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
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.3a as follows:
 
6    (215 ILCS 5/356z.3a)
7    Sec. 356z.3a. Nonparticipating facility-based physicians
8and providers.
9    (a) For purposes of this Section, "facility-based
10provider" means a physician or other provider who provide
11radiology, anesthesiology, pathology, neonatology, or
12emergency department services to insureds, beneficiaries, or
13enrollees in a participating hospital, or participating
14ambulatory surgical treatment center, specialty hospital, or
15urgent care center.
16    (b) When a beneficiary, insured, or enrollee utilizes a

 

 

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1participating network hospital, or a participating network
2ambulatory surgery center, a specialty hospital, or an urgent
3care center and, due to any reason, in network services for
4radiology, anesthesiology, pathology, emergency physician, or
5neonatology are unavailable and are provided by a
6nonparticipating facility-based physician or provider, the
7insurer or health plan shall ensure that the beneficiary,
8insured, or enrollee shall incur no greater out-of-pocket costs
9than the beneficiary, insured, or enrollee would have incurred
10with a participating physician or provider for covered
11services.
12    (c) If a beneficiary, insured, or enrollee agrees in
13writing, notwithstanding any other provision of this Code, any
14benefits a beneficiary, insured, or enrollee receives for
15services under the situation in subsection (b) are assigned to
16the nonparticipating facility-based providers. The insurer or
17health plan shall provide the nonparticipating provider with a
18written explanation of benefits that specifies the proposed
19reimbursement and the applicable deductible, copayment or
20coinsurance amounts owed by the insured, beneficiary or
21enrollee. The insurer or health plan shall pay any
22reimbursement directly to the nonparticipating facility-based
23provider. The nonparticipating facility-based physician or
24provider shall not bill the beneficiary, insured, or enrollee,
25except for applicable deductible, copayment, or coinsurance
26amounts that would apply if the beneficiary, insured, or

 

 

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1enrollee utilized a participating physician or provider for
2covered services. If a beneficiary, insured, or enrollee
3specifically rejects assignment under this Section in writing
4to the nonparticipating facility-based provider, then the
5nonparticipating facility-based provider may bill the
6beneficiary, insured, or enrollee for the services rendered.
7    (d) For bills assigned under subsection (c), the
8nonparticipating facility-based provider may bill the insurer
9or health plan for the services rendered, and the insurer or
10health plan may pay the billed amount or attempt to negotiate
11reimbursement with the nonparticipating facility-based
12provider. If attempts to negotiate reimbursement for services
13provided by a nonparticipating facility-based provider do not
14result in a resolution of the payment dispute within 30 days
15after receipt of written explanation of benefits by the insurer
16or health plan, then an insurer or health plan or
17nonparticipating facility-based physician or provider may
18initiate binding arbitration to determine payment for services
19provided on a per bill basis. The party requesting arbitration
20shall notify the other party arbitration has been initiated and
21state its final offer before arbitration. In response to this
22notice, the nonrequesting party shall inform the requesting
23party of its final offer before the arbitration occurs.
24Arbitration shall be initiated by filing a request with the
25Department of Insurance.
26    (e) The Department of Insurance shall publish a list of

 

 

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1approved arbitrators or entities that shall provide binding
2arbitration. These arbitrators shall be American Arbitration
3Association or American Health Lawyers Association trained
4arbitrators. Both parties must agree on an arbitrator from the
5Department of Insurance's list of arbitrators. If no agreement
6can be reached, then a list of 5 arbitrators shall be provided
7by the Department of Insurance. From the list of 5 arbitrators,
8the insurer can veto 2 arbitrators and the provider can veto 2
9arbitrators. The remaining arbitrator shall be the chosen
10arbitrator. This arbitration shall consist of a review of the
11written submissions by both parties. Binding arbitration shall
12provide for a written decision within 45 days after the request
13is filed with the Department of Insurance. Both parties shall
14be bound by the arbitrator's decision. The arbitrator's
15expenses and fees, together with other expenses, not including
16attorney's fees, incurred in the conduct of the arbitration,
17shall be paid as provided in the decision.
18    (f) This Section 356z.3a does not apply to a beneficiary,
19insured, or enrollee who willfully chooses to access a
20nonparticipating facility-based physician or provider for
21health care services available through the insurer's or plan's
22network of participating physicians and providers. In these
23circumstances, the contractual requirements for
24nonparticipating facility-based provider reimbursements will
25apply.
26    (g) Section 368a of this Act shall not apply during the

 

 

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1pendency of a decision under subsection (d) any interest
2required to be paid a provider under Section 368a shall not
3accrue until after 30 days of an arbitrator's decision as
4provided in subsection (d), but in no circumstances longer than
5150 days from date the nonparticipating facility-based
6provider billed for services rendered.
7    (h) Nothing in this Section shall be interpreted to change
8the prudent layperson provisions with respect to emergency
9services 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.)".