Public Act 096-1523
 
HB5085 EnrolledLRB096 17984 RPM 33355 b


  
    AN ACT concerning insurance.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  


 
    Section 5. The Illinois Insurance Code is amended  by 
changing Section 356z.3 and  by adding Section 356z.3a as 
follows:
 
    (215 ILCS 5/356z.3)
    Sec. 356z.3.  Disclosure of limited benefit. An insurer that

issues,
delivers,
amends, or
renews an individual or group 
policy of accident and health insurance in this
State after the

effective date of this amendatory Act of the 92nd General 
Assembly and
arranges, contracts
with, or administers 
contracts with a provider whereby beneficiaries are
provided an 
incentive to
use the services of such provider must include the 
following disclosure on its
contracts and
evidences of 
coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN

NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that 
when you elect
to
utilize the services of a non-participating 
provider for a covered service in non-emergency
situations, 
benefit payments to such non-participating provider are not 
based upon the amount
billed. The basis of your benefit payment 
will be determined according to your policy's fee
schedule, 
usual and customary charge (which is determined by comparing 
charges for similar
services adjusted to the geographical area 
where the services are performed), or other method as
defined 
by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE

AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS 
REQUIRED
PORTION. Non-participating providers may bill members 
for any amount up to the
billed
charge after the plan has paid 
its portion of the bill as provided in Section 356z.3a of this 
Code. Participating providers
have agreed to accept
discounted 
payments for services with no additional billing to the member 
other
than co-insurance and deductible amounts. You may obtain 
further information
about the
participating
status of 
professional providers and information on out-of-pocket 
expenses by
calling the toll
free telephone number on your 
identification card.".
(Source: P.A. 95-331, eff. 8-21-07.)
 
    (215 ILCS 5/356z.3a new)
    Sec. 356z.3a. Nonparticipating facility-based physicians 
and providers.
    (a)  For purposes of this Section, "facility-based 
provider" means a physician or other provider who provide 
radiology, anesthesiology, pathology, neonatology, or 
emergency department services to insureds, beneficiaries, or 
enrollees in a participating hospital or participating 
ambulatory surgical treatment center.
    (b)  When a beneficiary, insured, or enrollee utilizes a 
participating network hospital or a participating network 
ambulatory surgery center and, due to any reason, in network 
services for radiology, anesthesiology, pathology, emergency 
physician, or neonatology are unavailable and are provided by a 
nonparticipating facility-based physician or provider, the 
insurer or health plan shall ensure that the beneficiary, 
insured, or enrollee shall incur no greater out-of-pocket costs 
than the beneficiary, insured, or enrollee would have incurred 
with a participating physician or provider for covered 
services.
    (c)  If a beneficiary, insured, or enrollee agrees in 
writing, notwithstanding any other provision of this Code, any 
benefits a beneficiary, insured, or enrollee receives for 
services under the situation in subsection (b) are assigned to 
the nonparticipating facility-based providers.  The insurer or 
health plan shall provide the nonparticipating provider with a 
written explanation of benefits that specifies the proposed 
reimbursement and the applicable deductible, copayment or 
coinsurance amounts owed by the insured, beneficiary or 
enrollee.  The insurer or health plan shall pay any 
reimbursement directly to the nonparticipating facility-based 
provider.  The nonparticipating facility-based physician or 
provider shall not bill the beneficiary, insured, or enrollee, 
except for applicable deductible, copayment, or coinsurance 
amounts that would apply if the beneficiary, insured, or 
enrollee utilized a participating physician or provider for 
covered services.  If a beneficiary, insured, or enrollee 
specifically rejects assignment under this Section in writing 
to the nonparticipating facility-based provider, then the 
nonparticipating facility-based provider may bill the 
beneficiary, insured, or enrollee for the services rendered.
    (d)  For bills assigned under subsection (c), the 
nonparticipating facility-based provider may bill the insurer 
or health plan for the services rendered, and the insurer or 
health plan may pay the billed amount or attempt to negotiate 
reimbursement with the nonparticipating facility-based 
provider.  If attempts to negotiate reimbursement for services 
provided by a nonparticipating facility-based provider do not 
result in a resolution of the payment dispute within 30 days 
after receipt of written explanation of benefits by the insurer 
or health plan, then an insurer or health plan or 
nonparticipating facility-based physician or provider may 
initiate binding arbitration to determine payment for services 
provided on a per bill basis.  The party requesting arbitration 
shall notify the other party arbitration has been initiated and 
state its final offer before arbitration.  In response to this 
notice, the nonrequesting party shall inform the requesting 
party of its final offer before the arbitration occurs.  
Arbitration shall be initiated by filing a request with the 
Department of Insurance.
    (e)  The Department of Insurance shall publish a list of 
approved arbitrators or entities that shall provide binding 
arbitration.  These arbitrators shall be American Arbitration 
Association or American Health Lawyers Association trained 
arbitrators.  Both parties must agree on an arbitrator from the 
Department of Insurance's list of arbitrators.  If no agreement 
can be reached, then a list of 5 arbitrators shall be provided 
by the Department of Insurance.  From the list of 5 arbitrators, 
the insurer can veto 2 arbitrators and the provider can veto 2 
arbitrators. The remaining arbitrator shall be the chosen 
arbitrator.  This arbitration shall consist of a review of the 
written submissions by both parties.  Binding arbitration shall 
provide for a written decision within 45 days after the request 
is filed with the Department of Insurance.  Both parties shall 
be bound by the arbitrator's decision.  The arbitrator's 
expenses and fees, together with other expenses, not including 
attorney's fees, incurred in the conduct of the arbitration, 
shall be paid as provided in the decision.
    (f)  This Section 356z.3a does not apply to a beneficiary, 
insured, or enrollee  who willfully chooses to access a 
nonparticipating facility-based physician or provider for 
health care services available through the insurer's or plan's 
network of participating physicians and providers.  In these 
circumstances, the contractual requirements for 
nonparticipating facility-based provider reimbursements will 
apply.
    (g)  Section 368a of this Act shall not apply during the 
pendency of a decision under subsection (d)  any interest 
required to be paid a provider under Section 368a shall not 
accrue until after 30 days of an arbitrator's decision as 
provided in subsection (d), but in no circumstances longer than 
150 days from date the nonparticipating facility-based 
provider billed for services rendered.


Effective Date:  6/1/2011