Full Text of HB5085 96th General Assembly
HB5085sam001 96TH GENERAL ASSEMBLY
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Sen. David Koehler
Filed: 5/4/2010
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| AMENDMENT TO HOUSE BILL 5085
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| AMENDMENT NO. ______. Amend House Bill 5085 by replacing | 3 |
| everything after the enacting clause with the following:
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| "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
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| issues,
delivers,
amends, or
renews an individual or group | 10 |
| policy of accident and health insurance in this
State after the
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| 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
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| NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that | 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 | 10 |
| by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE
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| AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS | 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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| (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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| 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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| 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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| 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. ".
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