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Rep. Jack D. Franks
Filed: 3/2/2016
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1 | | AMENDMENT TO HOUSE BILL 5293
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2 | | AMENDMENT NO. ______. Amend House Bill 5293 by replacing |
3 | | everything after the enacting clause with the following:
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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.
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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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