Illinois Compiled Statutes 215 ILCS 5/370i – Policies, agreements or arrangements with incentives or limits on reimbursement authorized
Current as of: 2024 | Check for updates
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(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
(b) An insurer or administrator may:
Terms Used In Illinois Compiled Statutes 215 ILCS 5/370i
- Administrator: means any person, partnership or corporation, other than an insurer or health maintenance organization holding a certificate of authority under the "Health Maintenance Organization Act" as now or hereafter amended, that arranges, contracts with, or administers contracts with a provider whereby beneficiaries are provided an incentive to use the services of such provider. See Illinois Compiled Statutes 215 ILCS 5/370g
- Health care services: means health care services or products rendered or sold by a provider within the scope of the provider's license or legal authorization. See Illinois Compiled Statutes 215 ILCS 5/370g
- Insured: means an individual entitled to reimbursement for expenses of health care services under a policy or subscriber contract issued or administered by an insurer. See Illinois Compiled Statutes 215 ILCS 5/370g
- Insurer: means an insurance company or a health service corporation authorized in this State to issue policies or subscriber contracts which reimburse for expenses of health care services. See Illinois Compiled Statutes 215 ILCS 5/370g
- Provider: means an individual or entity duly licensed or legally authorized to provide health care services. See Illinois Compiled Statutes 215 ILCS 5/370g
- State: when applied to different parts of the United States, may be construed to include the District of Columbia and the several territories, and the words "United States" may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14
(1) enter into agreements with certain providers of
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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.”.