Rep. Frank J. Mautino
Filed: 4/1/2009
 
 

 




 

 		












09600HB3861ham003

LRB096 06606 RPM 24807 a






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AMENDMENT TO HOUSE BILL 3861




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    AMENDMENT NO. ______. Amend House Bill 3861 by replacing 
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everything after the enacting clause with the following:


 
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    "Section 5. The Illinois Insurance Code is amended  by 
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adding Section 370u as follows:
 
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    (215 ILCS 5/370u  new)
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    Sec. 370u. Out-of-network health care provider. Every 
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health insurer, health plan, and health maintenance 
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organization that provides incentives for insureds or 
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enrollees to seek services  from a specific provider network and  
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to pay co-payments for services must pay for out-of-network 
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health care provided by out-of-network physicians as provided 
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in this Section.  When an insured or enrollee utilizes a network 
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hospital and due to any reason services at that network 
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hospital are provided by an out-of-network physician with whom 
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the insured or enrollee does not have a physician-patient 
 


 






09600HB3861ham003
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LRB096 06606 RPM 24807 a




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relationship, the health insurer, health plan, or health 
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maintenance organization shall ensure that the insured or 
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enrollee is provided the covered service at no greater cost to 
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the insured or enrollee than if the service had been provided 
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by a network physician.  The insurer, plan, or health 
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maintenance organization shall pay the out-of-network 
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physician providing services in the network hospital  the  lesser 
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of the actual charged amount or the amount the insurer, plan, 
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or health maintenance organization pays to their 
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out-of-network physicians pursuant to the health benefits  plan 
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providing the coverage for the services to the insured or 
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enrollee, less any cost sharing that is the responsibility of 
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the insured or enrollee for similar in-network services.
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    Except for applicable co-payments, deductibles, or 
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co-insurance responsibilities of the insured or enrollee, a 
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healthcare provider shall not bill or otherwise attempt to 
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recover from the insured or enrollee the difference between the 
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healthcare provider's charge and the amount paid by the 
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insurer, plan, or health maintenance organization.".