Material Change Filings
The Network Adequacy and Transparency Act (“NATA”) sets forth standards for insurer networks offered in the fully-insured individual and group HMO and PPO markets in Illinois. 215 ILCS 124/1 et seq.
While network filings are generally prospectively reviewed by the Department for compliance with network adequacy standards prior to use, provider networks can change throughout the plan year. Accordingly, the NATA requires insurers to notify the Department if there is a significant change to the network – defined in statute as a “material change” - and certain consumer protections and insurer requirements must then be followed.
WHAT HAPPENS WHEN A MATERIAL CHANGE IN A PLAN’S NETWORK OCCURS?
A "material change" is a reduction of 10% or more of a specific type of provider in a plan, the removal of a major health system, or any other change that would cause the plan’s network to violate the Network Transparency and Adequacy Act. 215 ILCS 124/5.
If a material change occurs during the plan year, insurers are required to submit updated network adequacy filings to the Department within 15 days after the material change.
This flowchart illustrates the general processes that are triggered when a material change occurs. However additional regulatory actions, such as market conduct exams, may be conducted as a result of these reviews if warranted.
Updated network filings are only one form of compliance with NATA. If you are a consumer struggling to access care, please visit the link here: Health Insurance Shopping Tips (illinois.gov) .
LIST OF MATERIAL CHANGES REPORTED TO DEPARTMENT
When an insurer reports a material change to its network or DOI determines that a change to a network qualifies as a material change, that information will be included below. If additional related regulatory actions are taken, those actions will be linked as well.
HCSC (BCBS)/Springfield Clinic:
- Contract Termination Date: 07/01/2021 (HMO); 11/17/2021 (PPO)
- Networks Impacted
- Blue Choice PPO
- Blue Options PPO / Blue Choice Options PPO
- PPO / Blue PPO
- Blue Choice Preferred PPO
- Blue Advantage HMO
- HMO Illinois
- Networks Impacted
- Material Change Filings Due: HMO Filings on July 16, 2021 and PPO filings on December 2, 2021:
- Filings Submitted by Company: HMO Filings on March 17, 2022 and PPO Filings on March 3, 2022:
- Based on the Department’s review of the material change network filings submitted by Health Care Service Corporation (“HCSC”) and our additional targeted network examination, the Department found no instances of material inadequacy regarding time and distance standards or provider to patient ratios under the NATA. The Department issued findings regarding problems with the accuracy of the provider directory.
- This report discusses the Department’s review of the network adequacy and transparency of an insurer’s network based on the required network filing submitted by the insurer, including a material change in the number and location of providers.
- It does not constitute a determination of whether the insurer is in full compliance with the entire NATA.
- The Department separately evaluates the accuracy of provider network information presented by insurers through retrospective consumer complaints and market conduct exam processes, which are outside the scope of the prospective network adequacy filing review process discussed herein.
- This review does not provide comment on the real-time accuracy of the information provided nor the real-time provider availability.
Please see market conduct page linked here (Life & Health Examinations (illinois.gov) ) for additional related regulatory actions.