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Public Act 096-1523





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
    (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
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
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
    (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
    (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