103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2581 Introduced , by Rep. William E Hauter SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a Amends the Illinois Insurance Code. Provides that for any bill submitted to arbitration, the health insurance issuer shall pay the provider or facility at least the current Medicare reimbursement rate pending the resolution of the arbitration. LRB103 06011 BMS 51564 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2581 Introduced , by Rep. William E Hauter SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a 215 ILCS 5/356z.3a Amends the Illinois Insurance Code. Provides that for any bill submitted to arbitration, the health insurance issuer shall pay the provider or facility at least the current Medicare reimbursement rate pending the resolution of the arbitration. LRB103 06011 BMS 51564 b LRB103 06011 BMS 51564 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2581 Introduced , by Rep. William E Hauter SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.3a 215 ILCS 5/356z.3a
215 ILCS 5/356z.3a
Amends the Illinois Insurance Code. Provides that for any bill submitted to arbitration, the health insurance issuer shall pay the provider or facility at least the current Medicare reimbursement rate pending the resolution of the arbitration.
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A BILL FOR
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1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5 changing Section 356z.3a as follows:
6 (215 ILCS 5/356z.3a)
7 Sec. 356z.3a. Billing; emergency services;
8 nonparticipating providers.
9 (a) As used in this Section:
10 "Ancillary services" means:
11 (1) items and services related to emergency medicine,
12 anesthesiology, pathology, radiology, and neonatology that
13 are provided by any health care provider;
14 (2) items and services provided by assistant surgeons,
15 hospitalists, and intensivists;
16 (3) diagnostic services, including radiology and
17 laboratory services, except for advanced diagnostic
18 laboratory tests identified on the most current list
19 published by the United States Secretary of Health and
20 Human Services under 42 U.S.C. 300gg-132(b)(3);
21 (4) items and services provided by other specialty
22 practitioners as the United States Secretary of Health and
23 Human Services specifies through rulemaking under 42
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2581 Introduced , by Rep. William E Hauter SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.3a 215 ILCS 5/356z.3a
215 ILCS 5/356z.3a
Amends the Illinois Insurance Code. Provides that for any bill submitted to arbitration, the health insurance issuer shall pay the provider or facility at least the current Medicare reimbursement rate pending the resolution of the arbitration.
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A BILL FOR
215 ILCS 5/356z.3a
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1 U.S.C. 300gg-132(b)(3); and
2 (5) items and services provided by a nonparticipating
3 provider if there is no participating provider who can
4 furnish the item or service at the facility.
5 "Cost sharing" means the amount an insured, beneficiary,
6 or enrollee is responsible for paying for a covered item or
7 service under the terms of the policy or certificate. "Cost
8 sharing" includes copayments, coinsurance, and amounts paid
9 toward deductibles, but does not include amounts paid towards
10 premiums, balance billing by out-of-network providers, or the
11 cost of items or services that are not covered under the policy
12 or certificate.
13 "Emergency department of a hospital" means any hospital
14 department that provides emergency services, including a
15 hospital outpatient department.
16 "Emergency medical condition" has the meaning ascribed to
17 that term in Section 10 of the Managed Care Reform and Patient
18 Rights Act.
19 "Emergency medical screening examination" has the meaning
20 ascribed to that term in Section 10 of the Managed Care Reform
21 and Patient Rights Act.
22 "Emergency services" means, with respect to an emergency
23 medical condition:
24 (1) in general, an emergency medical screening
25 examination, including ancillary services routinely
26 available to the emergency department to evaluate such
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1 emergency medical condition, and such further medical
2 examination and treatment as would be required to
3 stabilize the patient regardless of the department of the
4 hospital or other facility in which such further
5 examination or treatment is furnished; or
6 (2) additional items and services for which benefits
7 are provided or covered under the coverage and that are
8 furnished by a nonparticipating provider or
9 nonparticipating emergency facility regardless of the
10 department of the hospital or other facility in which such
11 items are furnished after the insured, beneficiary, or
12 enrollee is stabilized and as part of outpatient
13 observation or an inpatient or outpatient stay with
14 respect to the visit in which the services described in
15 paragraph (1) are furnished. Services after stabilization
16 cease to be emergency services only when all the
17 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
18 regulations thereunder are met.
19 "Freestanding Emergency Center" means a facility licensed
20 under Section 32.5 of the Emergency Medical Services (EMS)
21 Systems Act.
22 "Health care facility" means, in the context of
23 non-emergency services, any of the following:
24 (1) a hospital as defined in 42 U.S.C. 1395x(e);
25 (2) a hospital outpatient department;
26 (3) a critical access hospital certified under 42
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1 U.S.C. 1395i-4(e);
2 (4) an ambulatory surgical treatment center as defined
3 in the Ambulatory Surgical Treatment Center Act; or
4 (5) any recipient of a license under the Hospital
5 Licensing Act that is not otherwise described in this
6 definition.
7 "Health care provider" means a provider as defined in
8 subsection (d) of Section 370g. "Health care provider" does
9 not include a provider of air ambulance or ground ambulance
10 services.
11 "Health care services" has the meaning ascribed to that
12 term in subsection (a) of Section 370g.
13 "Health insurance issuer" has the meaning ascribed to that
14 term in Section 5 of the Illinois Health Insurance Portability
15 and Accountability Act.
16 "Nonparticipating emergency facility" means, with respect
17 to the furnishing of an item or service under a policy of group
18 or individual health insurance coverage, any of the following
19 facilities that does not have a contractual relationship
20 directly or indirectly with a health insurance issuer in
21 relation to the coverage:
22 (1) an emergency department of a hospital;
23 (2) a Freestanding Emergency Center;
24 (3) an ambulatory surgical treatment center as defined
25 in the Ambulatory Surgical Treatment Center Act; or
26 (4) with respect to emergency services described in
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1 paragraph (2) of the definition of "emergency services", a
2 hospital.
3 "Nonparticipating provider" means, with respect to the
4 furnishing of an item or service under a policy of group or
5 individual health insurance coverage, any health care provider
6 who does not have a contractual relationship directly or
7 indirectly with a health insurance issuer in relation to the
8 coverage.
9 "Participating emergency facility" means any of the
10 following facilities that has a contractual relationship
11 directly or indirectly with a health insurance issuer offering
12 group or individual health insurance coverage setting forth
13 the terms and conditions on which a relevant health care
14 service is provided to an insured, beneficiary, or enrollee
15 under the coverage:
16 (1) an emergency department of a hospital;
17 (2) a Freestanding Emergency Center;
18 (3) an ambulatory surgical treatment center as defined
19 in the Ambulatory Surgical Treatment Center Act; or
20 (4) with respect to emergency services described in
21 paragraph (2) of the definition of "emergency services", a
22 hospital.
23 For purposes of this definition, a single case agreement
24 between an emergency facility and an issuer that is used to
25 address unique situations in which an insured, beneficiary, or
26 enrollee requires services that typically occur out-of-network
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1 constitutes a contractual relationship and is limited to the
2 parties to the agreement.
3 "Participating health care facility" means any health care
4 facility that has a contractual relationship directly or
5 indirectly with a health insurance issuer offering group or
6 individual health insurance coverage setting forth the terms
7 and conditions on which a relevant health care service is
8 provided to an insured, beneficiary, or enrollee under the
9 coverage. A single case agreement between an emergency
10 facility and an issuer that is used to address unique
11 situations in which an insured, beneficiary, or enrollee
12 requires services that typically occur out-of-network
13 constitutes a contractual relationship for purposes of this
14 definition and is limited to the parties to the agreement.
15 "Participating provider" means any health care provider
16 that has a contractual relationship directly or indirectly
17 with a health insurance issuer offering group or individual
18 health insurance coverage setting forth the terms and
19 conditions on which a relevant health care service is provided
20 to an insured, beneficiary, or enrollee under the coverage.
21 "Qualifying payment amount" has the meaning given to that
22 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
23 promulgated thereunder.
24 "Recognized amount" means the lesser of the amount
25 initially billed by the provider or the qualifying payment
26 amount.
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1 "Stabilize" means "stabilization" as defined in Section 10
2 of the Managed Care Reform and Patient Rights Act.
3 "Treating provider" means a health care provider who has
4 evaluated the individual.
5 "Visit" means, with respect to health care services
6 furnished to an individual at a health care facility, health
7 care services furnished by a provider at the facility, as well
8 as equipment, devices, telehealth services, imaging services,
9 laboratory services, and preoperative and postoperative
10 services regardless of whether the provider furnishing such
11 services is at the facility.
12 (b) Emergency services. When a beneficiary, insured, or
13 enrollee receives emergency services from a nonparticipating
14 provider or a nonparticipating emergency facility, the health
15 insurance issuer shall ensure that the beneficiary, insured,
16 or enrollee shall incur no greater out-of-pocket costs than
17 the beneficiary, insured, or enrollee would have incurred with
18 a participating provider or a participating emergency
19 facility. Any cost-sharing requirements shall be applied as
20 though the emergency services had been received from a
21 participating provider or a participating facility. Cost
22 sharing shall be calculated based on the recognized amount for
23 the emergency services. If the cost sharing for the same item
24 or service furnished by a participating provider would have
25 been a flat-dollar copayment, that amount shall be the
26 cost-sharing amount unless the provider has billed a lesser
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1 total amount. In no event shall the beneficiary, insured,
2 enrollee, or any group policyholder or plan sponsor be liable
3 to or billed by the health insurance issuer, the
4 nonparticipating provider, or the nonparticipating emergency
5 facility for any amount beyond the cost sharing calculated in
6 accordance with this subsection with respect to the emergency
7 services delivered. Administrative requirements or limitations
8 shall be no greater than those applicable to emergency
9 services received from a participating provider or a
10 participating emergency facility.
11 (b-5) Non-emergency services at participating health care
12 facilities.
13 (1) When a beneficiary, insured, or enrollee utilizes
14 a participating health care facility and, due to any
15 reason, covered ancillary services are provided by a
16 nonparticipating provider during or resulting from the
17 visit, the health insurance issuer shall ensure that the
18 beneficiary, insured, or enrollee shall incur no greater
19 out-of-pocket costs than the beneficiary, insured, or
20 enrollee would have incurred with a participating provider
21 for the ancillary services. Any cost-sharing requirements
22 shall be applied as though the ancillary services had been
23 received from a participating provider. Cost sharing shall
24 be calculated based on the recognized amount for the
25 ancillary services. If the cost sharing for the same item
26 or service furnished by a participating provider would
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1 have been a flat-dollar copayment, that amount shall be
2 the cost-sharing amount unless the provider has billed a
3 lesser total amount. In no event shall the beneficiary,
4 insured, enrollee, or any group policyholder or plan
5 sponsor be liable to or billed by the health insurance
6 issuer, the nonparticipating provider, or the
7 participating health care facility for any amount beyond
8 the cost sharing calculated in accordance with this
9 subsection with respect to the ancillary services
10 delivered. In addition to ancillary services, the
11 requirements of this paragraph shall also apply with
12 respect to covered items or services furnished as a result
13 of unforeseen, urgent medical needs that arise at the time
14 an item or service is furnished, regardless of whether the
15 nonparticipating provider satisfied the notice and consent
16 criteria under paragraph (2) of this subsection.
17 (2) When a beneficiary, insured, or enrollee utilizes
18 a participating health care facility and receives
19 non-emergency covered health care services other than
20 those described in paragraph (1) of this subsection from a
21 nonparticipating provider during or resulting from the
22 visit, the health insurance issuer shall ensure that the
23 beneficiary, insured, or enrollee incurs no greater
24 out-of-pocket costs than the beneficiary, insured, or
25 enrollee would have incurred with a participating provider
26 unless the nonparticipating provider, or the participating
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1 health care facility on behalf of the nonparticipating
2 provider, satisfies the notice and consent criteria
3 provided in 42 U.S.C. 300gg-132 and regulations
4 promulgated thereunder. If the notice and consent criteria
5 are not satisfied, then:
6 (A) any cost-sharing requirements shall be applied
7 as though the health care services had been received
8 from a participating provider;
9 (B) cost sharing shall be calculated based on the
10 recognized amount for the health care services; and
11 (C) in no event shall the beneficiary, insured,
12 enrollee, or any group policyholder or plan sponsor be
13 liable to or billed by the health insurance issuer,
14 the nonparticipating provider, or the participating
15 health care facility for any amount beyond the cost
16 sharing calculated in accordance with this subsection
17 with respect to the health care services delivered.
18 (c) Notwithstanding any other provision of this Code,
19 except when the notice and consent criteria are satisfied for
20 the situation in paragraph (2) of subsection (b-5), any
21 benefits a beneficiary, insured, or enrollee receives for
22 services under the situations in subsection subsections (b) or
23 (b-5) are assigned to the nonparticipating providers or the
24 facility acting on their behalf. Upon receipt of the
25 provider's bill or facility's bill, the health insurance
26 issuer shall provide the nonparticipating provider or the
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1 facility with a written explanation of benefits that specifies
2 the proposed reimbursement and the applicable deductible,
3 copayment, or coinsurance amounts owed by the insured,
4 beneficiary, or enrollee. The health insurance issuer shall
5 pay any reimbursement subject to this Section directly to the
6 nonparticipating provider or the facility.
7 (d) For bills assigned under subsection (c), the
8 nonparticipating provider or the facility may bill the health
9 insurance issuer for the services rendered, and the health
10 insurance issuer may pay the billed amount or attempt to
11 negotiate reimbursement with the nonparticipating provider or
12 the facility. Within 30 calendar days after the provider or
13 facility transmits the bill to the health insurance issuer,
14 the issuer shall send an initial payment or notice of denial of
15 payment with the written explanation of benefits to the
16 provider or facility. If attempts to negotiate reimbursement
17 for services provided by a nonparticipating provider do not
18 result in a resolution of the payment dispute within 30 days
19 after receipt of written explanation of benefits by the health
20 insurance issuer, then the health insurance issuer or
21 nonparticipating provider or the facility may initiate binding
22 arbitration to determine payment for services provided on a
23 per-bill per bill basis. The party requesting arbitration
24 shall notify the other party arbitration has been initiated
25 and state its final offer before arbitration. In response to
26 this notice, the nonrequesting party shall inform the
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1 requesting party of its final offer before the arbitration
2 occurs. Arbitration shall be initiated by filing a request
3 with the Department of Insurance. For any bill submitted to
4 arbitration, the health insurance issuer shall pay the
5 provider or facility at least the current Medicare
6 reimbursement rate pending the resolution of the arbitration.
7 (e) The Department of Insurance shall publish a list of
8 approved arbitrators or entities that shall provide binding
9 arbitration. These arbitrators shall be American Arbitration
10 Association or American Health Lawyers Association trained
11 arbitrators. Both parties must agree on an arbitrator from the
12 Department of Insurance's or its approved entity's list of
13 arbitrators. If no agreement can be reached, then a list of 5
14 arbitrators shall be provided by the Department of Insurance
15 or the approved entity. From the list of 5 arbitrators, the
16 health insurance issuer can veto 2 arbitrators and the
17 provider or facility can veto 2 arbitrators. The remaining
18 arbitrator shall be the chosen arbitrator. This arbitration
19 shall consist of a review of the written submissions by both
20 parties. The arbitrator shall not establish a rebuttable
21 presumption that the qualifying payment amount should be the
22 total amount owed to the provider or facility by the
23 combination of the issuer and the insured, beneficiary, or
24 enrollee. Binding arbitration shall provide for a written
25 decision within 45 days after the request is filed with the
26 Department of Insurance. Both parties shall be bound by the
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1 arbitrator's decision. The arbitrator's expenses and fees,
2 together with other expenses, not including attorney's fees,
3 incurred in the conduct of the arbitration, shall be paid as
4 provided in the decision.
5 (f) (Blank).
6 (g) Section 368a of this Act shall not apply during the
7 pendency of a decision under subsection (d). Upon the issuance
8 of the arbitrator's decision, Section 368a applies with
9 respect to the amount, if any, by which the arbitrator's
10 determination exceeds the issuer's initial payment under
11 subsection (c), or the entire amount of the arbitrator's
12 determination if initial payment was denied. Any interest
13 required to be paid to a provider under Section 368a shall not
14 accrue until after 30 days of an arbitrator's decision as
15 provided in subsection (d), but in no circumstances longer
16 than 150 days from the date the nonparticipating
17 facility-based provider billed for services rendered.
18 (h) Nothing in this Section shall be interpreted to change
19 the prudent layperson provisions with respect to emergency
20 services under the Managed Care Reform and Patient Rights Act.
21 (i) Nothing in this Section shall preclude a health care
22 provider from billing a beneficiary, insured, or enrollee for
23 reasonable administrative fees, such as service fees for
24 checks returned for nonsufficient funds and missed
25 appointments.
26 (j) Nothing in this Section shall preclude a beneficiary,
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1 insured, or enrollee from assigning benefits to a
2 nonparticipating provider when the notice and consent criteria
3 are satisfied under paragraph (2) of subsection (b-5) or in
4 any other situation not described in subsection subsections
5 (b) or (b-5).
6 (k) Except when the notice and consent criteria are
7 satisfied under paragraph (2) of subsection (b-5), if an
8 individual receives health care services under the situations
9 described in subsection subsections (b) or (b-5), no referral
10 requirement or any other provision contained in the policy or
11 certificate of coverage shall deny coverage, reduce benefits,
12 or otherwise defeat the requirements of this Section for
13 services that would have been covered with a participating
14 provider. However, this subsection shall not be construed to
15 preclude a provider contract with a health insurance issuer,
16 or with an administrator or similar entity acting on the
17 issuer's behalf, from imposing requirements on the
18 participating provider, participating emergency facility, or
19 participating health care facility relating to the referral of
20 covered individuals to nonparticipating providers.
21 (l) Except if the notice and consent criteria are
22 satisfied under paragraph (2) of subsection (b-5),
23 cost-sharing amounts calculated in conformity with this
24 Section shall count toward any deductible or out-of-pocket
25 maximum applicable to in-network coverage.
26 (m) The Department has the authority to enforce the
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1 requirements of this Section in the situations described in
2 subsections (b) and (b-5), and in any other situation for
3 which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
4 regulations promulgated thereunder would prohibit an
5 individual from being billed or liable for emergency services
6 furnished by a nonparticipating provider or nonparticipating
7 emergency facility or for non-emergency health care services
8 furnished by a nonparticipating provider at a participating
9 health care facility.
10 (n) This Section does not apply with respect to air
11 ambulance or ground ambulance services. This Section does not
12 apply to any policy of excepted benefits or to short-term,
13 limited-duration health insurance coverage.
14 (Source: P.A. 102-901, eff. 7-1-22; revised 8-19-22.)
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