Illinois 2023-2024 Regular Session

Illinois House Bill HB2581 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	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
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2581 Introduced , by Rep. William E Hauter SYNOPSIS AS INTRODUCED:
3	3	215 ILCS 5/356z.3a 215 ILCS 5/356z.3a
4	4	215 ILCS 5/356z.3a
5	5	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.
6	6	LRB103 06011 BMS 51564 b LRB103 06011 BMS 51564 b
7	7	LRB103 06011 BMS 51564 b
8	8	A BILL FOR
9	9	HB2581LRB103 06011 BMS 51564 b HB2581 LRB103 06011 BMS 51564 b
10	10	HB2581 LRB103 06011 BMS 51564 b
11	11	1 AN ACT concerning regulation.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Insurance Code is amended by
15	15	5 changing Section 356z.3a as follows:
16	16	6 (215 ILCS 5/356z.3a)
17	17	7 Sec. 356z.3a. Billing; emergency services;
18	18	8 nonparticipating providers.
19	19	9 (a) As used in this Section:
20	20	10 "Ancillary services" means:
21	21	11 (1) items and services related to emergency medicine,
22	22	12 anesthesiology, pathology, radiology, and neonatology that
23	23	13 are provided by any health care provider;
24	24	14 (2) items and services provided by assistant surgeons,
25	25	15 hospitalists, and intensivists;
26	26	16 (3) diagnostic services, including radiology and
27	27	17 laboratory services, except for advanced diagnostic
28	28	18 laboratory tests identified on the most current list
29	29	19 published by the United States Secretary of Health and
30	30	20 Human Services under 42 U.S.C. 300gg-132(b)(3);
31	31	21 (4) items and services provided by other specialty
32	32	22 practitioners as the United States Secretary of Health and
33	33	23 Human Services specifies through rulemaking under 42
34	34
35	35
36	36
37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB2581 Introduced , by Rep. William E Hauter SYNOPSIS AS INTRODUCED:
38	38	215 ILCS 5/356z.3a 215 ILCS 5/356z.3a
39	39	215 ILCS 5/356z.3a
40	40	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.
41	41	LRB103 06011 BMS 51564 b LRB103 06011 BMS 51564 b
42	42	LRB103 06011 BMS 51564 b
43	43	A BILL FOR
44	44
45	45
46	46
47	47
48	48
49	49	215 ILCS 5/356z.3a
50	50
51	51
52	52
53	53	LRB103 06011 BMS 51564 b
54	54
55	55
56	56
57	57
58	58
59	59
60	60
61	61
62	62
63	63	HB2581 LRB103 06011 BMS 51564 b
64	64
65	65
66	66	HB2581- 2 -LRB103 06011 BMS 51564 b HB2581 - 2 - LRB103 06011 BMS 51564 b
67	67	HB2581 - 2 - LRB103 06011 BMS 51564 b
68	68	1 U.S.C. 300gg-132(b)(3); and
69	69	2 (5) items and services provided by a nonparticipating
70	70	3 provider if there is no participating provider who can
71	71	4 furnish the item or service at the facility.
72	72	5 "Cost sharing" means the amount an insured, beneficiary,
73	73	6 or enrollee is responsible for paying for a covered item or
74	74	7 service under the terms of the policy or certificate. "Cost
75	75	8 sharing" includes copayments, coinsurance, and amounts paid
76	76	9 toward deductibles, but does not include amounts paid towards
77	77	10 premiums, balance billing by out-of-network providers, or the
78	78	11 cost of items or services that are not covered under the policy
79	79	12 or certificate.
80	80	13 "Emergency department of a hospital" means any hospital
81	81	14 department that provides emergency services, including a
82	82	15 hospital outpatient department.
83	83	16 "Emergency medical condition" has the meaning ascribed to
84	84	17 that term in Section 10 of the Managed Care Reform and Patient
85	85	18 Rights Act.
86	86	19 "Emergency medical screening examination" has the meaning
87	87	20 ascribed to that term in Section 10 of the Managed Care Reform
88	88	21 and Patient Rights Act.
89	89	22 "Emergency services" means, with respect to an emergency
90	90	23 medical condition:
91	91	24 (1) in general, an emergency medical screening
92	92	25 examination, including ancillary services routinely
93	93	26 available to the emergency department to evaluate such
94	94
95	95
96	96
97	97
98	98
99	99	HB2581 - 2 - LRB103 06011 BMS 51564 b
100	100
101	101
102	102	HB2581- 3 -LRB103 06011 BMS 51564 b HB2581 - 3 - LRB103 06011 BMS 51564 b
103	103	HB2581 - 3 - LRB103 06011 BMS 51564 b
104	104	1 emergency medical condition, and such further medical
105	105	2 examination and treatment as would be required to
106	106	3 stabilize the patient regardless of the department of the
107	107	4 hospital or other facility in which such further
108	108	5 examination or treatment is furnished; or
109	109	6 (2) additional items and services for which benefits
110	110	7 are provided or covered under the coverage and that are
111	111	8 furnished by a nonparticipating provider or
112	112	9 nonparticipating emergency facility regardless of the
113	113	10 department of the hospital or other facility in which such
114	114	11 items are furnished after the insured, beneficiary, or
115	115	12 enrollee is stabilized and as part of outpatient
116	116	13 observation or an inpatient or outpatient stay with
117	117	14 respect to the visit in which the services described in
118	118	15 paragraph (1) are furnished. Services after stabilization
119	119	16 cease to be emergency services only when all the
120	120	17 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
121	121	18 regulations thereunder are met.
122	122	19 "Freestanding Emergency Center" means a facility licensed
123	123	20 under Section 32.5 of the Emergency Medical Services (EMS)
124	124	21 Systems Act.
125	125	22 "Health care facility" means, in the context of
126	126	23 non-emergency services, any of the following:
127	127	24 (1) a hospital as defined in 42 U.S.C. 1395x(e);
128	128	25 (2) a hospital outpatient department;
129	129	26 (3) a critical access hospital certified under 42
130	130
131	131
132	132
133	133
134	134
135	135	HB2581 - 3 - LRB103 06011 BMS 51564 b
136	136
137	137
138	138	HB2581- 4 -LRB103 06011 BMS 51564 b HB2581 - 4 - LRB103 06011 BMS 51564 b
139	139	HB2581 - 4 - LRB103 06011 BMS 51564 b
140	140	1 U.S.C. 1395i-4(e);
141	141	2 (4) an ambulatory surgical treatment center as defined
142	142	3 in the Ambulatory Surgical Treatment Center Act; or
143	143	4 (5) any recipient of a license under the Hospital
144	144	5 Licensing Act that is not otherwise described in this
145	145	6 definition.
146	146	7 "Health care provider" means a provider as defined in
147	147	8 subsection (d) of Section 370g. "Health care provider" does
148	148	9 not include a provider of air ambulance or ground ambulance
149	149	10 services.
150	150	11 "Health care services" has the meaning ascribed to that
151	151	12 term in subsection (a) of Section 370g.
152	152	13 "Health insurance issuer" has the meaning ascribed to that
153	153	14 term in Section 5 of the Illinois Health Insurance Portability
154	154	15 and Accountability Act.
155	155	16 "Nonparticipating emergency facility" means, with respect
156	156	17 to the furnishing of an item or service under a policy of group
157	157	18 or individual health insurance coverage, any of the following
158	158	19 facilities that does not have a contractual relationship
159	159	20 directly or indirectly with a health insurance issuer in
160	160	21 relation to the coverage:
161	161	22 (1) an emergency department of a hospital;
162	162	23 (2) a Freestanding Emergency Center;
163	163	24 (3) an ambulatory surgical treatment center as defined
164	164	25 in the Ambulatory Surgical Treatment Center Act; or
165	165	26 (4) with respect to emergency services described in
166	166
167	167
168	168
169	169
170	170
171	171	HB2581 - 4 - LRB103 06011 BMS 51564 b
172	172
173	173
174	174	HB2581- 5 -LRB103 06011 BMS 51564 b HB2581 - 5 - LRB103 06011 BMS 51564 b
175	175	HB2581 - 5 - LRB103 06011 BMS 51564 b
176	176	1 paragraph (2) of the definition of "emergency services", a
177	177	2 hospital.
178	178	3 "Nonparticipating provider" means, with respect to the
179	179	4 furnishing of an item or service under a policy of group or
180	180	5 individual health insurance coverage, any health care provider
181	181	6 who does not have a contractual relationship directly or
182	182	7 indirectly with a health insurance issuer in relation to the
183	183	8 coverage.
184	184	9 "Participating emergency facility" means any of the
185	185	10 following facilities that has a contractual relationship
186	186	11 directly or indirectly with a health insurance issuer offering
187	187	12 group or individual health insurance coverage setting forth
188	188	13 the terms and conditions on which a relevant health care
189	189	14 service is provided to an insured, beneficiary, or enrollee
190	190	15 under the coverage:
191	191	16 (1) an emergency department of a hospital;
192	192	17 (2) a Freestanding Emergency Center;
193	193	18 (3) an ambulatory surgical treatment center as defined
194	194	19 in the Ambulatory Surgical Treatment Center Act; or
195	195	20 (4) with respect to emergency services described in
196	196	21 paragraph (2) of the definition of "emergency services", a
197	197	22 hospital.
198	198	23 For purposes of this definition, a single case agreement
199	199	24 between an emergency facility and an issuer that is used to
200	200	25 address unique situations in which an insured, beneficiary, or
201	201	26 enrollee requires services that typically occur out-of-network
202	202
203	203
204	204
205	205
206	206
207	207	HB2581 - 5 - LRB103 06011 BMS 51564 b
208	208
209	209
210	210	HB2581- 6 -LRB103 06011 BMS 51564 b HB2581 - 6 - LRB103 06011 BMS 51564 b
211	211	HB2581 - 6 - LRB103 06011 BMS 51564 b
212	212	1 constitutes a contractual relationship and is limited to the
213	213	2 parties to the agreement.
214	214	3 "Participating health care facility" means any health care
215	215	4 facility that has a contractual relationship directly or
216	216	5 indirectly with a health insurance issuer offering group or
217	217	6 individual health insurance coverage setting forth the terms
218	218	7 and conditions on which a relevant health care service is
219	219	8 provided to an insured, beneficiary, or enrollee under the
220	220	9 coverage. A single case agreement between an emergency
221	221	10 facility and an issuer that is used to address unique
222	222	11 situations in which an insured, beneficiary, or enrollee
223	223	12 requires services that typically occur out-of-network
224	224	13 constitutes a contractual relationship for purposes of this
225	225	14 definition and is limited to the parties to the agreement.
226	226	15 "Participating provider" means any health care provider
227	227	16 that has a contractual relationship directly or indirectly
228	228	17 with a health insurance issuer offering group or individual
229	229	18 health insurance coverage setting forth the terms and
230	230	19 conditions on which a relevant health care service is provided
231	231	20 to an insured, beneficiary, or enrollee under the coverage.
232	232	21 "Qualifying payment amount" has the meaning given to that
233	233	22 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
234	234	23 promulgated thereunder.
235	235	24 "Recognized amount" means the lesser of the amount
236	236	25 initially billed by the provider or the qualifying payment
237	237	26 amount.
238	238
239	239
240	240
241	241
242	242
243	243	HB2581 - 6 - LRB103 06011 BMS 51564 b
244	244
245	245
246	246	HB2581- 7 -LRB103 06011 BMS 51564 b HB2581 - 7 - LRB103 06011 BMS 51564 b
247	247	HB2581 - 7 - LRB103 06011 BMS 51564 b
248	248	1 "Stabilize" means "stabilization" as defined in Section 10
249	249	2 of the Managed Care Reform and Patient Rights Act.
250	250	3 "Treating provider" means a health care provider who has
251	251	4 evaluated the individual.
252	252	5 "Visit" means, with respect to health care services
253	253	6 furnished to an individual at a health care facility, health
254	254	7 care services furnished by a provider at the facility, as well
255	255	8 as equipment, devices, telehealth services, imaging services,
256	256	9 laboratory services, and preoperative and postoperative
257	257	10 services regardless of whether the provider furnishing such
258	258	11 services is at the facility.
259	259	12 (b) Emergency services. When a beneficiary, insured, or
260	260	13 enrollee receives emergency services from a nonparticipating
261	261	14 provider or a nonparticipating emergency facility, the health
262	262	15 insurance issuer shall ensure that the beneficiary, insured,
263	263	16 or enrollee shall incur no greater out-of-pocket costs than
264	264	17 the beneficiary, insured, or enrollee would have incurred with
265	265	18 a participating provider or a participating emergency
266	266	19 facility. Any cost-sharing requirements shall be applied as
267	267	20 though the emergency services had been received from a
268	268	21 participating provider or a participating facility. Cost
269	269	22 sharing shall be calculated based on the recognized amount for
270	270	23 the emergency services. If the cost sharing for the same item
271	271	24 or service furnished by a participating provider would have
272	272	25 been a flat-dollar copayment, that amount shall be the
273	273	26 cost-sharing amount unless the provider has billed a lesser
274	274
275	275
276	276
277	277
278	278
279	279	HB2581 - 7 - LRB103 06011 BMS 51564 b
280	280
281	281
282	282	HB2581- 8 -LRB103 06011 BMS 51564 b HB2581 - 8 - LRB103 06011 BMS 51564 b
283	283	HB2581 - 8 - LRB103 06011 BMS 51564 b
284	284	1 total amount. In no event shall the beneficiary, insured,
285	285	2 enrollee, or any group policyholder or plan sponsor be liable
286	286	3 to or billed by the health insurance issuer, the
287	287	4 nonparticipating provider, or the nonparticipating emergency
288	288	5 facility for any amount beyond the cost sharing calculated in
289	289	6 accordance with this subsection with respect to the emergency
290	290	7 services delivered. Administrative requirements or limitations
291	291	8 shall be no greater than those applicable to emergency
292	292	9 services received from a participating provider or a
293	293	10 participating emergency facility.
294	294	11 (b-5) Non-emergency services at participating health care
295	295	12 facilities.
296	296	13 (1) When a beneficiary, insured, or enrollee utilizes
297	297	14 a participating health care facility and, due to any
298	298	15 reason, covered ancillary services are provided by a
299	299	16 nonparticipating provider during or resulting from the
300	300	17 visit, the health insurance issuer shall ensure that the
301	301	18 beneficiary, insured, or enrollee shall incur no greater
302	302	19 out-of-pocket costs than the beneficiary, insured, or
303	303	20 enrollee would have incurred with a participating provider
304	304	21 for the ancillary services. Any cost-sharing requirements
305	305	22 shall be applied as though the ancillary services had been
306	306	23 received from a participating provider. Cost sharing shall
307	307	24 be calculated based on the recognized amount for the
308	308	25 ancillary services. If the cost sharing for the same item
309	309	26 or service furnished by a participating provider would
310	310
311	311
312	312
313	313
314	314
315	315	HB2581 - 8 - LRB103 06011 BMS 51564 b
316	316
317	317
318	318	HB2581- 9 -LRB103 06011 BMS 51564 b HB2581 - 9 - LRB103 06011 BMS 51564 b
319	319	HB2581 - 9 - LRB103 06011 BMS 51564 b
320	320	1 have been a flat-dollar copayment, that amount shall be
321	321	2 the cost-sharing amount unless the provider has billed a
322	322	3 lesser total amount. In no event shall the beneficiary,
323	323	4 insured, enrollee, or any group policyholder or plan
324	324	5 sponsor be liable to or billed by the health insurance
325	325	6 issuer, the nonparticipating provider, or the
326	326	7 participating health care facility for any amount beyond
327	327	8 the cost sharing calculated in accordance with this
328	328	9 subsection with respect to the ancillary services
329	329	10 delivered. In addition to ancillary services, the
330	330	11 requirements of this paragraph shall also apply with
331	331	12 respect to covered items or services furnished as a result
332	332	13 of unforeseen, urgent medical needs that arise at the time
333	333	14 an item or service is furnished, regardless of whether the
334	334	15 nonparticipating provider satisfied the notice and consent
335	335	16 criteria under paragraph (2) of this subsection.
336	336	17 (2) When a beneficiary, insured, or enrollee utilizes
337	337	18 a participating health care facility and receives
338	338	19 non-emergency covered health care services other than
339	339	20 those described in paragraph (1) of this subsection from a
340	340	21 nonparticipating provider during or resulting from the
341	341	22 visit, the health insurance issuer shall ensure that the
342	342	23 beneficiary, insured, or enrollee incurs no greater
343	343	24 out-of-pocket costs than the beneficiary, insured, or
344	344	25 enrollee would have incurred with a participating provider
345	345	26 unless the nonparticipating provider, or the participating
346	346
347	347
348	348
349	349
350	350
351	351	HB2581 - 9 - LRB103 06011 BMS 51564 b
352	352
353	353
354	354	HB2581- 10 -LRB103 06011 BMS 51564 b HB2581 - 10 - LRB103 06011 BMS 51564 b
355	355	HB2581 - 10 - LRB103 06011 BMS 51564 b
356	356	1 health care facility on behalf of the nonparticipating
357	357	2 provider, satisfies the notice and consent criteria
358	358	3 provided in 42 U.S.C. 300gg-132 and regulations
359	359	4 promulgated thereunder. If the notice and consent criteria
360	360	5 are not satisfied, then:
361	361	6 (A) any cost-sharing requirements shall be applied
362	362	7 as though the health care services had been received
363	363	8 from a participating provider;
364	364	9 (B) cost sharing shall be calculated based on the
365	365	10 recognized amount for the health care services; and
366	366	11 (C) in no event shall the beneficiary, insured,
367	367	12 enrollee, or any group policyholder or plan sponsor be
368	368	13 liable to or billed by the health insurance issuer,
369	369	14 the nonparticipating provider, or the participating
370	370	15 health care facility for any amount beyond the cost
371	371	16 sharing calculated in accordance with this subsection
372	372	17 with respect to the health care services delivered.
373	373	18 (c) Notwithstanding any other provision of this Code,
374	374	19 except when the notice and consent criteria are satisfied for
375	375	20 the situation in paragraph (2) of subsection (b-5), any
376	376	21 benefits a beneficiary, insured, or enrollee receives for
377	377	22 services under the situations in subsection subsections (b) or
378	378	23 (b-5) are assigned to the nonparticipating providers or the
379	379	24 facility acting on their behalf. Upon receipt of the
380	380	25 provider's bill or facility's bill, the health insurance
381	381	26 issuer shall provide the nonparticipating provider or the
382	382
383	383
384	384
385	385
386	386
387	387	HB2581 - 10 - LRB103 06011 BMS 51564 b
388	388
389	389
390	390	HB2581- 11 -LRB103 06011 BMS 51564 b HB2581 - 11 - LRB103 06011 BMS 51564 b
391	391	HB2581 - 11 - LRB103 06011 BMS 51564 b
392	392	1 facility with a written explanation of benefits that specifies
393	393	2 the proposed reimbursement and the applicable deductible,
394	394	3 copayment, or coinsurance amounts owed by the insured,
395	395	4 beneficiary, or enrollee. The health insurance issuer shall
396	396	5 pay any reimbursement subject to this Section directly to the
397	397	6 nonparticipating provider or the facility.
398	398	7 (d) For bills assigned under subsection (c), the
399	399	8 nonparticipating provider or the facility may bill the health
400	400	9 insurance issuer for the services rendered, and the health
401	401	10 insurance issuer may pay the billed amount or attempt to
402	402	11 negotiate reimbursement with the nonparticipating provider or
403	403	12 the facility. Within 30 calendar days after the provider or
404	404	13 facility transmits the bill to the health insurance issuer,
405	405	14 the issuer shall send an initial payment or notice of denial of
406	406	15 payment with the written explanation of benefits to the
407	407	16 provider or facility. If attempts to negotiate reimbursement
408	408	17 for services provided by a nonparticipating provider do not
409	409	18 result in a resolution of the payment dispute within 30 days
410	410	19 after receipt of written explanation of benefits by the health
411	411	20 insurance issuer, then the health insurance issuer or
412	412	21 nonparticipating provider or the facility may initiate binding
413	413	22 arbitration to determine payment for services provided on a
414	414	23 per-bill per bill basis. The party requesting arbitration
415	415	24 shall notify the other party arbitration has been initiated
416	416	25 and state its final offer before arbitration. In response to
417	417	26 this notice, the nonrequesting party shall inform the
418	418
419	419
420	420
421	421
422	422
423	423	HB2581 - 11 - LRB103 06011 BMS 51564 b
424	424
425	425
426	426	HB2581- 12 -LRB103 06011 BMS 51564 b HB2581 - 12 - LRB103 06011 BMS 51564 b
427	427	HB2581 - 12 - LRB103 06011 BMS 51564 b
428	428	1 requesting party of its final offer before the arbitration
429	429	2 occurs. Arbitration shall be initiated by filing a request
430	430	3 with the Department of Insurance. For any bill submitted to
431	431	4 arbitration, the health insurance issuer shall pay the
432	432	5 provider or facility at least the current Medicare
433	433	6 reimbursement rate pending the resolution of the arbitration.
434	434	7 (e) The Department of Insurance shall publish a list of
435	435	8 approved arbitrators or entities that shall provide binding
436	436	9 arbitration. These arbitrators shall be American Arbitration
437	437	10 Association or American Health Lawyers Association trained
438	438	11 arbitrators. Both parties must agree on an arbitrator from the
439	439	12 Department of Insurance's or its approved entity's list of
440	440	13 arbitrators. If no agreement can be reached, then a list of 5
441	441	14 arbitrators shall be provided by the Department of Insurance
442	442	15 or the approved entity. From the list of 5 arbitrators, the
443	443	16 health insurance issuer can veto 2 arbitrators and the
444	444	17 provider or facility can veto 2 arbitrators. The remaining
445	445	18 arbitrator shall be the chosen arbitrator. This arbitration
446	446	19 shall consist of a review of the written submissions by both
447	447	20 parties. The arbitrator shall not establish a rebuttable
448	448	21 presumption that the qualifying payment amount should be the
449	449	22 total amount owed to the provider or facility by the
450	450	23 combination of the issuer and the insured, beneficiary, or
451	451	24 enrollee. Binding arbitration shall provide for a written
452	452	25 decision within 45 days after the request is filed with the
453	453	26 Department of Insurance. Both parties shall be bound by the
454	454
455	455
456	456
457	457
458	458
459	459	HB2581 - 12 - LRB103 06011 BMS 51564 b
460	460
461	461
462	462	HB2581- 13 -LRB103 06011 BMS 51564 b HB2581 - 13 - LRB103 06011 BMS 51564 b
463	463	HB2581 - 13 - LRB103 06011 BMS 51564 b
464	464	1 arbitrator's decision. The arbitrator's expenses and fees,
465	465	2 together with other expenses, not including attorney's fees,
466	466	3 incurred in the conduct of the arbitration, shall be paid as
467	467	4 provided in the decision.
468	468	5 (f) (Blank).
469	469	6 (g) Section 368a of this Act shall not apply during the
470	470	7 pendency of a decision under subsection (d). Upon the issuance
471	471	8 of the arbitrator's decision, Section 368a applies with
472	472	9 respect to the amount, if any, by which the arbitrator's
473	473	10 determination exceeds the issuer's initial payment under
474	474	11 subsection (c), or the entire amount of the arbitrator's
475	475	12 determination if initial payment was denied. Any interest
476	476	13 required to be paid to a provider under Section 368a shall not
477	477	14 accrue until after 30 days of an arbitrator's decision as
478	478	15 provided in subsection (d), but in no circumstances longer
479	479	16 than 150 days from the date the nonparticipating
480	480	17 facility-based provider billed for services rendered.
481	481	18 (h) Nothing in this Section shall be interpreted to change
482	482	19 the prudent layperson provisions with respect to emergency
483	483	20 services under the Managed Care Reform and Patient Rights Act.
484	484	21 (i) Nothing in this Section shall preclude a health care
485	485	22 provider from billing a beneficiary, insured, or enrollee for
486	486	23 reasonable administrative fees, such as service fees for
487	487	24 checks returned for nonsufficient funds and missed
488	488	25 appointments.
489	489	26 (j) Nothing in this Section shall preclude a beneficiary,
490	490
491	491
492	492
493	493
494	494
495	495	HB2581 - 13 - LRB103 06011 BMS 51564 b
496	496
497	497
498	498	HB2581- 14 -LRB103 06011 BMS 51564 b HB2581 - 14 - LRB103 06011 BMS 51564 b
499	499	HB2581 - 14 - LRB103 06011 BMS 51564 b
500	500	1 insured, or enrollee from assigning benefits to a
501	501	2 nonparticipating provider when the notice and consent criteria
502	502	3 are satisfied under paragraph (2) of subsection (b-5) or in
503	503	4 any other situation not described in subsection subsections
504	504	5 (b) or (b-5).
505	505	6 (k) Except when the notice and consent criteria are
506	506	7 satisfied under paragraph (2) of subsection (b-5), if an
507	507	8 individual receives health care services under the situations
508	508	9 described in subsection subsections (b) or (b-5), no referral
509	509	10 requirement or any other provision contained in the policy or
510	510	11 certificate of coverage shall deny coverage, reduce benefits,
511	511	12 or otherwise defeat the requirements of this Section for
512	512	13 services that would have been covered with a participating
513	513	14 provider. However, this subsection shall not be construed to
514	514	15 preclude a provider contract with a health insurance issuer,
515	515	16 or with an administrator or similar entity acting on the
516	516	17 issuer's behalf, from imposing requirements on the
517	517	18 participating provider, participating emergency facility, or
518	518	19 participating health care facility relating to the referral of
519	519	20 covered individuals to nonparticipating providers.
520	520	21 (l) Except if the notice and consent criteria are
521	521	22 satisfied under paragraph (2) of subsection (b-5),
522	522	23 cost-sharing amounts calculated in conformity with this
523	523	24 Section shall count toward any deductible or out-of-pocket
524	524	25 maximum applicable to in-network coverage.
525	525	26 (m) The Department has the authority to enforce the
526	526
527	527
528	528
529	529
530	530
531	531	HB2581 - 14 - LRB103 06011 BMS 51564 b
532	532
533	533
534	534	HB2581- 15 -LRB103 06011 BMS 51564 b HB2581 - 15 - LRB103 06011 BMS 51564 b
535	535	HB2581 - 15 - LRB103 06011 BMS 51564 b
536	536	1 requirements of this Section in the situations described in
537	537	2 subsections (b) and (b-5), and in any other situation for
538	538	3 which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
539	539	4 regulations promulgated thereunder would prohibit an
540	540	5 individual from being billed or liable for emergency services
541	541	6 furnished by a nonparticipating provider or nonparticipating
542	542	7 emergency facility or for non-emergency health care services
543	543	8 furnished by a nonparticipating provider at a participating
544	544	9 health care facility.
545	545	10 (n) This Section does not apply with respect to air
546	546	11 ambulance or ground ambulance services. This Section does not
547	547	12 apply to any policy of excepted benefits or to short-term,
548	548	13 limited-duration health insurance coverage.
549	549	14 (Source: P.A. 102-901, eff. 7-1-22; revised 8-19-22.)
550	550
551	551
552	552
553	553
554	554
555	555	HB2581 - 15 - LRB103 06011 BMS 51564 b