Illinois § 20

§ 20.

Transition of services. (a) A network plan shall provide for continuity of care for its beneficiaries as follows: (1) If a beneficiary's provider leaves the network plan's network of providers for reasons other than termination of a contract in situations involving imminent harm to a patient or a final disciplinary action by a State licensing board and the provider remains within the network plan's service area, if benefits provided under such network plan with respect to such provider or facility are terminated because of a change in the terms of the participation of such provider or facility in such plan, or if a contract between a group health plan and a health insurance issuer offering a network plan in connection with the group health plan is terminated and results in a loss of benefits provided under such plan with respect to such provider, then the network plan shall permit the beneficiary to continue an ongoing course of treatment with that provider during a transitional period for the following duration: (A) 90 days from the date of the notice to the beneficiary of the provider's disaffiliation from the network plan if the beneficiary has an ongoing course of treatment; or (B) if the beneficiary has entered the third trimester of pregnancy at the time of the provider's disaffiliation, a period that includes the provision of post-partum care directly related to the delivery. (2) Notwithstanding the provisions of paragraph (1) of this subsection (a), such care shall be authorized by the network plan during the transitional period in accordance with the following: (A) the provider receives continued reimbursement from the network plan at the rates and terms and conditions applicable under the terminated contract prior to the start of the transitional period; (B) the provider adheres to the network plan's quality assurance requirements, including provision to the network plan of necessary medical information related to such care; and (C) the provider otherwise adheres to the network plan's policies and procedures, including, but not limited to, procedures regarding referrals and obtaining preauthorizations for treatment. (3) The provisions of this Section governing health care provided during the transition period do not apply if the beneficiary has successfully transitioned to another provider participating in the network plan, if the beneficiary has already met or exceeded the benefit limitations of the plan, or if the care provided is not medically necessary. (b) A network plan shall provide for continuity of care for new beneficiaries as follows: (1) If a new beneficiary whose provider is not a member of the network plan's provider network, but is within the network plan's service area, enrolls in the network plan, the network plan shall permit the beneficiary to continue an ongoing course of treatment with the beneficiary's current physician during a transitional period: (A) of 90 days from the effective date of enrollment if the beneficiary has an ongoing course of treatment; or (B) if the beneficiary has entered the third trimester of pregnancy at the effective date of enrollment, that includes the provision of post-partum care directly related to the delivery. (2) If a beneficiary, or a beneficiary's authorized representative, elects in writing to continue to receive care from such provider pursuant to paragraph (1) of this subsection (b), such care shall be authorized by the network plan for the transitional period in accordance with the following: (A) the provider receives reimbursement from the network plan at rates established by the network plan; (B) the provider adheres to the network plan's quality assurance requirements, including provision to the network plan of necessary medical information related to such care; and (C) the provider otherwise adheres to the network plan's policies and procedures, including, but not limited to, procedures regarding referrals and obtaining preauthorization for treatment. (3) The provisions of this Section governing health care provided during the transition period do not apply if the beneficiary has successfully transitioned to another provider participating in the network plan, if the beneficiary has already met or exceeded the benefit limitations of the plan, or if the care provided is not medically necessary. (c) In no event shall this Section be construed to require a network plan to provide coverage for benefits not otherwise covered or to diminish or impair preexisting condition limitations contained in the beneficiary's contract. (d) A provider shall comply with the requirements of 42 U.S.C. 300gg-138. (Source: P.A. 103-650, eff. 1-1-25.) (Text of Section after amendment by P.A. 104-333) Sec. 20. Transition of services. (a) A network plan shall provide for continuity of care for its beneficiaries as follows: (1) If a beneficiary's provider leaves the network plan's network of providers for reasons other than termination of a contract in situations involving imminent harm to a patient or a final disciplinary action by a State licensing board and the provider remains within the network plan's service area, if benefits provided under such network plan with respect to such provider or facility are terminated because of a change in the terms of the participation of such provider or facility in such plan, or if a contract between a group health plan and a health insurance issuer offering a network plan in connection with the group health plan is terminated and results in a loss of benefits provided under such plan with respect to such provider, then the network plan shall permit the beneficiary to continue an ongoing course of treatment with that provider during a transitional period for the following duration: (A) 90 days from the date of the notice to the beneficiary of the provider's disaffiliation from the network plan if the beneficiary has an ongoing course of treatment; (A-5) 90 days from the date of the notice to the beneficiary of the provider's disaffiliation from the network plan if the beneficiary has a confirmed appointment and the provider attests that the appointment was scheduled prior to the date of notification; or (B) if the beneficiary has entered the third trimester of pregnancy at the time of the provider's disaffiliation, a period that includes the provision of post-partum care directly related to the delivery. (2) Notwithstanding the provisions of paragraph (1) of this subsection (a), such care shall be authorized by the network plan during the transitional period in accordance with the following: (A) the provider receives continued reimbursement from the network plan at the rates and terms and conditions applicable under the terminated contract prior to the start of the transitional period; (B) the provider adheres to the network plan's quality assurance requirements, including provision to the network plan of necessary medical information related to such care; and (C) the provider otherwise adheres to the network plan's policies and procedures, including, but not limited to, procedures regarding referrals and obtaining preauthorizations for treatment. (3) The provisions of this Section governing health care provided during the transition period do not apply if the beneficiary has successfully transitioned to another provider participating in the network plan, if the beneficiary has already met or exceeded the benefit limitations of the plan, or if the care provided is not medically necessary. (4) The provisions of this Section governing health care provided during the transition period do not apply if the provider or the beneficiary, as set forth in item (A-5) of paragraph (1) of subsection (a), reschedules an appointment or schedules any follow up appointments after 90 days from the date of notice provided in Section 15. (b) A network plan shall provide for continuity of care for new beneficiaries as follows: (1) If a new beneficiary whose provider is not a member of the network plan's provider network, but is within the network plan's service area, enrolls in the network plan, the network plan shall permit the beneficiary to continue an ongoing course of treatment with the beneficiary's current physician during a transitional period: (A) of 90 days from the effective date of enrollment if the beneficiary has an ongoing course of treatment; (A-5) of 90 days from the effective date of enrollment if the beneficiary has a confirmed appointment and the current provider attests that the appointment was scheduled prior to the effective date of enrollment; or (B) if the beneficiary has entered the third trimester of pregnancy at the effective date of enrollment, that includes the provision of post-partum care directly related to the delivery. (2) If a beneficiary, or a beneficiary's authorized representative, elects in writing to continue to receive care from such provider pursuant to paragraph (1) of this subsection (b), such care shall be authorized by the network plan for the transitional period in accordance with the following: (A) the provider receives reimbursement from the network plan at rates established by the network plan; (B) the provider adheres to the network plan's quality assurance requirements, including provision to the network plan of necessary medical information related to such care; and (C) the provider otherwise adheres to the network plan's policies and procedures, including, but not limited to, procedures regarding referrals and obtaining preauthorization for treatment. (3) The provisions of this Section governing health care provided during the transition period do not apply if the beneficiary has successfully transitioned to another provider participating in the network plan, if the beneficiary has already met or exceeded the benefit limitations of the plan, or if the care provided is not medically necessary. (4) The provisions of this subsection governing health care provided during the transition period do not apply if the provider or the beneficiary, as set forth in item (A-5) of paragraph (1) of subsection (b), reschedules an appointment or schedules any follow up appointments after 90 days from the effective date of enrollment. (c) In no event shall this Section be construed to require a network plan to provide coverage for benefits not otherwise covered or to diminish or impair preexisting condition limitations contained in the beneficiary's contract. (d) A provider shall comply with the requirements of 42 U.S.C. 300gg-138. (Source: P.A. 103-650, eff. 1-1-25; 104-333, eff. 1-1-27.)