HB3312ham001 95TH GENERAL ASSEMBLY

Rep. William B. Black

Filed: 4/18/2007

09500HB3312ham001 LRB095 09179 KBJ 35016 a

AMENDMENT TO HOUSE BILL 3312

AMENDMENT NO. ______. Amend House Bill 3312 by replacing everything after the enacting clause with the following:

"Section 5. The Illinois Insurance Code is amended by adding Section 370m.1 as follows:

(215 ILCS 5/370m.1 new)

Sec. 370m.1. Assignment of benefits to nonparticipating physicians.

(a) In this Section:

"Exclusive arrangement" means a formal contract or informal arrangement between a physician and a health care facility under which only the physician, alone or with other physicians selected or designated by the facility, may provide a facility-based physician service at the facility.

"Facility-based physician service" means a service, the performance of which requires a license to practice medicine in this State; involving one or more of the medical specialties of radiology, anesthesia, pathology, emergency medicine, or nenonatology; and provided to a patient of a health care facility.

"Health benefit plan issuer" means a health insurer that issues a preferred provider program under this Article or a health maintenance organization operating under the Health Maintenance Organization Act.

"Health care facility" means any public or private hospital, clinic, center, medical school, medical training institution, laboratory or diagnostic facility, physician's or health care practitioner's office, infirmary, dispensary, ambulatory surgical treatment center, or other institution or location wherein health care services are provided to any person, including physician or health care practitioner organizations and associations, networks, joint ventures, and all other combinations of those organizations.

"Member" means an individual insured by a preferred provider program under this Article, including a covered dependent or enrollee.

"Nonparticipating physician" means a physician who, with respect to a health benefit plan, is not part of the network of providers with whom the health benefit plan issuer has contracted to provide medical care or health care to members of the health benefit plan.

"Nonparticipating provider" means a provider who, with respect to a health benefit plan, is not part of the network of providers with whom the health benefit plan issuer has contracted to provide health care to members of the health benefit plan.

"Physician" means a person licensed to practice medicine in all its branches under the Medical Practice Act of 1987.

(b) If a member offers to assign to a nonparticipating physician the member's right to benefits from the member's health benefit plan issuer, the nonparticipating physician may not charge the member or the member's representative any amount for any facility-based physician service provided under an exclusive arrangement, other than amounts for copayments, coinsurance, or deductibles as provided by the member's policy or contract with the health benefit plan issuer. If a member does not offer to assign or refuses to assign to a nonparticipating physician the member's right to benefits from the member's health benefit plan issuer, the nonparticipating physician may charge the member for the facility-based physician service provided under an exclusive arrangement.

A health benefit plan issuer's liability to a nonparticipating physician for a facility-based physician service provided under an exclusive arrangement is limited to the health benefit plan issuer's obligation under the issuer's policy of contract with the member. A nonparticipating physician's charge for a facility-based physician service provided under an exclusive arrangement must be the physician's usual and customary charge, but may not exceed 125% of the amount payable for the service under the Medicare program.

(b) A nonparticipating physician or provider may require a member to assign the member's benefits from the member's health benefit plan issuer to the nonparticipating physician or provider. Except as provided in subsection (a) of this Section, if a nonparticipating physician or provider accepts a member's assignment of the member's benefits, the nonparticipating physician or provider may not charge the member or the member's representative any amount for a physician or provider service, other than amounts for copayments, coinsurance, or deductibles under the member's policy or contract with the health benefit plan issuer.

A health benefit plan issuer's liability to a nonparticipating physician or provider who has accepted an assignment of benefits from a member for a physician or provider service is limited to the issuer's obligation under the issuer's policy or contract with the member. If the a nonparticipating physician or provider does not require a member to assign the member's benefits or otherwise accept the member's assignment of benefits, the nonparticipating physician or provider may charge the member or the member's representative for the physician or provider service.".