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


Sen. David Koehler

Filed: 5/4/2010





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2     AMENDMENT NO. ______. Amend House Bill 5085 by replacing
3 everything after the enacting clause with the following:
4     "Section 5. The Illinois Insurance Code is amended by
5 changing Section 356z.3 and by adding Section 356z.3a as
6 follows:
7     (215 ILCS 5/356z.3)
8     Sec. 356z.3. Disclosure of limited benefit. An insurer that
9 issues, delivers, amends, or renews an individual or group
10 policy of accident and health insurance in this State after the
11 effective date of this amendatory Act of the 92nd General
12 Assembly and arranges, contracts with, or administers
13 contracts with a provider whereby beneficiaries are provided an
14 incentive to use the services of such provider must include the
15 following disclosure on its contracts and evidences of



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2 when you elect to utilize the services of a non-participating
3 provider for a covered service in non-emergency situations,
4 benefit payments to such non-participating provider are not
5 based upon the amount billed. The basis of your benefit payment
6 will be determined according to your policy's fee schedule,
7 usual and customary charge (which is determined by comparing
8 charges for similar services adjusted to the geographical area
9 where the services are performed), or other method as defined
12 REQUIRED PORTION. Non-participating providers may bill members
13 for any amount up to the billed charge after the plan has paid
14 its portion of the bill as provided in Section 356z.3a of this
15 Code. Participating providers have agreed to accept discounted
16 payments for services with no additional billing to the member
17 other than co-insurance and deductible amounts. You may obtain
18 further information about the participating status of
19 professional providers and information on out-of-pocket
20 expenses by calling the toll free telephone number on your
21 identification card.".
22 (Source: P.A. 95-331, eff. 8-21-07.)
23     (215 ILCS 5/356z.3a new)
24     Sec. 356z.3a. Nonparticipating facility-based physicians
25 and providers.



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1     (a) For purposes of this Section, "facility-based
2 provider" means a physician or other provider who provide
3 radiology, anesthesiology, pathology, neonatology, or
4 emergency department services to insureds, beneficiaries, or
5 enrollees in a participating hospital or participating
6 ambulatory surgical treatment center.
7     (b) When a beneficiary, insured, or enrollee utilizes a
8 participating network hospital or a participating network
9 ambulatory surgery center and, due to any reason, in network
10 services for radiology, anesthesiology, pathology, emergency
11 physician, or neonatology are unavailable and are provided by a
12 nonparticipating facility-based physician or provider, the
13 insurer or health plan shall ensure that the beneficiary,
14 insured, or enrollee shall incur no greater out-of-pocket costs
15 than the beneficiary, insured, or enrollee would have incurred
16 with a participating physician or provider for covered
17 services.
18     (c) If a beneficiary, insured, or enrollee agrees in
19 writing, notwithstanding any other provision of this Code, any
20 benefits a beneficiary, insured, or enrollee receives for
21 services under the situation in subsection (b) are assigned to
22 the nonparticipating facility-based providers. The insurer or
23 health plan shall provide the nonparticipating provider with a
24 written explanation of benefits that specifies the proposed
25 reimbursement and the applicable deductible, copayment or
26 coinsurance amounts owed by the insured, beneficiary or



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1 enrollee. The insurer or health plan shall pay any
2 reimbursement directly to the nonparticipating facility-based
3 provider. The nonparticipating facility-based physician or
4 provider shall not bill the beneficiary, insured, or enrollee,
5 except for applicable deductible, copayment, or coinsurance
6 amounts that would apply if the beneficiary, insured, or
7 enrollee utilized a participating physician or provider for
8 covered services. If a beneficiary, insured, or enrollee
9 specifically rejects assignment under this Section in writing
10 to the nonparticipating facility-based provider, then the
11 nonparticipating facility-based provider may bill the
12 beneficiary, insured, or enrollee for the services rendered.
13     (d) For bills assigned under subsection (c), the
14 nonparticipating facility-based provider may bill the insurer
15 or health plan for the services rendered, and the insurer or
16 health plan may pay the billed amount or attempt to negotiate
17 reimbursement with the nonparticipating facility-based
18 provider. If attempts to negotiate reimbursement for services
19 provided by a nonparticipating facility-based provider do not
20 result in a resolution of the payment dispute within 30 days
21 after receipt of written explanation of benefits by the insurer
22 or health plan, then an insurer or health plan or
23 nonparticipating facility-based physician or provider may
24 initiate binding arbitration to determine payment for services
25 provided on a per bill basis. The party requesting arbitration
26 shall notify the other party arbitration has been initiated and



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1 state its final offer before arbitration. In response to this
2 notice, the nonrequesting party shall inform the requesting
3 party of its final offer before the arbitration occurs.
4 Arbitration shall be initiated by filing a request with the
5 Department of Insurance.
6     (e) The Department of Insurance shall publish a list of
7 approved arbitrators or entities that shall provide binding
8 arbitration. These arbitrators shall be American Arbitration
9 Association or American Health Lawyers Association trained
10 arbitrators. Both parties must agree on an arbitrator from the
11 Department of Insurance's list of arbitrators. If no agreement
12 can be reached, then a list of 5 arbitrators shall be provided
13 by the Department of Insurance. From the list of 5 arbitrators,
14 the insurer can veto 2 arbitrators and the provider can veto 2
15 arbitrators. The remaining arbitrator shall be the chosen
16 arbitrator. This arbitration shall consist of a review of the
17 written submissions by both parties. Binding arbitration shall
18 provide for a written decision within 45 days after the request
19 is filed with the Department of Insurance. Both parties shall
20 be bound by the arbitrator's decision. The arbitrator's
21 expenses and fees, together with other expenses, not including
22 attorney's fees, incurred in the conduct of the arbitration,
23 shall be paid as provided in the decision.
24     (f) This Section 356z.3a does not apply to a beneficiary,
25 insured, or enrollee who willfully chooses to access a
26 nonparticipating facility-based physician or provider for



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1 health care services available through the insurer's or plan's
2 network of participating physicians and providers. In these
3 circumstances, the contractual requirements for
4 nonparticipating facility-based provider reimbursements will
5 apply.
6     (g) Section 368a of this Act shall not apply during the
7 pendency of a decision under subsection (d) any interest
8 required to be paid a provider under Section 368a shall not
9 accrue until after 30 days of an arbitrator's decision as
10 provided in subsection (d), but in no circumstances longer than
11 150 days from date the nonparticipating facility-based
12 provider billed for services rendered.".