Illinois General Assembly - Full Text of HB5085
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Full Text of HB5085  96th General Assembly




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1    AN ACT concerning insurance.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.3 and by adding Section 356z.3a as
7    (215 ILCS 5/356z.3)
8    Sec. 356z.3. Disclosure of limited benefit. An insurer that
9issues, delivers, amends, or renews an individual or group
10policy of accident and health insurance in this State after the
11effective date of this amendatory Act of the 92nd General
12Assembly and arranges, contracts with, or administers
13contracts with a provider whereby beneficiaries are provided an
14incentive to use the services of such provider must include the
15following disclosure on its contracts and evidences of
18when you elect to utilize the services of a non-participating
19provider for a covered service in non-emergency situations,
20benefit payments to such non-participating provider are not
21based upon the amount billed. The basis of your benefit payment
22will be determined according to your policy's fee schedule,
23usual and customary charge (which is determined by comparing



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1charges for similar services adjusted to the geographical area
2where the services are performed), or other method as defined
5REQUIRED PORTION. Non-participating providers may bill members
6for any amount up to the billed charge after the plan has paid
7its portion of the bill as provided in Section 356z.3a of this
8Code. Participating providers have agreed to accept discounted
9payments for services with no additional billing to the member
10other than co-insurance and deductible amounts. You may obtain
11further information about the participating status of
12professional providers and information on out-of-pocket
13expenses by calling the toll free telephone number on your
14identification card.".
15(Source: P.A. 95-331, eff. 8-21-07.)
16    (215 ILCS 5/356z.3a new)
17    Sec. 356z.3a. Nonparticipating facility-based physicians
18and providers.
19    (a) For purposes of this Section, "facility-based
20provider" means a physician or other provider who provide
21radiology, anesthesiology, pathology, neonatology, or
22emergency department services to insureds, beneficiaries, or
23enrollees in a participating hospital or participating
24ambulatory surgical treatment center.
25    (b) When a beneficiary, insured, or enrollee utilizes a



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1participating network hospital or a participating network
2ambulatory surgery center and, due to any reason, in network
3services for radiology, anesthesiology, pathology, emergency
4physician, or neonatology are unavailable and are provided by a
5nonparticipating facility-based physician or provider, the
6insurer or health plan shall ensure that the beneficiary,
7insured, or enrollee shall incur no greater out-of-pocket costs
8than the beneficiary, insured, or enrollee would have incurred
9with a participating physician or provider for covered
11    (c) If a beneficiary, insured, or enrollee agrees in
12writing, notwithstanding any other provision of this Code, any
13benefits a beneficiary, insured, or enrollee receives for
14services under the situation in subsection (b) are assigned to
15the nonparticipating facility-based providers. The insurer or
16health plan shall provide the nonparticipating provider with a
17written explanation of benefits that specifies the proposed
18reimbursement and the applicable deductible, copayment or
19coinsurance amounts owed by the insured, beneficiary or
20enrollee. The insurer or health plan shall pay any
21reimbursement directly to the nonparticipating facility-based
22provider. The nonparticipating facility-based physician or
23provider shall not bill the beneficiary, insured, or enrollee,
24except for applicable deductible, copayment, or coinsurance
25amounts that would apply if the beneficiary, insured, or
26enrollee utilized a participating physician or provider for



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1covered services. If a beneficiary, insured, or enrollee
2specifically rejects assignment under this Section in writing
3to the nonparticipating facility-based provider, then the
4nonparticipating facility-based provider may bill the
5beneficiary, insured, or enrollee for the services rendered.
6    (d) For bills assigned under subsection (c), the
7nonparticipating facility-based provider may bill the insurer
8or health plan for the services rendered, and the insurer or
9health plan may pay the billed amount or attempt to negotiate
10reimbursement with the nonparticipating facility-based
11provider. If attempts to negotiate reimbursement for services
12provided by a nonparticipating facility-based provider do not
13result in a resolution of the payment dispute within 30 days
14after receipt of written explanation of benefits by the insurer
15or health plan, then an insurer or health plan or
16nonparticipating facility-based physician or provider may
17initiate binding arbitration to determine payment for services
18provided on a per bill basis. The party requesting arbitration
19shall notify the other party arbitration has been initiated and
20state its final offer before arbitration. In response to this
21notice, the nonrequesting party shall inform the requesting
22party of its final offer before the arbitration occurs.
23Arbitration shall be initiated by filing a request with the
24Department of Insurance.
25    (e) The Department of Insurance shall publish a list of
26approved arbitrators or entities that shall provide binding



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1arbitration. These arbitrators shall be American Arbitration
2Association or American Health Lawyers Association trained
3arbitrators. Both parties must agree on an arbitrator from the
4Department of Insurance's list of arbitrators. If no agreement
5can be reached, then a list of 5 arbitrators shall be provided
6by the Department of Insurance. From the list of 5 arbitrators,
7the insurer can veto 2 arbitrators and the provider can veto 2
8arbitrators. The remaining arbitrator shall be the chosen
9arbitrator. This arbitration shall consist of a review of the
10written submissions by both parties. Binding arbitration shall
11provide for a written decision within 45 days after the request
12is filed with the Department of Insurance. Both parties shall
13be bound by the arbitrator's decision. The arbitrator's
14expenses and fees, together with other expenses, not including
15attorney's fees, incurred in the conduct of the arbitration,
16shall be paid as provided in the decision.
17    (f) This Section 356z.3a does not apply to a beneficiary,
18insured, or enrollee who willfully chooses to access a
19nonparticipating facility-based physician or provider for
20health care services available through the insurer's or plan's
21network of participating physicians and providers. In these
22circumstances, the contractual requirements for
23nonparticipating facility-based provider reimbursements will
25    (g) Section 368a of this Act shall not apply during the
26pendency of a decision under subsection (d) any interest



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1required to be paid a provider under Section 368a shall not
2accrue until after 30 days of an arbitrator's decision as
3provided in subsection (d), but in no circumstances longer than
4150 days from date the nonparticipating facility-based
5provider billed for services rendered.