Full Text of HB5293 99th General Assembly
HB5293ham001 99TH GENERAL ASSEMBLY | Rep. Jack D. Franks Filed: 3/2/2016
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| 1 | | AMENDMENT TO HOUSE BILL 5293
| 2 | | AMENDMENT NO. ______. Amend House Bill 5293 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.3a as follows: | 6 | | (215 ILCS 5/356z.3a) | 7 | | Sec. 356z.3a. Nonparticipating facility-based physicians | 8 | | and providers. | 9 | | (a) For purposes of this Section, "facility-based | 10 | | provider" means a physician or other provider who provide | 11 | | radiology, anesthesiology, pathology, neonatology, or | 12 | | emergency department services to insureds, beneficiaries, or | 13 | | enrollees in a participating hospital , or participating | 14 | | ambulatory surgical treatment center , specialty hospital, or | 15 | | urgent care center . | 16 | | (b) When a beneficiary, insured, or enrollee utilizes a |
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| 1 | | participating network hospital , or a participating network | 2 | | ambulatory surgery center , a specialty hospital, or an urgent | 3 | | care center and, due to any reason, in network services for | 4 | | radiology, anesthesiology, pathology, emergency physician, or | 5 | | neonatology are unavailable and are provided by a | 6 | | nonparticipating facility-based physician or provider, the | 7 | | insurer or health plan shall ensure that the beneficiary, | 8 | | insured, or enrollee shall incur no greater out-of-pocket costs | 9 | | than the beneficiary, insured, or enrollee would have incurred | 10 | | with a participating physician or provider for covered | 11 | | services. | 12 | | (c) If a beneficiary, insured, or enrollee agrees in | 13 | | writing, notwithstanding any other provision of this Code, any | 14 | | benefits a beneficiary, insured, or enrollee receives for | 15 | | services under the situation in subsection (b) are assigned to | 16 | | the nonparticipating facility-based providers. The insurer or | 17 | | health plan shall provide the nonparticipating provider with a | 18 | | written explanation of benefits that specifies the proposed | 19 | | reimbursement and the applicable deductible, copayment or | 20 | | coinsurance amounts owed by the insured, beneficiary or | 21 | | enrollee. The insurer or health plan shall pay any | 22 | | reimbursement directly to the nonparticipating facility-based | 23 | | provider. The nonparticipating facility-based physician or | 24 | | provider shall not bill the beneficiary, insured, or enrollee, | 25 | | except for applicable deductible, copayment, or coinsurance | 26 | | amounts that would apply if the beneficiary, insured, or |
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| 1 | | enrollee utilized a participating physician or provider for | 2 | | covered services. If a beneficiary, insured, or enrollee | 3 | | specifically rejects assignment under this Section in writing | 4 | | to the nonparticipating facility-based provider, then the | 5 | | nonparticipating facility-based provider may bill the | 6 | | beneficiary, insured, or enrollee for the services rendered. | 7 | | (d) For bills assigned under subsection (c), the | 8 | | nonparticipating facility-based provider may bill the insurer | 9 | | or health plan for the services rendered, and the insurer or | 10 | | health plan may pay the billed amount or attempt to negotiate | 11 | | reimbursement with the nonparticipating facility-based | 12 | | provider. If attempts to negotiate reimbursement for services | 13 | | provided by a nonparticipating facility-based provider do not | 14 | | result in a resolution of the payment dispute within 30 days | 15 | | after receipt of written explanation of benefits by the insurer | 16 | | or health plan, then an insurer or health plan or | 17 | | nonparticipating facility-based physician or provider may | 18 | | initiate binding arbitration to determine payment for services | 19 | | provided on a per bill basis. The party requesting arbitration | 20 | | shall notify the other party arbitration has been initiated and | 21 | | state its final offer before arbitration. In response to this | 22 | | notice, the nonrequesting party shall inform the requesting | 23 | | party of its final offer before the arbitration occurs. | 24 | | Arbitration shall be initiated by filing a request with the | 25 | | Department of Insurance. | 26 | | (e) The Department of Insurance shall publish a list of |
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| 1 | | approved arbitrators or entities that shall provide binding | 2 | | arbitration. These arbitrators shall be American Arbitration | 3 | | Association or American Health Lawyers Association trained | 4 | | arbitrators. Both parties must agree on an arbitrator from the | 5 | | Department of Insurance's list of arbitrators. If no agreement | 6 | | can be reached, then a list of 5 arbitrators shall be provided | 7 | | by the Department of Insurance. From the list of 5 arbitrators, | 8 | | the insurer can veto 2 arbitrators and the provider can veto 2 | 9 | | arbitrators. The remaining arbitrator shall be the chosen | 10 | | arbitrator. This arbitration shall consist of a review of the | 11 | | written submissions by both parties. Binding arbitration shall | 12 | | provide for a written decision within 45 days after the request | 13 | | is filed with the Department of Insurance. Both parties shall | 14 | | be bound by the arbitrator's decision. The arbitrator's | 15 | | expenses and fees, together with other expenses, not including | 16 | | attorney's fees, incurred in the conduct of the arbitration, | 17 | | shall be paid as provided in the decision. | 18 | | (f) This Section 356z.3a does not apply to a beneficiary, | 19 | | insured, or enrollee who willfully chooses to access a | 20 | | nonparticipating facility-based physician or provider for | 21 | | health care services available through the insurer's or plan's | 22 | | network of participating physicians and providers. In these | 23 | | circumstances, the contractual requirements for | 24 | | nonparticipating facility-based provider reimbursements will | 25 | | apply. | 26 | | (g) Section 368a of this Act shall not apply during the |
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| 1 | | pendency of a decision under subsection (d) any interest | 2 | | required to be paid a provider under Section 368a shall not | 3 | | accrue until after 30 days of an arbitrator's decision as | 4 | | provided in subsection (d), but in no circumstances longer than | 5 | | 150 days from date the nonparticipating facility-based | 6 | | provider billed for services rendered.
| 7 | | (h) Nothing in this Section shall be interpreted to change | 8 | | the prudent layperson provisions with respect to emergency | 9 | | services under the Managed Care Reform and Patient Rights Act. | 10 | | (i) A participating hospital shall post on its website: | 11 | | (1) the names and hyperlinks for direct access to the | 12 | | websites of all health insurers and health maintenance | 13 | | organizations for which the hospital contracts as a network | 14 | | provider or participating provider; | 15 | | (2) a statement that: | 16 | | (A) services provided in the hospital by health | 17 | | care practitioners may not be included in the | 18 | | hospital's charges; | 19 | | (B) health care practitioners who provide services | 20 | | in the hospital may or may not participate in the same | 21 | | health insurance plans as the hospital; and | 22 | | (C) prospective patients should contact the health | 23 | | care practitioner arranging for the services to | 24 | | determine the health care plans in which the health | 25 | | care practitioner participates; and | 26 | | (3) as applicable, the names, mailing addresses, and |
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| 1 | | telephone numbers of the health care practitioners and | 2 | | practice groups that the hospital has contracted with to | 3 | | provide services in the hospital and instructions on how to | 4 | | contact these health care practitioners and practice | 5 | | groups to determine the health insurers and health | 6 | | maintenance organizations for which the hospital contracts | 7 | | as a network provider or participating provider. | 8 | | (Source: P.A. 98-154, eff. 8-2-13.)".
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