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(215 ILCS 5/370i) (from Ch. 73, par. 982i)
Sec. 370i.
Policies, agreements or arrangements with incentives or
limits on reimbursement authorized.
(a) Policies, agreements or arrangements issued under this Article may
not contain terms or conditions that would operate unreasonably to restrict
the access and availability of health care services for the insured.
(b) An insurer or administrator may:
(1) enter into agreements with certain providers of |
| its choice relating to health care services which may be rendered to insureds or beneficiaries of the insurer or administrator, including agreements relating to the amounts to be charged the insureds or beneficiaries for services rendered;
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(2) issue or administer programs, policies or
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| subscriber contracts in this State that include incentives for the insured or beneficiary to utilize the services of a provider which has entered into an agreement with the insurer or administrator pursuant to paragraph (1) above.
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(c) After the effective date of this amendatory Act of the 92nd General
Assembly, any insurer
that 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.
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. 92-579, eff. 1-1-03.)
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