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1 | AN ACT concerning insurance.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Department of Insurance Law of the
Civil | ||||||||||||||||||||||||||
5 | Administrative Code of Illinois is amended by adding Section | ||||||||||||||||||||||||||
6 | 1405-40 as follows: | ||||||||||||||||||||||||||
7 | (20 ILCS 1405/1405-40 new) | ||||||||||||||||||||||||||
8 | Sec. 1405-40. Study of out-of-network facility-based | ||||||||||||||||||||||||||
9 | physician and provider claims. | ||||||||||||||||||||||||||
10 | (a) For purposes of this Section only, "facility-based | ||||||||||||||||||||||||||
11 | provider" means a physician or other provider who provides | ||||||||||||||||||||||||||
12 | radiology, anesthesiology, pathology, neonatology, or | ||||||||||||||||||||||||||
13 | emergency department services to insureds, beneficiaries, or | ||||||||||||||||||||||||||
14 | enrollees in a participating hospital or participating | ||||||||||||||||||||||||||
15 | ambulatory surgical treatment center. | ||||||||||||||||||||||||||
16 | (b) The Department shall study the frequency and economic | ||||||||||||||||||||||||||
17 | impact of nonparticipating facility-based physician and | ||||||||||||||||||||||||||
18 | provider claims addressed in subsection (c) of this Section. | ||||||||||||||||||||||||||
19 | The Department shall have the authority to request insurers, | ||||||||||||||||||||||||||
20 | health plans, and applicable nonparticipating facility-based | ||||||||||||||||||||||||||
21 | physician and provider trade associations to assemble and | ||||||||||||||||||||||||||
22 | submit information for the purposes of this study to the extent | ||||||||||||||||||||||||||
23 | permitted by law. |
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1 | (c) The Department shall study the issue of when a | ||||||
2 | beneficiary, insured, or enrollee utilizes a participating | ||||||
3 | network hospital or a participating network ambulatory surgery | ||||||
4 | center and, due to any reason, in-network services for | ||||||
5 | radiology, anesthesiology, pathology, emergency physician, or | ||||||
6 | neonatology are unavailable and are provided by a | ||||||
7 | nonparticipating facility-based physician or provider and the | ||||||
8 | insurer's or health plan's responsibility to ensure that the | ||||||
9 | beneficiary, insured, or enrollee incurs no greater | ||||||
10 | out-of-pocket costs than the beneficiary, insured, or enrollee | ||||||
11 | would have incurred with a participating physician or provider | ||||||
12 | for covered services. | ||||||
13 | (d) The Department shall report its findings and | ||||||
14 | recommendations to the General Assembly no later than October | ||||||
15 | 1, 2012. | ||||||
16 | Section 10. The Illinois Insurance Code is amended by | ||||||
17 | changing Section 356z.3a as follows: | ||||||
18 | (215 ILCS 5/356z.3a) | ||||||
19 | Sec. 356z.3a. Nonparticipating facility-based physicians | ||||||
20 | and providers. | ||||||
21 | (a) For purposes of this Section, "facility-based | ||||||
22 | provider" means a physician or other provider who provide | ||||||
23 | radiology, anesthesiology, pathology, neonatology, or | ||||||
24 | emergency department services to insureds, beneficiaries, or |
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1 | enrollees in a participating hospital or participating | ||||||
2 | ambulatory surgical treatment center. | ||||||
3 | (b) When a beneficiary, insured, or enrollee utilizes a | ||||||
4 | participating network hospital or a participating network | ||||||
5 | ambulatory surgery center and, due to any reason, in network | ||||||
6 | services for radiology, anesthesiology, pathology, emergency | ||||||
7 | physician, or neonatology are unavailable and are provided by a | ||||||
8 | nonparticipating facility-based physician or provider, the | ||||||
9 | insurer or health plan shall ensure that the beneficiary, | ||||||
10 | insured, or enrollee shall incur no greater out-of-pocket costs | ||||||
11 | than the beneficiary, insured, or enrollee would have incurred | ||||||
12 | with a participating physician or provider for covered | ||||||
13 | services. | ||||||
14 | (c) If a beneficiary, insured, or enrollee agrees in | ||||||
15 | writing, notwithstanding any other provision of this Code, any | ||||||
16 | benefits a beneficiary, insured, or enrollee receives for | ||||||
17 | services under the situation in subsection (b) are assigned to | ||||||
18 | the nonparticipating facility-based providers. The insurer or | ||||||
19 | health plan shall provide the nonparticipating provider with a | ||||||
20 | written explanation of benefits that specifies the proposed | ||||||
21 | reimbursement and the applicable deductible, copayment or | ||||||
22 | coinsurance amounts owed by the insured, beneficiary or | ||||||
23 | enrollee. The insurer or health plan shall pay any | ||||||
24 | reimbursement directly to the nonparticipating facility-based | ||||||
25 | provider. The nonparticipating facility-based physician or | ||||||
26 | provider shall not bill the beneficiary, insured, or enrollee, |
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1 | except for applicable deductible, copayment, or coinsurance | ||||||
2 | amounts that would apply if the beneficiary, insured, or | ||||||
3 | enrollee utilized a participating physician or provider for | ||||||
4 | covered services. If a beneficiary, insured, or enrollee | ||||||
5 | specifically rejects assignment under this Section in writing | ||||||
6 | to the nonparticipating facility-based provider, then the | ||||||
7 | nonparticipating facility-based provider may bill the | ||||||
8 | beneficiary, insured, or enrollee for the services rendered. | ||||||
9 | (d) For bills assigned under subsection (c), the | ||||||
10 | nonparticipating facility-based provider may bill the insurer | ||||||
11 | or health plan for the services rendered, and the insurer or | ||||||
12 | health plan may pay the billed amount or attempt to negotiate | ||||||
13 | reimbursement with the nonparticipating facility-based | ||||||
14 | provider. If attempts to negotiate reimbursement for services | ||||||
15 | provided by a nonparticipating facility-based provider do not | ||||||
16 | result in a resolution of the payment dispute within 30 days | ||||||
17 | after receipt of written explanation of benefits by the insurer | ||||||
18 | or health plan, then an insurer or health plan or | ||||||
19 | nonparticipating facility-based physician or provider may | ||||||
20 | initiate binding arbitration to determine payment for services | ||||||
21 | provided on a per bill basis. The party requesting arbitration | ||||||
22 | shall notify the other party arbitration has been initiated and | ||||||
23 | state its final offer before arbitration. In response to this | ||||||
24 | notice, the nonrequesting party shall inform the requesting | ||||||
25 | party of its final offer before the arbitration occurs. | ||||||
26 | Arbitration shall be initiated by filing a request with the |
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1 | Department of Insurance. | ||||||
2 | (e) The Department of Insurance shall publish a list of | ||||||
3 | approved arbitrators or entities that shall provide binding | ||||||
4 | arbitration. These arbitrators shall be American Arbitration | ||||||
5 | Association or American Health Lawyers Association trained | ||||||
6 | arbitrators. Both parties must agree on an arbitrator from the | ||||||
7 | Department of Insurance's list of arbitrators. If no agreement | ||||||
8 | can be reached, then a list of 5 arbitrators shall be provided | ||||||
9 | by the Department of Insurance. From the list of 5 arbitrators, | ||||||
10 | the insurer can veto 2 arbitrators and the provider can veto 2 | ||||||
11 | arbitrators. The remaining arbitrator shall be the chosen | ||||||
12 | arbitrator. This arbitration shall consist of a review of the | ||||||
13 | written submissions by both parties. Binding arbitration shall | ||||||
14 | provide for a written decision within 45 days after the request | ||||||
15 | is filed with the Department of Insurance. Both parties shall | ||||||
16 | be bound by the arbitrator's decision. The arbitrator's | ||||||
17 | expenses and fees, together with other expenses, not including | ||||||
18 | attorney's fees, incurred in the conduct of the arbitration, | ||||||
19 | shall be paid as provided in the decision. | ||||||
20 | (f) This Section 356z.3a does not apply to a beneficiary, | ||||||
21 | insured, or enrollee who willfully chooses to access a | ||||||
22 | nonparticipating facility-based physician or provider for | ||||||
23 | health care services available through the insurer's or plan's | ||||||
24 | network of participating physicians and providers. In these | ||||||
25 | circumstances, the contractual requirements for | ||||||
26 | nonparticipating facility-based provider reimbursements will |
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1 | apply. | ||||||
2 | (g) Section 368a of this Act shall not apply during the | ||||||
3 | pendency of a decision under subsection (d) any interest | ||||||
4 | required to be paid a provider under Section 368a shall not | ||||||
5 | accrue until after 30 days of an arbitrator's decision as | ||||||
6 | provided in subsection (d), but in no circumstances longer than | ||||||
7 | 150 days from date the nonparticipating facility-based | ||||||
8 | provider billed for services rendered.
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9 | (h) Nothing in this Section shall be interpreted to change | ||||||
10 | the prudent layperson provisions with respect to emergency | ||||||
11 | services under the Managed Care Reform and Patient Rights Act. | ||||||
12 | (Source: P.A. 96-1523, eff. 6-1-11 .)
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13 | Section 99. Effective date. This Act takes effect upon | ||||||
14 | becoming law.
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