All Roll Calls
Yes: 197 • No: 0
IllinoisHB1331104th General Assembly (2025–2026)HouseWALLET
NETWORK ADEQUACY-GENETIC MED
Sponsored By: Sonya M. Harper (Democratic)
Became Law
insuranceassignments
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Bill Overview
Analyzed Economic Effects
10 provisions identified: 9 benefits, 0 costs, 1 mixed.
Protections when no in-network care
If your plan lacks the right in-network provider in your county, your out-of-network claim is paid at in-network levels. The insurer must also pay you back if it wrongly treated a claim as out-of-network. Beginning January 1, 2025, if you make a good‑faith effort to find an in‑network provider and none is available, you pay no more than in‑network costs for covered care. This protection does not apply if you choose an out‑of‑network provider on purpose or if you are in an HMO. Emergency care is always covered at the same level whether the provider is in‑network or not.
Cap on inpatient pre‑cert penalties
If your plan penalizes you for not pre‑certifying inpatient hospital care, the extra penalty cannot exceed $1,000 per occurrence. Normal deductibles, copays, and coinsurance still apply. This cap applies beginning January 1, 2025.
Faster reporting and $5,000‑a‑day fines
Insurers must report any material network change within 15 days and submit revised sections within 15 business days. The Director may fine $5,000 per day after the 15‑business‑day deadline. The Director can also stop a plan from being sold or renewed in a county until adequacy is met, and may fine $5,000 per policy for violations. Current coverage is not ended before the policy period ends.
Faster, closer mental health care
Plans must meet mental health and substance use parity. In Cook, DuPage, Kane, Lake, McHenry, and Will counties, outpatient care must be within 30 minutes or 30 miles. In other counties, outpatient care must be within 60 minutes or 60 miles. First outpatient visits must be within 10 business days and follow‑ups within 20 business days. Inpatient or residential care must be within 60 minutes or 60 miles statewide, and if no in‑network option exists, the plan must grant an exception so you can get admitted and treated.
In‑network hospitals need key specialists
Beginning January 1, 2026, each in‑network hospital must have at least one radiologist, pathologist, anesthesiologist, and emergency room doctor listed as preferred providers. The Department may add more hospital‑based specialist types by rule. This reduces the chance of out‑of‑network bills for common hospital services.
Stronger plan filing and transparency
Starting January 1, 2025, insurers must file policies on how they add providers, make referrals, and ensure 24/7 access to primary care, emergency care, and women’s principal health care. They must submit maps of provider locations by county and ZIP code, provider lists with contacts and specialties, expected enrollment, a website, and a toll‑free number. They must explain how services are accessible, including provider ratios, travel and distance limits, and any use of telehealth or mobile care. Exchange plans must also show that essential community providers will participate.
Stronger network standards and exceptions
The Department sets yearly minimum provider‑to‑enrollee ratios and maximum travel and wait‑time standards, using federal guidance. These rules cover many specialties, including genetic medicine and genetic counseling, and cannot be looser than federal exchange standards; if federal rules are stricter for a plan year, Illinois uses them. Standards apply to the lowest cost‑sharing tier of tiered networks (not to plans offered only as group health plans). Exchange plans must include essential community providers. Plans may count telehealth, mobile clinics, or centers of excellence in part. If no local providers meet a standard or local care patterns differ, insurers can request a limited exception; mental‑health standards cannot be waived. The Department reviews and updates specialties and adequacy rules over time.
Find in-network doctors online or by phone
Beginning January 1, 2025, insurers must provide a website and a toll-free phone number with up-to-date in-network provider lists and plan details. You can check doctors and facilities before you get care. This helps you avoid out-of-network surprises.
Doctors can speak and advocate freely
Insurers cannot stop in‑network providers from talking with you about any treatment options. Providers can also advocate for you in utilization review, grievances, and appeals. Beginning January 1, 2025, these protections apply to all preferred providers.
Early notice on federal network standards
The Department must tell insurers by May 15 before the plan year if it will enforce a new or changed federal network standard before adopting state rules. This gives insurers time to prepare.
Sponsors & Cosponsors
Sponsor
Sonya M. Harper
Democratic • House
Cosponsors
David Koehler
Democratic • Senate
Hoan Huynh
Democratic • House
Mattie Hunter
Democratic • Senate
Roll Call Votes
Senate vote • 5/22/2025
Third Reading - Passed;
Yes: 58 • No: 0
Senate vote • 4/30/2025
Do Pass Insurance;
Yes: 9 • No: 0
House vote • 4/9/2025
Third Reading - Short Debate - Passed
Yes: 114 • No: 0
House vote • 3/18/2025
Do Pass / Short Debate Insurance Committee;
Yes: 16 • No: 0
Actions Timeline
Public Act . . . . . . . . . 104-0175
8/15/2025HouseEffective Date January 1, 2026
8/15/2025HouseGovernor Approved
8/15/2025HouseSent to the Governor
6/20/2025HousePassed Both Houses
5/22/2025HouseThird Reading - Passed; 058-000-000
5/22/2025SenatePlaced on Calendar Order of 3rd Reading **
5/20/2025SenatePlaced on Calendar Order of 3rd Reading May 15, 2025
5/14/2025SenateSecond Reading
5/14/2025SenateAdded as Alternate Chief Co-Sponsor Sen. David Koehler
5/14/2025SenatePlaced on Calendar Order of 2nd Reading May 1, 2025
4/30/2025SenateDo Pass Insurance; 009-000-000
4/30/2025SenateAssigned to Insurance
4/23/2025SenateReferred to Assignments
4/9/2025SenateFirst Reading
4/9/2025SenateChief Senate Sponsor Sen. Mattie Hunter
4/9/2025SenateAdded Co-Sponsor Rep. Hoan Huynh
4/9/2025HousePlaced on Calendar Order of First Reading
4/9/2025SenateArrive in Senate
4/9/2025SenateThird Reading - Short Debate - Passed 114-000-000
4/9/2025HousePlaced on Calendar Order of 3rd Reading - Short Debate
3/25/2025HouseSecond Reading - Short Debate
3/25/2025HousePlaced on Calendar 2nd Reading - Short Debate
3/19/2025HouseDo Pass / Short Debate Insurance Committee; 016-000-000
3/18/2025HouseAssigned to Insurance Committee
2/11/2025House
Bill Text
Engrossed
Enrolled
Introduced