Full Text of HB3312 95th General Assembly
HB3312ham001 95TH GENERAL ASSEMBLY
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Rep. William B. Black
Filed: 4/18/2007
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| AMENDMENT TO HOUSE BILL 3312
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| AMENDMENT NO. ______. Amend House Bill 3312 by replacing | 3 |
| everything after the enacting clause with the following:
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| "Section 5. The Illinois Insurance Code is amended by | 5 |
| adding Section 370m.1 as follows: | 6 |
| (215 ILCS 5/370m.1 new) | 7 |
| Sec. 370m.1. Assignment of benefits to nonparticipating | 8 |
| physicians. | 9 |
| (a) In this Section: | 10 |
| "Exclusive arrangement" means a formal contract or | 11 |
| informal arrangement between a physician and a health care | 12 |
| facility under which only the physician, alone or with other | 13 |
| physicians selected or designated by the facility, may provide | 14 |
| a facility-based physician service at the facility. | 15 |
| "Facility-based physician service" means a service, the | 16 |
| performance of which requires a license to practice medicine in |
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| this State; involving one or more of the medical specialties of | 2 |
| radiology, anesthesia, pathology, emergency medicine, or | 3 |
| nenonatology; and provided to a patient of a health care | 4 |
| facility. | 5 |
| "Health benefit plan issuer" means a health insurer that | 6 |
| issues a preferred provider program under this Article or a | 7 |
| health maintenance organization operating under the Health | 8 |
| Maintenance Organization Act. | 9 |
| "Health care facility" means any public or private
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| hospital, clinic,
center, medical school, medical training | 11 |
| institution, laboratory or
diagnostic
facility, physician's or | 12 |
| health care practitioner's office, infirmary, dispensary, | 13 |
| ambulatory surgical
treatment center, or other institution or | 14 |
| location wherein health care
services are provided to any | 15 |
| person, including physician or health care practitioner | 16 |
| organizations and
associations, networks, joint ventures, and | 17 |
| all
other combinations of those organizations. | 18 |
| "Member" means an individual insured by a preferred | 19 |
| provider program under this Article, including a covered | 20 |
| dependent or enrollee. | 21 |
| "Nonparticipating physician" means a physician who, with | 22 |
| respect to a health benefit plan, is not part of the network of | 23 |
| providers with whom the health benefit plan issuer has | 24 |
| contracted to provide medical care or health care to members of | 25 |
| the health benefit plan. | 26 |
| "Nonparticipating provider" means a provider who, with |
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| respect to a health benefit plan, is not part of the network of | 2 |
| providers with whom the health benefit plan issuer has | 3 |
| contracted to provide health care to members of the health | 4 |
| benefit plan. | 5 |
| "Physician" means a person licensed to practice medicine in | 6 |
| all its branches under the Medical Practice Act of 1987. | 7 |
| (b) If a member offers to assign to a nonparticipating | 8 |
| physician the member's right to benefits from the member's | 9 |
| health benefit plan issuer, the nonparticipating physician may | 10 |
| not charge the member or the member's representative any amount | 11 |
| for any facility-based physician service provided under an | 12 |
| exclusive arrangement, other than amounts for copayments, | 13 |
| coinsurance, or deductibles as provided by the member's policy | 14 |
| or contract with the health benefit plan issuer. If a member | 15 |
| does not offer to assign or refuses to assign to a | 16 |
| nonparticipating physician the member's right to benefits from | 17 |
| the member's health benefit plan issuer, the nonparticipating | 18 |
| physician may charge the member for the facility-based | 19 |
| physician service provided under an exclusive arrangement. | 20 |
| A health benefit plan issuer's liability to a | 21 |
| nonparticipating physician for a facility-based physician | 22 |
| service provided under an exclusive arrangement is limited to | 23 |
| the health benefit plan issuer's obligation under the issuer's | 24 |
| policy of contract with the member. A nonparticipating | 25 |
| physician's charge for a facility-based physician service | 26 |
| provided under an exclusive arrangement must be the physician's |
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| usual and customary charge, but may not exceed 125% of the | 2 |
| amount payable for the service under the Medicare program. | 3 |
| (b) A nonparticipating physician or provider may require a | 4 |
| member to assign the member's benefits from the member's health | 5 |
| benefit plan issuer to the nonparticipating physician or | 6 |
| provider. Except as provided in subsection (a) of this Section, | 7 |
| if a nonparticipating physician or provider accepts a member's | 8 |
| assignment of the member's benefits, the nonparticipating | 9 |
| physician or provider may not charge the member or the member's | 10 |
| representative any amount for a physician or provider service, | 11 |
| other than amounts for copayments, coinsurance, or deductibles | 12 |
| under the member's policy or contract with the health benefit | 13 |
| plan issuer. | 14 |
| A health benefit plan issuer's liability to a | 15 |
| nonparticipating physician or provider who has accepted an | 16 |
| assignment of benefits from a member for a physician or | 17 |
| provider service is limited to the issuer's obligation under | 18 |
| the issuer's policy or contract with the member. If the a | 19 |
| nonparticipating physician or provider does not require a | 20 |
| member to assign the member's benefits or otherwise accept the | 21 |
| member's assignment of benefits, the nonparticipating | 22 |
| physician or provider may charge the member or the member's | 23 |
| representative for the physician or provider service. ".
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