Illinois Continuity of Care Laws: 90-Day Rule and Appeals

Illinois continuity of care laws give you the right to keep seeing your current doctor for at least 90 days after your health plan tells you the provider is leaving its network. The protection comes from the Managed Care Reform and Patient Rights Act, codified at 215 ILCS 134, and it applies to most HMOs and managed care plans regulated by the state.¹ A parallel federal law, the No Surprises Act, adds a 90-day transitional right that reaches plans Illinois cannot regulate, and both regimes protect you from surprise bills during the transition.

The 90-Day Transitional Care Period

Section 25 of the Act requires your health plan to let you continue an ongoing course of treatment with your current provider for at least 90 days after you receive notice that the provider is leaving the network. The clock starts on the date the plan notifies you, not the date the provider actually walks out the door.¹

The transitional period applies when your provider voluntarily leaves the network, when the plan changes the terms of the provider’s participation, or when a group health plan switches to a different managed care product that no longer includes your provider.¹

One condition is easy to miss. Transitional care only happens if your provider agrees to specific terms: accepting the same reimbursement rates that applied before the transition, following the plan’s quality assurance requirements, sharing necessary medical information with the plan, and continuing to follow the plan’s referral and preauthorization procedures.¹ If your provider refuses, the plan is not required to extend coverage. Most providers agree because they want to keep their existing patients, but confirm it directly with your provider’s office when you learn about a network change.

The duty to tell you about the change falls on the plan, not the doctor. If you only found out your provider had left the network after the fact, the plan may itself be in violation.

When the 90-Day Rule Does Not Apply

Several situations fall outside the Act, and knowing them upfront saves you from assuming a right you don’t have.

The law covers health care plans that operate provider networks and arrange care through them. Traditional indemnity health insurance policies are not covered, even when they happen to use a contracted provider network, and standalone dental and vision plans are not covered either.¹

Transitional care also does not apply when a provider’s contract is terminated for imminent harm to patients or because of a final disciplinary action by a state licensing board.¹

The biggest gap involves self-insured employer plans. If you get coverage through a large employer that pays claims directly rather than buying insurance from a carrier, the Illinois statute likely does not apply, because federal ERISA law preempts state insurance regulation of self-insured plans. A significant share of workers with employer coverage are in self-insured plans. Your HR or benefits office can tell you which type you have. If you are in a self-insured plan, your continuity of care rights come from federal law and your plan documents rather than from Illinois statute.

Pregnancy Extension

If you are in the third trimester of pregnancy when your provider leaves the network, the transitional period extends beyond 90 days. The plan must cover postpartum care directly related to the delivery, regardless of when the standard window would otherwise expire.¹

Prescription Drug Formulary Changes

The Act also limits how fast a plan can drop a drug from its formulary or move it to a more expensive cost-sharing tier. Before either change, the plan must give at least 60 days’ notice. During that window, it must directly notify enrollees currently receiving coverage for the affected drug, explain the change, and tell them how to request a coverage determination or exception. If your prescribing provider certifies that the drug is medically necessary, the plan must continue covering it at your existing cost-sharing level.¹

If a letter arrives saying your medication is moving to a higher tier, that letter should include instructions for requesting an exception. The medical necessity certification from your doctor is the lever that keeps your pricing where it was.

Federal Protection Under the No Surprises Act

The federal No Surprises Act, effective in 2022, added continuity of care protection that applies regardless of whether your plan is self-insured or state-regulated. When a provider or facility leaves a plan’s network because of a contract termination, the plan must notify each “continuing care patient” and offer transitional coverage. If you elect it, the plan must continue the same benefits under the same terms for up to 90 days from the notification date.²

To qualify as a continuing care patient under federal law, you must fall into one of these categories:³

You have a serious and complex condition. For acute illness, that means a condition serious enough that without specialized treatment there is a reasonable possibility of death or permanent harm. For chronic conditions, it covers life-threatening, degenerative, potentially disabling, or congenital conditions needing specialized care over a prolonged period.
You are currently undergoing a course of institutional or inpatient care at a hospital or similar facility.
You have a scheduled non-elective surgery, including postoperative care from that surgery.
You are currently receiving treatment for pregnancy.
You are receiving treatment for a terminal illness.

Balance Billing During the Transition

You should not face surprise balance bills from your outgoing provider during the transitional period. Under the No Surprises Act, a provider continuing to treat you must accept payment from the plan plus your normal cost-sharing as payment in full and must keep following the plan’s policies and quality standards as if the network termination had not happened.² The Illinois statute applies the same principle: during the 90-day window, the provider must accept the plan’s prior reimbursement rates.¹

If a provider tries to bill you for the difference between their usual charge and the plan’s payment during a valid transitional period, document the charge and file a complaint with the Illinois Department of Insurance.

Appealing a Denial of Continued Care

If your plan denies transitional care or any other covered service, Illinois law requires an appeals process with timelines keyed to urgency.¹

Urgent Appeals

When the denial involves an ongoing course of treatment and a delay could significantly increase risk to your health, you can appeal orally or in writing. The plan must tell you within 24 hours what information it needs, then issue a decision within 24 hours of receiving that information. It must notify you, your primary care physician, and the provider who recommended the service.¹

Standard Appeals

For non-urgent denials, the plan has three business days to tell you what information it needs and then 15 business days to decide after receiving that information. The decision must come in writing with clear reasons and the medical criteria used.¹

External Independent Review

If the internal appeal is denied, you can request an external independent review under the Illinois Health Carrier External Review Act, which puts your case in front of an independent reviewer outside the insurance company. Qualifying reasons include a determination that the service is not medically necessary, denial of specific tests or procedures, denial of a specialist referral, and denial of hospitalization requests.¹ Your provider can file the appeal on your behalf, and the law prohibits the plan from retaliating against a doctor for taking part in an appeal or review.

If your plan uses the federal HHS-administered external review process, there is no charge. Standard reviews must be completed within 45 days; expedited reviews for urgent medical situations must finish within 72 hours or less. File online at externalappeal.cms.gov or call 1-888-866-6205.⁴

Filing a Complaint and Enforcement

If you believe your plan is violating the Act, you can file a complaint with the Illinois Department of Insurance. The Department reviews every complaint it receives and investigates those that appear to state a potential violation.¹ File online through the IDOI Help Center at idoihelpcenter.illinois.gov, or submit the Consumer Health Care Complaint Form by mail. Forms are available in English and Spanish.⁵ The Department’s Office of Consumer Health Insurance can also answer questions about your plan and explain your rights.⁶

Under Section 105, the Director of Insurance can issue a cease and desist order, require a corrective action plan, or both. For plans that fail to submit a requested corrective plan, fail to follow through on one, or commit repeated violations, the Director can impose administrative fines up to $250,000.¹

1
Justia. Illinois Code 215 ILCS 134 – Managed Care Reform and Patient Rights Act
2
Centers for Medicare and Medicaid Services. The No Surprises Act Continuity of Care, Provider Directory, and Public Disclosure Requirements
3
Centers for Medicare and Medicaid Services. No Surprises Act Overview of Key Consumer Protections
4
HealthCare.gov. External Review
5
Illinois Department of Insurance. How to File a Complaint
6
Illinois Department of Insurance. Illinois Department of Insurance Home