Full Text of HB5085 96th General Assembly
HB5085enr 96TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning insurance.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 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 | 16 | | coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
| 17 | | NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that | 18 | | when you elect
to
utilize the services of a non-participating | 19 | | provider for a covered service in non-emergency
situations, | 20 | | benefit payments to such non-participating provider are not | 21 | | based upon the amount
billed. The basis of your benefit payment | 22 | | will be determined according to your policy's fee
schedule, | 23 | | usual and customary charge (which is determined by comparing |
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| 1 | | charges for similar
services adjusted to the geographical area | 2 | | where the services are performed), or other method as
defined | 3 | | by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE
| 4 | | AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS | 5 | | REQUIRED
PORTION. Non-participating providers may bill members | 6 | | for any amount up to the
billed
charge after the plan has paid | 7 | | its portion of the bill as provided in Section 356z.3a of this | 8 | | Code . Participating providers
have agreed to accept
discounted | 9 | | payments for services with no additional billing to the member | 10 | | other
than co-insurance and deductible amounts. You may obtain | 11 | | further information
about the
participating
status of | 12 | | professional providers and information on out-of-pocket | 13 | | expenses by
calling the toll
free telephone number on your | 14 | | identification 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 | 18 | | and providers. | 19 | | (a) For purposes of this Section, "facility-based | 20 | | provider" means a physician or other provider who provide | 21 | | radiology, anesthesiology, pathology, neonatology, or | 22 | | emergency department services to insureds, beneficiaries, or | 23 | | enrollees in a participating hospital or participating | 24 | | ambulatory surgical treatment center. | 25 | | (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 and, due to any reason, in network | 3 | | services for radiology, anesthesiology, pathology, emergency | 4 | | physician, or neonatology are unavailable and are provided by a | 5 | | nonparticipating facility-based physician or provider, the | 6 | | insurer or health plan shall ensure that the beneficiary, | 7 | | insured, or enrollee shall incur no greater out-of-pocket costs | 8 | | than the beneficiary, insured, or enrollee would have incurred | 9 | | with a participating physician or provider for covered | 10 | | services. | 11 | | (c) If a beneficiary, insured, or enrollee agrees in | 12 | | writing, notwithstanding any other provision of this Code, any | 13 | | benefits a beneficiary, insured, or enrollee receives for | 14 | | services under the situation in subsection (b) are assigned to | 15 | | the nonparticipating facility-based providers. The insurer or | 16 | | health plan shall provide the nonparticipating provider with a | 17 | | written explanation of benefits that specifies the proposed | 18 | | reimbursement and the applicable deductible, copayment or | 19 | | coinsurance amounts owed by the insured, beneficiary or | 20 | | enrollee. The insurer or health plan shall pay any | 21 | | reimbursement directly to the nonparticipating facility-based | 22 | | provider. The nonparticipating facility-based physician or | 23 | | provider shall not bill the beneficiary, insured, or enrollee, | 24 | | except for applicable deductible, copayment, or coinsurance | 25 | | amounts that would apply if the beneficiary, insured, or | 26 | | enrollee utilized a participating physician or provider for |
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| 1 | | covered services. If a beneficiary, insured, or enrollee | 2 | | specifically rejects assignment under this Section in writing | 3 | | to the nonparticipating facility-based provider, then the | 4 | | nonparticipating facility-based provider may bill the | 5 | | beneficiary, insured, or enrollee for the services rendered. | 6 | | (d) For bills assigned under subsection (c), the | 7 | | nonparticipating facility-based provider may bill the insurer | 8 | | or health plan for the services rendered, and the insurer or | 9 | | health plan may pay the billed amount or attempt to negotiate | 10 | | reimbursement with the nonparticipating facility-based | 11 | | provider. If attempts to negotiate reimbursement for services | 12 | | provided by a nonparticipating facility-based provider do not | 13 | | result in a resolution of the payment dispute within 30 days | 14 | | after receipt of written explanation of benefits by the insurer | 15 | | or health plan, then an insurer or health plan or | 16 | | nonparticipating facility-based physician or provider may | 17 | | initiate binding arbitration to determine payment for services | 18 | | provided on a per bill basis. The party requesting arbitration | 19 | | shall notify the other party arbitration has been initiated and | 20 | | state its final offer before arbitration. In response to this | 21 | | notice, the nonrequesting party shall inform the requesting | 22 | | party of its final offer before the arbitration occurs. | 23 | | Arbitration shall be initiated by filing a request with the | 24 | | Department of Insurance. | 25 | | (e) The Department of Insurance shall publish a list of | 26 | | approved arbitrators or entities that shall provide binding |
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| 1 | | arbitration. These arbitrators shall be American Arbitration | 2 | | Association or American Health Lawyers Association trained | 3 | | arbitrators. Both parties must agree on an arbitrator from the | 4 | | Department of Insurance's list of arbitrators. If no agreement | 5 | | can be reached, then a list of 5 arbitrators shall be provided | 6 | | by the Department of Insurance. From the list of 5 arbitrators, | 7 | | the insurer can veto 2 arbitrators and the provider can veto 2 | 8 | | arbitrators. The remaining arbitrator shall be the chosen | 9 | | arbitrator. This arbitration shall consist of a review of the | 10 | | written submissions by both parties. Binding arbitration shall | 11 | | provide for a written decision within 45 days after the request | 12 | | is filed with the Department of Insurance. Both parties shall | 13 | | be bound by the arbitrator's decision. The arbitrator's | 14 | | expenses and fees, together with other expenses, not including | 15 | | attorney's fees, incurred in the conduct of the arbitration, | 16 | | shall be paid as provided in the decision. | 17 | | (f) This Section 356z.3a does not apply to a beneficiary, | 18 | | insured, or enrollee who willfully chooses to access a | 19 | | nonparticipating facility-based physician or provider for | 20 | | health care services available through the insurer's or plan's | 21 | | network of participating physicians and providers. In these | 22 | | circumstances, the contractual requirements for | 23 | | nonparticipating facility-based provider reimbursements will | 24 | | apply. | 25 | | (g) Section 368a of this Act shall not apply during the | 26 | | pendency of a decision under subsection (d) any interest |
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| 1 | | required to be paid a provider under Section 368a shall not | 2 | | accrue until after 30 days of an arbitrator's decision as | 3 | | provided in subsection (d), but in no circumstances longer than | 4 | | 150 days from date the nonparticipating facility-based | 5 | | provider billed for services rendered.
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