (Tiered) Collection Template located on the Department’s website at

https://idoi.illinois.gov/content/dam/soi/en/web/insurance/sites/insurance/companies/documents/appendixa4networkadequacycollectiontemplate.xls.

All applicable fields must be completed in full. This is a separate requirement

from the requirement to file provider directories. The template requires the

following information:

1)         on the Providers tab, the insurer’s federal Health

Insurance Oversight System (HIOS) Issuer ID, if applicable, and the Issuer

State, as well as each provider’s National Provider Identifier (NPI) Number,

provider name prefix, first name, middle initial (if applicable), last name,

name suffix, physician or non-physician status, specialty type, street address,

second line of street address (if applicable), city, state, county, ZIP code,

network IDs, and provider tier;

2)         on the Non-ECP Facilities tab, for each facility provider

that is not an “essen

nal Provider Identifier (NPI) Number,

provider name prefix, first name, middle initial (if applicable), last name,

name suffix, physician or non-physician status, specialty type, street address,

second line of street address (if applicable), city, state, county, ZIP code,

network IDs, and provider tier;

2)         on the Non-ECP Facilities tab, for each facility provider

that is not an “essential community provider” as defined in 45 CFR 156.235(c)

(March 31, 2022) (no later editions or amendments), the facility’s NPI Number,

facility name, facility type, street address, second line of street address (if

applicable), city, state, county, ZIP code, network IDs, and provider tier;

3)         on the Dental Network tab, each dental provider’s NPI

Number, provider name prefix, first name, middle initial (if applicable), last

name, name suffix, physician or non-physician status, specialty type, street

address, second line of street address (if applicable), city, state, county,

ZIP code, and network IDs;

j)          The number of network plan participants anticipated to be

covered by the network plan, as well as the aggregate participants anticipated

for all of the filing insurer's network plans that use the network. An insurer

may satisfy this requirement by filing the Proposed Enrollment Template (https://idoi.illinois.gov/content/dam/soi/en/web/insurance/sites/insurance/companies/documents/proposedenrollmenttemplate.xls)

it has used in the annual certification process for a qualified health plan (see

42 U.S.C

te participants anticipated

for all of the filing insurer's network plans that use the network. An insurer

may satisfy this requirement by filing the Proposed Enrollment Template (https://idoi.illinois.gov/content/dam/soi/en/web/insurance/sites/insurance/companies/documents/proposedenrollmenttemplate.xls)

it has used in the annual certification process for a qualified health plan (see

42 U.S.C. 18021(a)(1));

k)         Samples of any notices of nonrenewal or termination that

will be sent to providers and beneficiaries served by those providers (see

Section 15 of the Act);

l)          Language from policy forms about non-emergency health

care services from non-preferred providers, as follows:

1)

For network plans not issued by an HMO, a provision that

the beneficiary will be provided a covered service at no

greater cost to the beneficiary than if the service had been provided by a

preferred provider

if

the beneficiary

has made a good faith effort

by accessing the provider directory, calling

the network plan, and calling the provider,

to utilize preferred providers

for

that

service and it is determined that the insurer does not have

appropriate preferred providers due to insufficient number, type, or

unreasonable travel distance or delay

. This provision shall comply with all

applicable requirements and exceptions under Section 10(b)(6) of the Act; and

2)

for an HMO network plan,

language

specifying the procedure for a primary care physician to follow to refer the

beneficiary to a non-preferred provider when a specialist is not available

within the HMO network

nsufficient number, type, or

unreasonable travel distance or delay

. This provision shall comply with all

applicable requirements and exceptions under Section 10(b)(6) of the Act; and

2)

for an HMO network plan,

language

specifying the procedure for a primary care physician to follow to refer the

beneficiary to a non-preferred provider when a specialist is not available

within the HMO network.

This provision shall comply

with all applicable requirements and exceptions under Section 10(b)(6) of the

Act

;

m)        For each network plan that will use the network, language

from the policy forms providing

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

requirement, “

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

. (Section 10(b)(7) of the Act) Additionally,

this provision must comply with all requirements described or incorporated

under Section 10(b)(7) of the Act;

n)         If a network plan imposes precertification penalties for

inpatient hospital stays, language from the policy form complying with Section

10(b)(8) of the Act;

o)         For each network plan that will utilize the network,

language from the provider contract demonstrating that preferred providers are

not prohibited 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

; (Section

10(a) o

prohibited 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

; (Section

10(a) of the Act)

p)

A description of how health care services to be

rendered under the network plan are reasonably accessible and available to

beneficiaries,

including the type of health care services to be provided by

the network plan.

The description shall address

all of the following:

1)

the type of health care services to be

provided by the network plan;

(Section 10(b)(5) of the Act)

2)

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;

3)

the travel and distance standards for network

beneficiaries in county service areas; and

4)

the availability of

telehealth care, including

how the use of telemedicine, telehealth, or

mobile care services may be used to partially meet the network adequacy

standards, if applicable

(Section 10(b)(5) of the Act);

q)         Any exceptions requested for the network plan’s compliance

with any provider ratio, time and distance, or appointment waiting time

standards specified or implemented under Section 10 of the Act, which shall be

filed using the Network Adequacy Exception Form available on the Department’s

website at https://insurance2.illinois.gov/HealthInsurance/NetworkAdequacyExcemptionForm.pdf

ct);

q)         Any exceptions requested for the network plan’s compliance

with any provider ratio, time and distance, or appointment waiting time

standards specified or implemented under Section 10 of the Act, which shall be

filed using the Network Adequacy Exception Form available on the Department’s

website at https://insurance2.illinois.gov/HealthInsurance/NetworkAdequacyExcemptionForm.pdf.

The insurer must disclose on this form the following information:

1)         insurer contact information, including the insurer’s legal

name, address, city, state, ZIP code, contact name, contact phone number, and

email address;

2)         for network plans that do not meet one or more of this

Part's time and distance standards in any county, the following information:

A)        Contact information for the next closest preferred provider

or facility with that specialty, including name, address, city, state, county,

ZIP code, and phone number, and the distance and time that beneficiaries would

have to travel beyond the required criteria to reach that provider (Section

10(g)(1) of the Act); and

B)        Any providers or facilities that would satisfy the time and

distance standards if they were contracted for use with the network plan;

3)         if the insurer believes that

patterns of care in the

service area do not support the need for

compliance with the required ratio

for a specific provider or facility type, all applicable 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,

and an

explanation of how the data supports the insurer’s position (Section 10(g)(2)

of the Act);

4)         any network deficiencies in any county with respect to the

time and distance or appointment waiting time standards established by Section

10(d-5) of the Act

dicating where the beneficiaries currently seek this type of care

or where the physicians currently refer beneficiaries, or both,

and an

explanation of how the data supports the insurer’s position (Section 10(g)(2)

of the Act);

4)         any network deficiencies in any county with respect to the

time and distance or appointment waiting time standards established by Section

10(d-5) of the Act.  No exceptions will be granted to the requirements of

Section 10(d-5) of the Act; and

5)         any other circumstances that the insurer believes justify

an exception to the provider ratios or time and distance standards specified in

this Part, along with supporting documentation. With respect to time and

distance standards, the Department may take into consideration other obstacles

to a network plan's timely compliance, including, but not limited to, the

following factors that may, but are not required to, be submitted on any

federal QHP template or justification form that lists substantially similar

factors:

A)        no provider can satisfy the time and distance standards for

beneficiaries residing in some or all areas of the county because of unpassable

topographical features, such as bodies of water or mountainous areas where

bridges, tunnels, or other reasonably direct roads are not in close proximity;

B)        no provider of the specialty type within the county's time

and distance standards is licensed, accredited, or certified by the State;

C)        all providers of the specialty type within the county's

time and distance standards contract exclusively with another insurer, whether

directly or through their contracted network group;

D)        no providers of the specialty type within the county's time

and distance standards directly or indirectly contract with any commercial

insurer;

E)        no providers of the specialty type practice within the

county's time and distance standards;

F)         good faith contracting offers to providers of the

specialty type or potential contracted network

their contracted network group;

D)        no providers of the specialty type within the county's time

and distance standards directly or indirectly contract with any commercial

insurer;

E)        no providers of the specialty type practice within the

county's time and distance standards;

F)         good faith contracting offers to providers of the

specialty type or potential contracted network groups have been rejected by the

provider or group;

G)        the network is still under development with respect to the

specialty type but will be in compliance by the start of open enrollment or the

start of the plan or policy year; or

H)        the preferred providers within the county's time and distance

standards for the specialty type have recently moved, retired, or closed; and

r)          A completed Network Adequacy Checklist, available on the

Department’s website (https://idoi.illinois.gov/content/dam/soi/en/web/insurance/companies/documents/NetworkAdequacyTransparencyChecklist.pdf),

in which the insurer must:

1)         identify itself by its legal entity name and the SERFF

Tracking Number of the filing made under this Section; and

2)         write the word "Affirmed", the name of the

document where the requirement is satisfied, and any applicable page, tab, or

section in the document, next to every requirement on the checklist applicable

to the network plan.

s)         For a network plan issued or renewed during 2023 that does

not use the same network as any Department-approved QHP from the same insurer

for the same year, an insurer may submit a filing no later than July 1, 2023

that combines the annual filings described in this Section for both 2023 and

2024 issuance and renewals.

1)         For 2023 issuances and renewals, the combination filing

shall demonstrate the network plan's compliance and request exceptions based on

the network status on the filing date

ed QHP from the same insurer

for the same year, an insurer may submit a filing no later than July 1, 2023

that combines the annual filings described in this Section for both 2023 and

2024 issuance and renewals.

1)         For 2023 issuances and renewals, the combination filing

shall demonstrate the network plan's compliance and request exceptions based on

the network status on the filing date.

2)         For 2024 issuances and renewals, the combination filing

shall demonstrate the network plan's compliance and request exceptions based on

the network conditions anticipated to exist by the issue or renewal date.  An

insurer may rely on network status on the filing date whenever the conditions

are anticipated to remain materially unchanged by the issue or renewal date.

3)         An insurer shall expressly distinguish in a cover letter

or by computer filename which filed documents are intended to apply to both

2023 and 2024 or just to one of those years.  The filing does not need to

include duplicates of any policy form provision, provider contract, internal

policy or procedure, provider list, provider directory, or map if, as of the

filing date, the contents are not expected to change from 2023 to 2024.

4)         Provider lists and directories filed for 2023 issuances

and renewals must be the most recent editions as of the filing date.  Provider

lists and directories for 2024 must include any providers contracted to be in

the network by the start of the plan or policy year.

5)         This combination filing option is not available for any

network plan offered in 2023 for which the insurer previously submitted a

filing that demonstrated its degree of compliance and requested exceptions from

the time and distance standards specified in the 2023 Letter.