New Illinois Healthcare Law: Ensuring Compliance For Payers

28 Jan, 2025, 5 min read

Illinois has introduced a new bill that significantly impacts healthcare delivery, adding complexities for payers managing provider data. The Health Care Protection Act (Public Act 103-0650) is designed to bolster patient rights and expand oversight of health plans operating in the state.

This article examines different aspects of the Illinois Healthcare Protection Act that impact payers and how it could redefine provider and payer responsibilities.

Updates at a glance

Expanded applicability: Covers most IL network plans and excludes certain limited policies.

Network adequacy: Sets provider-to-beneficiary ratios, time/distance standards, and appointment wait times (with stricter mental health requirements).

Continuity of care: This requires notice before providers leave a network, protecting ongoing treatments.

Reporting and penalties: Mandates timely reporting of material changes; fines apply for noncompliance.

Mental health parity: Enforces equal standards for behavioral health access.

Federal alignment: Adopts or exceeds new or stricter CMS standards; allows emergency rulemaking.

The Impact of the New Law on Payers

The new law significantly impacts payers. If you manage provider networks, this law spells out how preferred networks should operate, clarifies the role of telemedicine, and sets rules for network adequacy and travel distances.

Let’s take a look at the impact in detail below:

Provider network management

Payers must maintain specific provider-to-patient ratios across various specialties. Ensure patients have reasonable travel distances to in-network providers based on whether they’re in urban, suburban, or rural areas. Meet maximum wait times for scheduling appointments, especially for primary and specialty care.

What you can do:

Conduct self-audits regularly to ensure your network is compliant.
Use telehealth services to fill gaps in network adequacy.

Telemedicine requirements

The law officially recognizes telemedicine as a part of network adequacy. What does that mean for payers?

List telemedicine providers in your network directories.
Include details on what services they offer via telehealth (video consultations, phone consultations, etc.).
Ensure patients can access telehealth services without additional costs.

What you can do:

Work with providers to make sure telehealth options are represented in your directories.
Educate your members on how to use telehealth services.

Directory accuracy requirements

This is the big one. Accurate provider directories are no longer “nice to have”—they’re mandatory. Here’s what you need to do:

Update online directories monthly.
Conduct self-audits quarterly, covering at least 25% of your listings.
Ensure providers notify you within 10 days of any changes.
Provide printed directories upon request, updated every 90 days.

Penalties for non-compliance:

$5,000 per month for failing to update online directories.
Up to $25,000 per violation if you knowingly list incorrect provider information.

What you can do:

Implement automated solutions to keep directories accurate.
Make self-audits a routine process to catch errors before regulators do.

How Atlas Systems Can Help Payers Comply with the New Law

Prime by Atlas Systems is a provider lifecycle management solutions that helps payers to adhere to Illinois’s new network adequacy and transparency rules. We help with self-audits, printed directories, maintaining accuracy, and doing all this cost-effectively and without handholding.
Triangle diagram showing three provider life cycle management components for healthcare payer compliance.

Provider data management

Illinois’s new law requires payers to maintain accurate directories, meet strict time/distance standards, and keep members informed.

For instance, providers move their offices, change phone numbers, or stop accepting new patients—sometimes without telling you. If you don’t track these shifts, your members end up frustrated, calling the wrong number, or driving to an old address. That’s where provider data management comes in.

At Prime, we go straight to the source:

We directly contact health systems, provider groups, and individual practitioners so your network directory remains consistently accurate and up-to-date.
Prime enables you to speed up the validation process and improve provider response rates by contacting them how they prefer.
Providers can either choose to update their data themselves through our self-service portal, or we validate the data at source.
You get an at-a-glance view of provider data quality and see attestation progress in real time on a dashboard.
Prime can integrate compliance checks (like CMS appointment wait times) to ensure your network meets Illinois’s time/distance and prompt-access requirements.

Case in point : We have a record of achieving 95% success rates in validating provider data.. We bring years of experience conducting these surveys on behalf of health plans, boosting your readiness for upcoming state and federal mandates.

Read more about Provider data management here.

Comprehensive audit trails

One of the biggest hurdles is verifying that provider information and prior authorization rules remain accurate over time. Atlas conducts network audits, identifies outdated or duplicate data, and helps you correct errors before they become compliance headaches. Health plans can benefit from streamlined oversight without incurring massive overhead.

Training and compliance support

Even the most advanced platform won’t solve all challenges if employees aren’t comfortable with the new procedures. Atlas delivers targeted workshops and resources, preparing health plan employees and provider groups to adapt quickly and confidently to regulatory changes.

Next Step: Reinforce Your Payer Compliance

With the new Illinois healthcare regulations tightening requirements on network adequacy, provider data accuracy, and accessibility, payers face a growing pressure to keep their directories current and their compliance workflows running smoothly.

Falling behind can mean hefty fines, dissatisfied members, and potential harm to your organization’s reputation.

Prime by Atlas Systems was built to tackle these challenges head-on by validating provider information at the source and ensuring that any changes, such as address updates, new specialties, or provider terminations, are reflected instantly.

With Prime, you can stop juggling multiple spreadsheets and chasing down missing data and instead focus on delivering quality care.

If you’re looking for an easy way to stay ahead of upcoming rules, contact Atlas Systems. We’ll show you how Prime can help your operations, maintain compliance, and keep your provider directories error-free.