(a) A network plan shall provide for continuity of care for its beneficiaries as follows:
         (1) If a beneficiary‘s physician or hospital 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, 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:

Terms Used In Illinois Compiled Statutes 215 ILCS 124/20

  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Contract: A legal written agreement that becomes binding when signed.
  • State: when applied to different parts of the United States, may be construed to include the District of Columbia and the several territories, and the words "United States" may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14

         (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.
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