December 10, 2023

Health Insurance

Follow Your Health Insurance

Illinois strengthens regulations on health insurance companies following Blue Cross Blue Shield investigation

SPRINGFIELD, Ill. (NEXSTAR) – Health insurance companies will be under much more scrutiny going forward.

The Joint Commission on Administrative Rules passed a new set of rules for how the Department of Insurance will enforce the Network Adequacy and Transparency Act.

The new rules were proposed in April of last year following a Target 3 investigation into Blue Cross Blue Shield of Illinois.

Central Illinois lawmakers celebrated the changes.

“Taking on insurance companies is like taking on the elephant in the living room,” Rep. Sue Scherer (D-Decatur). “And how do you eat an elephant one bite at a time. And that’s what I feel like we’re doing here is one bite at a time we’re packing away until we get this right.”

The Network Adequacy and Transparency Act requires health insurance networks to meet certain adequacy standards, but the Department of Insurance could not enforce the law effectively because of the rules laid out by the Joint Committee on Administrative Rules years ago.

Now, the state makes the requirements for companies much more clear.

Under the new rules, health insurance companies will need to clarify the distance a doctor is from a patient in their directory in two ways. One listing includes the distance between the patients address and the provider if a straight line was drawn between the two. The other is the distance and time it takes to drive to the provider’s office from the patients house. Before these new rules, Blue Cross Blue Shield of Illinois was only including the former on their directories.

That shortcoming was one of several that led to the company getting a $600 thousand fine earlier this month.

The new rules also list exact patient to provider ratios needed to be considered an adequate network. Out of 28 specialists listed in the Network Adequacy and Transparency Act, 22 now have official ratios.

The Illinois State Medical Society helped advocate for the original law in 2017, but since it passed, they have been pushing for more strict enforcement.

“The Illinois State Medical Society (ISMS) had encouraged the Department to develop rules to ensure the provisions in the Act are implemented consistent with their legislative intent,” Rodney S. Alford, President-Elect, Illinois State Medical Society, said. “In particular, we have stressed the importance of using the rulemaking process to strengthen protections related to making sure patients have access to proper healthcare provider networks and that consumers know what physicians are in those networks. The new rules also support continuity of care for patients during network transitions and maintaining the accuracy of provider directories.”

Now it is up to the Department of Insurance to enforce the rules.

Under the new rules, health insurance companies will be required to self audit their directories at least twice per year, and they will be required to submit their findings to the Department of Insurance.

Insurance companies will also have to give more detailed reports after material changes to their networks. An example of this kind of change is Blue Cross Blue Shield dropping Springfield Clinic out of their network.

“We urge DOI to fully enforce this law and to continue to hold insurance companies accountable to provide the healthcare they have promised patients,” Alford said in a statement.

To help with enforcement, the Department of Insurance created a seven person panel dedicated to reviewing network adequacy issues.

Blue Cross Blue Shield of Illinois responded to the new rules by saying they appreciate the changes.

“Rule development is an important part of the regulatory process in Illinois and we appreciate the efforts of the Illinois Department of Insurance and the Joint Committee on Administrative Rules to provide more clarity on the requirements associated with the Network Adequacy and Transparency Act,” a spokesperson for the health insurance company said in a statement.

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