Accessing Care and Navigating Provider Networks

The Network Adequacy and Transparency Act (“NATA”) provides standards for individual and fully-insured group (employer) health plans in Illinois that use provider networks. These standards are enforced by the Illinois Department of Insurance (“DOI”). IDOI recognizes that health care coverage is often confusing and understanding how to access this coverage can require navigation of complex documents and systems. Consumers should familiarize themselves with their policy for specific terms of coverage, utilize the plan’s Provider Directory, and consult with their insurer to confirm access to covered health care. Below are some things you should know, as a consumer, regarding Health Plans and their Networks.

What Should You Know About NATA and Networks?

NATA applies to Illinois consumers who enroll or participate in any individual or fully-insured group Preferred Provider Organization (“PPO”) or Health Maintenance Organization (“HMO”) plan and their provider networks.

What is a Network?

A network is a group or groups of preferred providers (sometimes called participating providers) that are contracted, managed, owned, or employed by an insurance company or HMO. Plan participants are required or given incentives to use the preferred providers of the network to receive the most cost-effective care.

Who is in a Network?

The collection of health care providers makes up the plan’s network. Providers are licensed professionals or facilities providing health care services. A Provider Directory must clearly identify the health plan that is using the provider network.

What is a Provider Directory?

Insurers are required to make an up to date, accurate, and complete Provider Directory available to all consumers, including current enrollees and consumers who are shopping for coverage. A Provider Directory contains key information about in-network healthcare professionals, hospitals, and other facilities. This information includes but is not limited to name, location, provider specialty type (such as primary care, OB/GYN, neurology, etc.), languages spoken other than English (if applicable), and which providers are currently accepting new patients. The Provider Directory must be made available online and in print, upon request.

Illinois law requires insurers to regularly verify and update Provider Directories for all networks. The providers are also required to send updated information to the insurer when any information for their directory entry needs to be changed. However, consumers should follow procedures in their policies and contact the provider to confirm network status in case the directory has not yet been updated.

When can I go Out-of-Network?

Generally, consumers with PPO plans can access covered services from out-of-network providers at their discretion. However, for non-emergency situations, doing so will generally result in higher cost-sharing, as well as being subject to potential "surprise" or balance billing from the out-of-network provider.

Consumers with HMO plans generally do not have out-of-network benefits and generally must use network providers within the HMO's service area. However, like PPOs, there are certain exceptions to this requirement, such as emergency care.

Both PPO and HMO plans are required to ensure consumers have timely access to care. They must design their networks to have preferred providers located within reasonable travel time and distance from where beneficiaries live and must contract with enough providers so that there are not too many beneficiaries per health care provider.

If a consumer has difficulty accessing network care, they should contact the issuer to assist with finding a preferred provider. Also, IDOI is available to assist consumers with navigating their health insurance related issues.

By law, consumers are allowed to access out-of-network care at the in-network benefit level under certain circumstances, such as:

• Emergency care;
• For consumers in an ongoing course of treatment or third trimester of pregnancy, temporary continuation of care when the consumer’s health care provider leaves their plan’s network;
• For consumers in an ongoing course of treatment or third trimester of pregnancy, temporary continuation of care when the consumer enrolls in a new plan where their existing provider is not in-network;
• When the consumer receives covered services at an in-network health care facility from any out-of-network provider who performs the service:
  • in anesthesiology, radiology, neonatology, pathology, or emergency medicine
  • as an assistant surgeon, hospitalist, or intensivist
  • as diagnostic services (other than advanced diagnostic laboratory tests identified by the U.S. Department of Health and Human Services)
  • because there is no preferred provider at that in-network facility who can do it
  • because the preferred providers at the in-network facility refuse to perform the service (such as contraception, sterilization, or abortion) due to a conscience-based objection under the Health Care Right of Conscience Act
  • because of an unforeseen, urgent medical need that arises when the consumer is already receiving another service at that in-network facility
  • without providing proper notice that the provider is out-of-network and obtaining consent from the consumer for out-of-network billing (Note: If any of the previous conditions applies, the consumer must be covered at the in-network benefit level even if the provider gave notice and consent for out-of-network care); and
• The plan network does not have the right type of provider accessible to provide a covered service that the consumer needs.
  • If a consumer in a PPO plan makes a good faith effort to identify in-network providers by accessing the online provider directory, calling the plan, and calling the provider to obtain network status to ensure they are using preferred providers, and if the plan’s network lacks the appropriate provider due to insufficient number, specialty type, requires unreasonable travel distance or delay, or the preferred providers (whether or not at an in-network facility) have conscience-based objections under the Health Care Right of Conscience Act against providing certain services (e.g., contraception, sterilization, or abortion), the consumer may be eligible to access an out-of-network provider at the in-network benefit level. However, the consumer still could be subject to balance billing from the out-of-network provider.
  • If a consumer in an HMO plan needs a covered service that the HMO is unable to furnish through a preferred provider, the HMO must allow the consumer to get a referral from their primary care physician to see an out-of-network provider within a reasonable travel time and distance who can provide the service.
  • For mental health and substance use disorder services, consumers in either a PPO or an HMO plan must be allowed to see an out-of-network provider at the in-network benefit level if there are no preferred providers who can offer the service within a specific travel time and distance or within a specific appointment wait time. The time, distance, and appointment wait time standards are provided at Section 10(d-5) of the NATA. 215 ILCS 124/  Network Adequacy and Transparency Act. (ilga.gov)

Members should review their policy or consult with their insurer before seeking out-of-network care, except for emergency situations.

If a consumer has trouble accessing care, they can file complaints either online: https://mc.insurance.illinois.gov/messagecenter.nsf

or by submitting this form: https://www2.illinois.gov/sites/Insurance/Consumers/Documents/ConsumerHealthCareComplaintForm.pdf

Regulatory filings, reviews, and reports related to network adequacy can be found on the reports (Reports (illinois.gov)) page.