Illinois 2023-2024 Regular Session

Illinois House Bill HB3030 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	Public Act 103-0440
2	1		HB3030 EnrolledLRB103 05013 BMS 56587 b HB3030 Enrolled LRB103 05013 BMS 56587 b
3	2		HB3030 Enrolled LRB103 05013 BMS 56587 b
4		-	AN ACT concerning regulation.
5		-	Be it enacted by the People of the State of Illinois,
6		-	represented in the General Assembly:
7		-	Section 5. The Illinois Insurance Code is amended by
8		-	changing Section 356z.3a as follows:
9		-	(215 ILCS 5/356z.3a)
10		-	Sec. 356z.3a. Billing; emergency services;
11		-	nonparticipating providers.
12		-	(a) As used in this Section:
13		-	"Ancillary services" means:
14		-	(1) items and services related to emergency medicine,
15		-	anesthesiology, pathology, radiology, and neonatology that
16		-	are provided by any health care provider;
17		-	(2) items and services provided by assistant surgeons,
18		-	hospitalists, and intensivists;
19		-	(3) diagnostic services, including radiology and
20		-	laboratory services, except for advanced diagnostic
21		-	laboratory tests identified on the most current list
22		-	published by the United States Secretary of Health and
23		-	Human Services under 42 U.S.C. 300gg-132(b)(3);
24		-	(4) items and services provided by other specialty
25		-	practitioners as the United States Secretary of Health and
26		-	Human Services specifies through rulemaking under 42
	3	+	1 AN ACT concerning regulation.
	4	+	2 Be it enacted by the People of the State of Illinois,
	5	+	3 represented in the General Assembly:
	6	+	4 Section 5. The Illinois Insurance Code is amended by
	7	+	5 changing Section 356z.3a as follows:
	8	+	6 (215 ILCS 5/356z.3a)
	9	+	7 Sec. 356z.3a. Billing; emergency services;
	10	+	8 nonparticipating providers.
	11	+	9 (a) As used in this Section:
	12	+	10 "Ancillary services" means:
	13	+	11 (1) items and services related to emergency medicine,
	14	+	12 anesthesiology, pathology, radiology, and neonatology that
	15	+	13 are provided by any health care provider;
	16	+	14 (2) items and services provided by assistant surgeons,
	17	+	15 hospitalists, and intensivists;
	18	+	16 (3) diagnostic services, including radiology and
	19	+	17 laboratory services, except for advanced diagnostic
	20	+	18 laboratory tests identified on the most current list
	21	+	19 published by the United States Secretary of Health and
	22	+	20 Human Services under 42 U.S.C. 300gg-132(b)(3);
	23	+	21 (4) items and services provided by other specialty
	24	+	22 practitioners as the United States Secretary of Health and
	25	+	23 Human Services specifies through rulemaking under 42
27	26
28	27
29	28
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31	30
32	31
33		-	U.S.C. 300gg-132(b)(3);
34		-	(5) items and services provided by a nonparticipating
35		-	provider if there is no participating provider who can
36		-	furnish the item or service at the facility; and
37		-	(6) items and services provided by a nonparticipating
38		-	provider if there is no participating provider who will
39		-	furnish the item or service because a participating
40		-	provider has asserted the participating provider's rights
41		-	under the Health Care Right of Conscience Act.
42		-	"Cost sharing" means the amount an insured, beneficiary,
43		-	or enrollee is responsible for paying for a covered item or
44		-	service under the terms of the policy or certificate. "Cost
45		-	sharing" includes copayments, coinsurance, and amounts paid
46		-	toward deductibles, but does not include amounts paid towards
47		-	premiums, balance billing by out-of-network providers, or the
48		-	cost of items or services that are not covered under the policy
49		-	or certificate.
50		-	"Emergency department of a hospital" means any hospital
51		-	department that provides emergency services, including a
52		-	hospital outpatient department.
53		-	"Emergency medical condition" has the meaning ascribed to
54		-	that term in Section 10 of the Managed Care Reform and Patient
55		-	Rights Act.
56		-	"Emergency medical screening examination" has the meaning
57		-	ascribed to that term in Section 10 of the Managed Care Reform
58		-	and Patient Rights Act.
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	34	+	1 U.S.C. 300gg-132(b)(3);
	35	+	2 (5) items and services provided by a nonparticipating
	36	+	3 provider if there is no participating provider who can
	37	+	4 furnish the item or service at the facility; and
	38	+	5 (6) items and services provided by a nonparticipating
	39	+	6 provider if there is no participating provider who will
	40	+	7 furnish the item or service because a participating
	41	+	8 provider has asserted the participating provider's rights
	42	+	9 under the Health Care Right of Conscience Act.
	43	+	10 "Cost sharing" means the amount an insured, beneficiary,
	44	+	11 or enrollee is responsible for paying for a covered item or
	45	+	12 service under the terms of the policy or certificate. "Cost
	46	+	13 sharing" includes copayments, coinsurance, and amounts paid
	47	+	14 toward deductibles, but does not include amounts paid towards
	48	+	15 premiums, balance billing by out-of-network providers, or the
	49	+	16 cost of items or services that are not covered under the policy
	50	+	17 or certificate.
	51	+	18 "Emergency department of a hospital" means any hospital
	52	+	19 department that provides emergency services, including a
	53	+	20 hospital outpatient department.
	54	+	21 "Emergency medical condition" has the meaning ascribed to
	55	+	22 that term in Section 10 of the Managed Care Reform and Patient
	56	+	23 Rights Act.
	57	+	24 "Emergency medical screening examination" has the meaning
	58	+	25 ascribed to that term in Section 10 of the Managed Care Reform
	59	+	26 and Patient Rights Act.
59	60
60	61
61		-	"Emergency services" means, with respect to an emergency
62		-	medical condition:
63		-	(1) in general, an emergency medical screening
64		-	examination, including ancillary services routinely
65		-	available to the emergency department to evaluate such
66		-	emergency medical condition, and such further medical
67		-	examination and treatment as would be required to
68		-	stabilize the patient regardless of the department of the
69		-	hospital or other facility in which such further
70		-	examination or treatment is furnished; or
71		-	(2) additional items and services for which benefits
72		-	are provided or covered under the coverage and that are
73		-	furnished by a nonparticipating provider or
74		-	nonparticipating emergency facility regardless of the
75		-	department of the hospital or other facility in which such
76		-	items are furnished after the insured, beneficiary, or
77		-	enrollee is stabilized and as part of outpatient
78		-	observation or an inpatient or outpatient stay with
79		-	respect to the visit in which the services described in
80		-	paragraph (1) are furnished. Services after stabilization
81		-	cease to be emergency services only when all the
82		-	conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
83		-	regulations thereunder are met.
84		-	"Freestanding Emergency Center" means a facility licensed
85		-	under Section 32.5 of the Emergency Medical Services (EMS)
86		-	Systems Act.
87	62
88	63
89		-	"Health care facility" means, in the context of
90		-	non-emergency services, any of the following:
91		-	(1) a hospital as defined in 42 U.S.C. 1395x(e);
92		-	(2) a hospital outpatient department;
93		-	(3) a critical access hospital certified under 42
94		-	U.S.C. 1395i-4(e);
95		-	(4) an ambulatory surgical treatment center as defined
96		-	in the Ambulatory Surgical Treatment Center Act; or
97		-	(5) any recipient of a license under the Hospital
98		-	Licensing Act that is not otherwise described in this
99		-	definition.
100		-	"Health care provider" means a provider as defined in
101		-	subsection (d) of Section 370g. "Health care provider" does
102		-	not include a provider of air ambulance or ground ambulance
103		-	services.
104		-	"Health care services" has the meaning ascribed to that
105		-	term in subsection (a) of Section 370g.
106		-	"Health insurance issuer" has the meaning ascribed to that
107		-	term in Section 5 of the Illinois Health Insurance Portability
108		-	and Accountability Act.
109		-	"Nonparticipating emergency facility" means, with respect
110		-	to the furnishing of an item or service under a policy of group
111		-	or individual health insurance coverage, any of the following
112		-	facilities that does not have a contractual relationship
113		-	directly or indirectly with a health insurance issuer in
114		-	relation to the coverage:
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116	67
117		-	(1) an emergency department of a hospital;
118		-	(2) a Freestanding Emergency Center;
119		-	(3) an ambulatory surgical treatment center as defined
120		-	in the Ambulatory Surgical Treatment Center Act; or
121		-	(4) with respect to emergency services described in
122		-	paragraph (2) of the definition of "emergency services", a
123		-	hospital.
124		-	"Nonparticipating provider" means, with respect to the
125		-	furnishing of an item or service under a policy of group or
126		-	individual health insurance coverage, any health care provider
127		-	who does not have a contractual relationship directly or
128		-	indirectly with a health insurance issuer in relation to the
129		-	coverage.
130		-	"Participating emergency facility" means any of the
131		-	following facilities that has a contractual relationship
132		-	directly or indirectly with a health insurance issuer offering
133		-	group or individual health insurance coverage setting forth
134		-	the terms and conditions on which a relevant health care
135		-	service is provided to an insured, beneficiary, or enrollee
136		-	under the coverage:
137		-	(1) an emergency department of a hospital;
138		-	(2) a Freestanding Emergency Center;
139		-	(3) an ambulatory surgical treatment center as defined
140		-	in the Ambulatory Surgical Treatment Center Act; or
141		-	(4) with respect to emergency services described in
142		-	paragraph (2) of the definition of "emergency services", a
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	70	+	1 "Emergency services" means, with respect to an emergency
	71	+	2 medical condition:
	72	+	3 (1) in general, an emergency medical screening
	73	+	4 examination, including ancillary services routinely
	74	+	5 available to the emergency department to evaluate such
	75	+	6 emergency medical condition, and such further medical
	76	+	7 examination and treatment as would be required to
	77	+	8 stabilize the patient regardless of the department of the
	78	+	9 hospital or other facility in which such further
	79	+	10 examination or treatment is furnished; or
	80	+	11 (2) additional items and services for which benefits
	81	+	12 are provided or covered under the coverage and that are
	82	+	13 furnished by a nonparticipating provider or
	83	+	14 nonparticipating emergency facility regardless of the
	84	+	15 department of the hospital or other facility in which such
	85	+	16 items are furnished after the insured, beneficiary, or
	86	+	17 enrollee is stabilized and as part of outpatient
	87	+	18 observation or an inpatient or outpatient stay with
	88	+	19 respect to the visit in which the services described in
	89	+	20 paragraph (1) are furnished. Services after stabilization
	90	+	21 cease to be emergency services only when all the
	91	+	22 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
	92	+	23 regulations thereunder are met.
	93	+	24 "Freestanding Emergency Center" means a facility licensed
	94	+	25 under Section 32.5 of the Emergency Medical Services (EMS)
	95	+	26 Systems Act.
143	96
144	97
145		-	hospital.
146		-	For purposes of this definition, a single case agreement
147		-	between an emergency facility and an issuer that is used to
148		-	address unique situations in which an insured, beneficiary, or
149		-	enrollee requires services that typically occur out-of-network
150		-	constitutes a contractual relationship and is limited to the
151		-	parties to the agreement.
152		-	"Participating health care facility" means any health care
153		-	facility that has a contractual relationship directly or
154		-	indirectly with a health insurance issuer offering group or
155		-	individual health insurance coverage setting forth the terms
156		-	and conditions on which a relevant health care service is
157		-	provided to an insured, beneficiary, or enrollee under the
158		-	coverage. A single case agreement between an emergency
159		-	facility and an issuer that is used to address unique
160		-	situations in which an insured, beneficiary, or enrollee
161		-	requires services that typically occur out-of-network
162		-	constitutes a contractual relationship for purposes of this
163		-	definition and is limited to the parties to the agreement.
164		-	"Participating provider" means any health care provider
165		-	that has a contractual relationship directly or indirectly
166		-	with a health insurance issuer offering group or individual
167		-	health insurance coverage setting forth the terms and
168		-	conditions on which a relevant health care service is provided
169		-	to an insured, beneficiary, or enrollee under the coverage.
170		-	"Qualifying payment amount" has the meaning given to that
171	98
172	99
173		-	term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
174		-	promulgated thereunder.
175		-	"Recognized amount" means the lesser of the amount
176		-	initially billed by the provider or the qualifying payment
177		-	amount.
178		-	"Stabilize" means "stabilization" as defined in Section 10
179		-	of the Managed Care Reform and Patient Rights Act.
180		-	"Treating provider" means a health care provider who has
181		-	evaluated the individual.
182		-	"Visit" means, with respect to health care services
183		-	furnished to an individual at a health care facility, health
184		-	care services furnished by a provider at the facility, as well
185		-	as equipment, devices, telehealth services, imaging services,
186		-	laboratory services, and preoperative and postoperative
187		-	services regardless of whether the provider furnishing such
188		-	services is at the facility.
189		-	(b) Emergency services. When a beneficiary, insured, or
190		-	enrollee receives emergency services from a nonparticipating
191		-	provider or a nonparticipating emergency facility, the health
192		-	insurance issuer shall ensure that the beneficiary, insured,
193		-	or enrollee shall incur no greater out-of-pocket costs than
194		-	the beneficiary, insured, or enrollee would have incurred with
195		-	a participating provider or a participating emergency
196		-	facility. Any cost-sharing requirements shall be applied as
197		-	though the emergency services had been received from a
198		-	participating provider or a participating facility. Cost
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199	102
200	103
201		-	sharing shall be calculated based on the recognized amount for
202		-	the emergency services. If the cost sharing for the same item
203		-	or service furnished by a participating provider would have
204		-	been a flat-dollar copayment, that amount shall be the
205		-	cost-sharing amount unless the provider has billed a lesser
206		-	total amount. In no event shall the beneficiary, insured,
207		-	enrollee, or any group policyholder or plan sponsor be liable
208		-	to or billed by the health insurance issuer, the
209		-	nonparticipating provider, or the nonparticipating emergency
210		-	facility for any amount beyond the cost sharing calculated in
211		-	accordance with this subsection with respect to the emergency
212		-	services delivered. Administrative requirements or limitations
213		-	shall be no greater than those applicable to emergency
214		-	services received from a participating provider or a
215		-	participating emergency facility.
216		-	(b-5) Non-emergency services at participating health care
217		-	facilities.
218		-	(1) When a beneficiary, insured, or enrollee utilizes
219		-	a participating health care facility and, due to any
220		-	reason, covered ancillary services are provided by a
221		-	nonparticipating provider during or resulting from the
222		-	visit, the health insurance issuer shall ensure that the
223		-	beneficiary, insured, or enrollee shall incur no greater
224		-	out-of-pocket costs than the beneficiary, insured, or
225		-	enrollee would have incurred with a participating provider
226		-	for the ancillary services. Any cost-sharing requirements
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	106	+	1 "Health care facility" means, in the context of
	107	+	2 non-emergency services, any of the following:
	108	+	3 (1) a hospital as defined in 42 U.S.C. 1395x(e);
	109	+	4 (2) a hospital outpatient department;
	110	+	5 (3) a critical access hospital certified under 42
	111	+	6 U.S.C. 1395i-4(e);
	112	+	7 (4) an ambulatory surgical treatment center as defined
	113	+	8 in the Ambulatory Surgical Treatment Center Act; or
	114	+	9 (5) any recipient of a license under the Hospital
	115	+	10 Licensing Act that is not otherwise described in this
	116	+	11 definition.
	117	+	12 "Health care provider" means a provider as defined in
	118	+	13 subsection (d) of Section 370g. "Health care provider" does
	119	+	14 not include a provider of air ambulance or ground ambulance
	120	+	15 services.
	121	+	16 "Health care services" has the meaning ascribed to that
	122	+	17 term in subsection (a) of Section 370g.
	123	+	18 "Health insurance issuer" has the meaning ascribed to that
	124	+	19 term in Section 5 of the Illinois Health Insurance Portability
	125	+	20 and Accountability Act.
	126	+	21 "Nonparticipating emergency facility" means, with respect
	127	+	22 to the furnishing of an item or service under a policy of group
	128	+	23 or individual health insurance coverage, any of the following
	129	+	24 facilities that does not have a contractual relationship
	130	+	25 directly or indirectly with a health insurance issuer in
	131	+	26 relation to the coverage:
227	132
228	133
229		-	shall be applied as though the ancillary services had been
230		-	received from a participating provider. Cost sharing shall
231		-	be calculated based on the recognized amount for the
232		-	ancillary services. If the cost sharing for the same item
233		-	or service furnished by a participating provider would
234		-	have been a flat-dollar copayment, that amount shall be
235		-	the cost-sharing amount unless the provider has billed a
236		-	lesser total amount. In no event shall the beneficiary,
237		-	insured, enrollee, or any group policyholder or plan
238		-	sponsor be liable to or billed by the health insurance
239		-	issuer, the nonparticipating provider, or the
240		-	participating health care facility for any amount beyond
241		-	the cost sharing calculated in accordance with this
242		-	subsection with respect to the ancillary services
243		-	delivered. In addition to ancillary services, the
244		-	requirements of this paragraph shall also apply with
245		-	respect to covered items or services furnished as a result
246		-	of unforeseen, urgent medical needs that arise at the time
247		-	an item or service is furnished, regardless of whether the
248		-	nonparticipating provider satisfied the notice and consent
249		-	criteria under paragraph (2) of this subsection.
250		-	(2) When a beneficiary, insured, or enrollee utilizes
251		-	a participating health care facility and receives
252		-	non-emergency covered health care services other than
253		-	those described in paragraph (1) of this subsection from a
254		-	nonparticipating provider during or resulting from the
255	134
256	135
257		-	visit, the health insurance issuer shall ensure that the
258		-	beneficiary, insured, or enrollee incurs no greater
259		-	out-of-pocket costs than the beneficiary, insured, or
260		-	enrollee would have incurred with a participating provider
261		-	unless the nonparticipating provider or the participating
262		-	health care facility on behalf of the nonparticipating
263		-	provider satisfies the notice and consent criteria
264		-	provided in 42 U.S.C. 300gg-132 and regulations
265		-	promulgated thereunder. If the notice and consent criteria
266		-	are not satisfied, then:
267		-	(A) any cost-sharing requirements shall be applied
268		-	as though the health care services had been received
269		-	from a participating provider;
270		-	(B) cost sharing shall be calculated based on the
271		-	recognized amount for the health care services; and
272		-	(C) in no event shall the beneficiary, insured,
273		-	enrollee, or any group policyholder or plan sponsor be
274		-	liable to or billed by the health insurance issuer,
275		-	the nonparticipating provider, or the participating
276		-	health care facility for any amount beyond the cost
277		-	sharing calculated in accordance with this subsection
278		-	with respect to the health care services delivered.
279		-	(c) Notwithstanding any other provision of this Code,
280		-	except when the notice and consent criteria are satisfied for
281		-	the situation in paragraph (2) of subsection (b-5), any
282		-	benefits a beneficiary, insured, or enrollee receives for
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283	138
284	139
285		-	services under the situations in subsection (b) or (b-5) are
286		-	assigned to the nonparticipating providers or the facility
287		-	acting on their behalf. Upon receipt of the provider's bill or
288		-	facility's bill, the health insurance issuer shall provide the
289		-	nonparticipating provider or the facility with a written
290		-	explanation of benefits that specifies the proposed
291		-	reimbursement and the applicable deductible, copayment, or
292		-	coinsurance amounts owed by the insured, beneficiary, or
293		-	enrollee. The health insurance issuer shall pay any
294		-	reimbursement subject to this Section directly to the
295		-	nonparticipating provider or the facility.
296		-	(d) For bills assigned under subsection (c), the
297		-	nonparticipating provider or the facility may bill the health
298		-	insurance issuer for the services rendered, and the health
299		-	insurance issuer may pay the billed amount or attempt to
300		-	negotiate reimbursement with the nonparticipating provider or
301		-	the facility. Within 30 calendar days after the provider or
302		-	facility transmits the bill to the health insurance issuer,
303		-	the issuer shall send an initial payment or notice of denial of
304		-	payment with the written explanation of benefits to the
305		-	provider or facility. If attempts to negotiate reimbursement
306		-	for services provided by a nonparticipating provider do not
307		-	result in a resolution of the payment dispute within 30 days
308		-	after receipt of written explanation of benefits by the health
309		-	insurance issuer, then the health insurance issuer or
310		-	nonparticipating provider or the facility may initiate binding
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	142	+	1 (1) an emergency department of a hospital;
	143	+	2 (2) a Freestanding Emergency Center;
	144	+	3 (3) an ambulatory surgical treatment center as defined
	145	+	4 in the Ambulatory Surgical Treatment Center Act; or
	146	+	5 (4) with respect to emergency services described in
	147	+	6 paragraph (2) of the definition of "emergency services", a
	148	+	7 hospital.
	149	+	8 "Nonparticipating provider" means, with respect to the
	150	+	9 furnishing of an item or service under a policy of group or
	151	+	10 individual health insurance coverage, any health care provider
	152	+	11 who does not have a contractual relationship directly or
	153	+	12 indirectly with a health insurance issuer in relation to the
	154	+	13 coverage.
	155	+	14 "Participating emergency facility" means any of the
	156	+	15 following facilities that has a contractual relationship
	157	+	16 directly or indirectly with a health insurance issuer offering
	158	+	17 group or individual health insurance coverage setting forth
	159	+	18 the terms and conditions on which a relevant health care
	160	+	19 service is provided to an insured, beneficiary, or enrollee
	161	+	20 under the coverage:
	162	+	21 (1) an emergency department of a hospital;
	163	+	22 (2) a Freestanding Emergency Center;
	164	+	23 (3) an ambulatory surgical treatment center as defined
	165	+	24 in the Ambulatory Surgical Treatment Center Act; or
	166	+	25 (4) with respect to emergency services described in
	167	+	26 paragraph (2) of the definition of "emergency services", a
311	168
312	169
313		-	arbitration to determine payment for services provided on a
314		-	per-bill or batched-bill basis, in accordance with Section
315		-	300gg-111 of the Public Health Service Act and the regulations
316		-	promulgated thereunder. The party requesting arbitration shall
317		-	notify the other party arbitration has been initiated and
318		-	state its final offer before arbitration. In response to this
319		-	notice, the nonrequesting party shall inform the requesting
320		-	party of its final offer before the arbitration occurs.
321		-	Arbitration shall be initiated by filing a request with the
322		-	Department of Insurance.
323		-	(e) The Department of Insurance shall publish a list of
324		-	approved arbitrators or entities that shall provide binding
325		-	arbitration. These arbitrators shall be American Arbitration
326		-	Association or American Health Lawyers Association trained
327		-	arbitrators. Both parties must agree on an arbitrator from the
328		-	Department of Insurance's or its approved entity's list of
329		-	arbitrators. If no agreement can be reached, then a list of 5
330		-	arbitrators shall be provided by the Department of Insurance
331		-	or the approved entity. From the list of 5 arbitrators, the
332		-	health insurance issuer can veto 2 arbitrators and the
333		-	provider or facility can veto 2 arbitrators. The remaining
334		-	arbitrator shall be the chosen arbitrator. This arbitration
335		-	shall consist of a review of the written submissions by both
336		-	parties. The arbitrator shall not establish a rebuttable
337		-	presumption that the qualifying payment amount should be the
338		-	total amount owed to the provider or facility by the
339	170
340	171
341		-	combination of the issuer and the insured, beneficiary, or
342		-	enrollee. Binding arbitration shall provide for a written
343		-	decision within 45 days after the request is filed with the
344		-	Department of Insurance. Both parties shall be bound by the
345		-	arbitrator's decision. The arbitrator's expenses and fees,
346		-	together with other expenses, not including attorney's fees,
347		-	incurred in the conduct of the arbitration, shall be paid as
348		-	provided in the decision.
349		-	(f) (Blank).
350		-	(g) Section 368a of this Act shall not apply during the
351		-	pendency of a decision under subsection (d). Upon the issuance
352		-	of the arbitrator's decision, Section 368a applies with
353		-	respect to the amount, if any, by which the arbitrator's
354		-	determination exceeds the issuer's initial payment under
355		-	subsection (c), or the entire amount of the arbitrator's
356		-	determination if initial payment was denied. Any interest
357		-	required to be paid to a provider under Section 368a shall not
358		-	accrue until after 30 days of an arbitrator's decision as
359		-	provided in subsection (d), but in no circumstances longer
360		-	than 150 days from the date the nonparticipating
361		-	facility-based provider billed for services rendered.
362		-	(h) Nothing in this Section shall be interpreted to change
363		-	the prudent layperson provisions with respect to emergency
364		-	services under the Managed Care Reform and Patient Rights Act.
365		-	(i) Nothing in this Section shall preclude a health care
366		-	provider from billing a beneficiary, insured, or enrollee for
	172	+
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367	174
368	175
369		-	reasonable administrative fees, such as service fees for
370		-	checks returned for nonsufficient funds and missed
371		-	appointments.
372		-	(j) Nothing in this Section shall preclude a beneficiary,
373		-	insured, or enrollee from assigning benefits to a
374		-	nonparticipating provider when the notice and consent criteria
375		-	are satisfied under paragraph (2) of subsection (b-5) or in
376		-	any other situation not described in subsection (b) or (b-5).
377		-	(k) Except when the notice and consent criteria are
378		-	satisfied under paragraph (2) of subsection (b-5), if an
379		-	individual receives health care services under the situations
380		-	described in subsection (b) or (b-5), no referral requirement
381		-	or any other provision contained in the policy or certificate
382		-	of coverage shall deny coverage, reduce benefits, or otherwise
383		-	defeat the requirements of this Section for services that
384		-	would have been covered with a participating provider.
385		-	However, this subsection shall not be construed to preclude a
386		-	provider contract with a health insurance issuer, or with an
387		-	administrator or similar entity acting on the issuer's behalf,
388		-	from imposing requirements on the participating provider,
389		-	participating emergency facility, or participating health care
390		-	facility relating to the referral of covered individuals to
391		-	nonparticipating providers.
392		-	(l) Except if the notice and consent criteria are
393		-	satisfied under paragraph (2) of subsection (b-5),
394		-	cost-sharing amounts calculated in conformity with this
	176	+	HB3030 Enrolled- 6 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 6 - LRB103 05013 BMS 56587 b
	177	+	HB3030 Enrolled - 6 - LRB103 05013 BMS 56587 b
	178	+	1 hospital.
	179	+	2 For purposes of this definition, a single case agreement
	180	+	3 between an emergency facility and an issuer that is used to
	181	+	4 address unique situations in which an insured, beneficiary, or
	182	+	5 enrollee requires services that typically occur out-of-network
	183	+	6 constitutes a contractual relationship and is limited to the
	184	+	7 parties to the agreement.
	185	+	8 "Participating health care facility" means any health care
	186	+	9 facility that has a contractual relationship directly or
	187	+	10 indirectly with a health insurance issuer offering group or
	188	+	11 individual health insurance coverage setting forth the terms
	189	+	12 and conditions on which a relevant health care service is
	190	+	13 provided to an insured, beneficiary, or enrollee under the
	191	+	14 coverage. A single case agreement between an emergency
	192	+	15 facility and an issuer that is used to address unique
	193	+	16 situations in which an insured, beneficiary, or enrollee
	194	+	17 requires services that typically occur out-of-network
	195	+	18 constitutes a contractual relationship for purposes of this
	196	+	19 definition and is limited to the parties to the agreement.
	197	+	20 "Participating provider" means any health care provider
	198	+	21 that has a contractual relationship directly or indirectly
	199	+	22 with a health insurance issuer offering group or individual
	200	+	23 health insurance coverage setting forth the terms and
	201	+	24 conditions on which a relevant health care service is provided
	202	+	25 to an insured, beneficiary, or enrollee under the coverage.
	203	+	26 "Qualifying payment amount" has the meaning given to that
395	204
396	205
397		-	Section shall count toward any deductible or out-of-pocket
398		-	maximum applicable to in-network coverage.
399		-	(m) The Department has the authority to enforce the
400		-	requirements of this Section in the situations described in
401		-	subsections (b) and (b-5), and in any other situation for
402		-	which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
403		-	regulations promulgated thereunder would prohibit an
404		-	individual from being billed or liable for emergency services
405		-	furnished by a nonparticipating provider or nonparticipating
406		-	emergency facility or for non-emergency health care services
407		-	furnished by a nonparticipating provider at a participating
408		-	health care facility.
409		-	(n) This Section does not apply with respect to air
410		-	ambulance or ground ambulance services. This Section does not
411		-	apply to any policy of excepted benefits or to short-term,
412		-	limited-duration health insurance coverage.
413		-	(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
	206	+
	207	+
	208	+
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	210	+
	211	+
	212	+	HB3030 Enrolled- 7 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 7 - LRB103 05013 BMS 56587 b
	213	+	HB3030 Enrolled - 7 - LRB103 05013 BMS 56587 b
	214	+	1 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
	215	+	2 promulgated thereunder.
	216	+	3 "Recognized amount" means the lesser of the amount
	217	+	4 initially billed by the provider or the qualifying payment
	218	+	5 amount.
	219	+	6 "Stabilize" means "stabilization" as defined in Section 10
	220	+	7 of the Managed Care Reform and Patient Rights Act.
	221	+	8 "Treating provider" means a health care provider who has
	222	+	9 evaluated the individual.
	223	+	10 "Visit" means, with respect to health care services
	224	+	11 furnished to an individual at a health care facility, health
	225	+	12 care services furnished by a provider at the facility, as well
	226	+	13 as equipment, devices, telehealth services, imaging services,
	227	+	14 laboratory services, and preoperative and postoperative
	228	+	15 services regardless of whether the provider furnishing such
	229	+	16 services is at the facility.
	230	+	17 (b) Emergency services. When a beneficiary, insured, or
	231	+	18 enrollee receives emergency services from a nonparticipating
	232	+	19 provider or a nonparticipating emergency facility, the health
	233	+	20 insurance issuer shall ensure that the beneficiary, insured,
	234	+	21 or enrollee shall incur no greater out-of-pocket costs than
	235	+	22 the beneficiary, insured, or enrollee would have incurred with
	236	+	23 a participating provider or a participating emergency
	237	+	24 facility. Any cost-sharing requirements shall be applied as
	238	+	25 though the emergency services had been received from a
	239	+	26 participating provider or a participating facility. Cost
	240	+
	241	+
	242	+
	243	+
	244	+
	245	+	HB3030 Enrolled - 7 - LRB103 05013 BMS 56587 b
	246	+
	247	+
	248	+	HB3030 Enrolled- 8 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 8 - LRB103 05013 BMS 56587 b
	249	+	HB3030 Enrolled - 8 - LRB103 05013 BMS 56587 b
	250	+	1 sharing shall be calculated based on the recognized amount for
	251	+	2 the emergency services. If the cost sharing for the same item
	252	+	3 or service furnished by a participating provider would have
	253	+	4 been a flat-dollar copayment, that amount shall be the
	254	+	5 cost-sharing amount unless the provider has billed a lesser
	255	+	6 total amount. In no event shall the beneficiary, insured,
	256	+	7 enrollee, or any group policyholder or plan sponsor be liable
	257	+	8 to or billed by the health insurance issuer, the
	258	+	9 nonparticipating provider, or the nonparticipating emergency
	259	+	10 facility for any amount beyond the cost sharing calculated in
	260	+	11 accordance with this subsection with respect to the emergency
	261	+	12 services delivered. Administrative requirements or limitations
	262	+	13 shall be no greater than those applicable to emergency
	263	+	14 services received from a participating provider or a
	264	+	15 participating emergency facility.
	265	+	16 (b-5) Non-emergency services at participating health care
	266	+	17 facilities.
	267	+	18 (1) When a beneficiary, insured, or enrollee utilizes
	268	+	19 a participating health care facility and, due to any
	269	+	20 reason, covered ancillary services are provided by a
	270	+	21 nonparticipating provider during or resulting from the
	271	+	22 visit, the health insurance issuer shall ensure that the
	272	+	23 beneficiary, insured, or enrollee shall incur no greater
	273	+	24 out-of-pocket costs than the beneficiary, insured, or
	274	+	25 enrollee would have incurred with a participating provider
	275	+	26 for the ancillary services. Any cost-sharing requirements
	276	+
	277	+
	278	+
	279	+
	280	+
	281	+	HB3030 Enrolled - 8 - LRB103 05013 BMS 56587 b
	282	+
	283	+
	284	+	HB3030 Enrolled- 9 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 9 - LRB103 05013 BMS 56587 b
	285	+	HB3030 Enrolled - 9 - LRB103 05013 BMS 56587 b
	286	+	1 shall be applied as though the ancillary services had been
	287	+	2 received from a participating provider. Cost sharing shall
	288	+	3 be calculated based on the recognized amount for the
	289	+	4 ancillary services. If the cost sharing for the same item
	290	+	5 or service furnished by a participating provider would
	291	+	6 have been a flat-dollar copayment, that amount shall be
	292	+	7 the cost-sharing amount unless the provider has billed a
	293	+	8 lesser total amount. In no event shall the beneficiary,
	294	+	9 insured, enrollee, or any group policyholder or plan
	295	+	10 sponsor be liable to or billed by the health insurance
	296	+	11 issuer, the nonparticipating provider, or the
	297	+	12 participating health care facility for any amount beyond
	298	+	13 the cost sharing calculated in accordance with this
	299	+	14 subsection with respect to the ancillary services
	300	+	15 delivered. In addition to ancillary services, the
	301	+	16 requirements of this paragraph shall also apply with
	302	+	17 respect to covered items or services furnished as a result
	303	+	18 of unforeseen, urgent medical needs that arise at the time
	304	+	19 an item or service is furnished, regardless of whether the
	305	+	20 nonparticipating provider satisfied the notice and consent
	306	+	21 criteria under paragraph (2) of this subsection.
	307	+	22 (2) When a beneficiary, insured, or enrollee utilizes
	308	+	23 a participating health care facility and receives
	309	+	24 non-emergency covered health care services other than
	310	+	25 those described in paragraph (1) of this subsection from a
	311	+	26 nonparticipating provider during or resulting from the
	312	+
	313	+
	314	+
	315	+
	316	+
	317	+	HB3030 Enrolled - 9 - LRB103 05013 BMS 56587 b
	318	+
	319	+
	320	+	HB3030 Enrolled- 10 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 10 - LRB103 05013 BMS 56587 b
	321	+	HB3030 Enrolled - 10 - LRB103 05013 BMS 56587 b
	322	+	1 visit, the health insurance issuer shall ensure that the
	323	+	2 beneficiary, insured, or enrollee incurs no greater
	324	+	3 out-of-pocket costs than the beneficiary, insured, or
	325	+	4 enrollee would have incurred with a participating provider
	326	+	5 unless the nonparticipating provider or the participating
	327	+	6 health care facility on behalf of the nonparticipating
	328	+	7 provider satisfies the notice and consent criteria
	329	+	8 provided in 42 U.S.C. 300gg-132 and regulations
	330	+	9 promulgated thereunder. If the notice and consent criteria
	331	+	10 are not satisfied, then:
	332	+	11 (A) any cost-sharing requirements shall be applied
	333	+	12 as though the health care services had been received
	334	+	13 from a participating provider;
	335	+	14 (B) cost sharing shall be calculated based on the
	336	+	15 recognized amount for the health care services; and
	337	+	16 (C) in no event shall the beneficiary, insured,
	338	+	17 enrollee, or any group policyholder or plan sponsor be
	339	+	18 liable to or billed by the health insurance issuer,
	340	+	19 the nonparticipating provider, or the participating
	341	+	20 health care facility for any amount beyond the cost
	342	+	21 sharing calculated in accordance with this subsection
	343	+	22 with respect to the health care services delivered.
	344	+	23 (c) Notwithstanding any other provision of this Code,
	345	+	24 except when the notice and consent criteria are satisfied for
	346	+	25 the situation in paragraph (2) of subsection (b-5), any
	347	+	26 benefits a beneficiary, insured, or enrollee receives for
	348	+
	349	+
	350	+
	351	+
	352	+
	353	+	HB3030 Enrolled - 10 - LRB103 05013 BMS 56587 b
	354	+
	355	+
	356	+	HB3030 Enrolled- 11 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 11 - LRB103 05013 BMS 56587 b
	357	+	HB3030 Enrolled - 11 - LRB103 05013 BMS 56587 b
	358	+	1 services under the situations in subsection (b) or (b-5) are
	359	+	2 assigned to the nonparticipating providers or the facility
	360	+	3 acting on their behalf. Upon receipt of the provider's bill or
	361	+	4 facility's bill, the health insurance issuer shall provide the
	362	+	5 nonparticipating provider or the facility with a written
	363	+	6 explanation of benefits that specifies the proposed
	364	+	7 reimbursement and the applicable deductible, copayment, or
	365	+	8 coinsurance amounts owed by the insured, beneficiary, or
	366	+	9 enrollee. The health insurance issuer shall pay any
	367	+	10 reimbursement subject to this Section directly to the
	368	+	11 nonparticipating provider or the facility.
	369	+	12 (d) For bills assigned under subsection (c), the
	370	+	13 nonparticipating provider or the facility may bill the health
	371	+	14 insurance issuer for the services rendered, and the health
	372	+	15 insurance issuer may pay the billed amount or attempt to
	373	+	16 negotiate reimbursement with the nonparticipating provider or
	374	+	17 the facility. Within 30 calendar days after the provider or
	375	+	18 facility transmits the bill to the health insurance issuer,
	376	+	19 the issuer shall send an initial payment or notice of denial of
	377	+	20 payment with the written explanation of benefits to the
	378	+	21 provider or facility. If attempts to negotiate reimbursement
	379	+	22 for services provided by a nonparticipating provider do not
	380	+	23 result in a resolution of the payment dispute within 30 days
	381	+	24 after receipt of written explanation of benefits by the health
	382	+	25 insurance issuer, then the health insurance issuer or
	383	+	26 nonparticipating provider or the facility may initiate binding
	384	+
	385	+
	386	+
	387	+
	388	+
	389	+	HB3030 Enrolled - 11 - LRB103 05013 BMS 56587 b
	390	+
	391	+
	392	+	HB3030 Enrolled- 12 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 12 - LRB103 05013 BMS 56587 b
	393	+	HB3030 Enrolled - 12 - LRB103 05013 BMS 56587 b
	394	+	1 arbitration to determine payment for services provided on a
	395	+	2 per-bill or batched-bill basis, in accordance with Section
	396	+	3 300gg-111 of the Public Health Service Act and the regulations
	397	+	4 promulgated thereunder. The party requesting arbitration shall
	398	+	5 notify the other party arbitration has been initiated and
	399	+	6 state its final offer before arbitration. In response to this
	400	+	7 notice, the nonrequesting party shall inform the requesting
	401	+	8 party of its final offer before the arbitration occurs.
	402	+	9 Arbitration shall be initiated by filing a request with the
	403	+	10 Department of Insurance.
	404	+	11 (e) The Department of Insurance shall publish a list of
	405	+	12 approved arbitrators or entities that shall provide binding
	406	+	13 arbitration. These arbitrators shall be American Arbitration
	407	+	14 Association or American Health Lawyers Association trained
	408	+	15 arbitrators. Both parties must agree on an arbitrator from the
	409	+	16 Department of Insurance's or its approved entity's list of
	410	+	17 arbitrators. If no agreement can be reached, then a list of 5
	411	+	18 arbitrators shall be provided by the Department of Insurance
	412	+	19 or the approved entity. From the list of 5 arbitrators, the
	413	+	20 health insurance issuer can veto 2 arbitrators and the
	414	+	21 provider or facility can veto 2 arbitrators. The remaining
	415	+	22 arbitrator shall be the chosen arbitrator. This arbitration
	416	+	23 shall consist of a review of the written submissions by both
	417	+	24 parties. The arbitrator shall not establish a rebuttable
	418	+	25 presumption that the qualifying payment amount should be the
	419	+	26 total amount owed to the provider or facility by the
	420	+
	421	+
	422	+
	423	+
	424	+
	425	+	HB3030 Enrolled - 12 - LRB103 05013 BMS 56587 b
	426	+
	427	+
	428	+	HB3030 Enrolled- 13 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 13 - LRB103 05013 BMS 56587 b
	429	+	HB3030 Enrolled - 13 - LRB103 05013 BMS 56587 b
	430	+	1 combination of the issuer and the insured, beneficiary, or
	431	+	2 enrollee. Binding arbitration shall provide for a written
	432	+	3 decision within 45 days after the request is filed with the
	433	+	4 Department of Insurance. Both parties shall be bound by the
	434	+	5 arbitrator's decision. The arbitrator's expenses and fees,
	435	+	6 together with other expenses, not including attorney's fees,
	436	+	7 incurred in the conduct of the arbitration, shall be paid as
	437	+	8 provided in the decision.
	438	+	9 (f) (Blank).
	439	+	10 (g) Section 368a of this Act shall not apply during the
	440	+	11 pendency of a decision under subsection (d). Upon the issuance
	441	+	12 of the arbitrator's decision, Section 368a applies with
	442	+	13 respect to the amount, if any, by which the arbitrator's
	443	+	14 determination exceeds the issuer's initial payment under
	444	+	15 subsection (c), or the entire amount of the arbitrator's
	445	+	16 determination if initial payment was denied. Any interest
	446	+	17 required to be paid to a provider under Section 368a shall not
	447	+	18 accrue until after 30 days of an arbitrator's decision as
	448	+	19 provided in subsection (d), but in no circumstances longer
	449	+	20 than 150 days from the date the nonparticipating
	450	+	21 facility-based provider billed for services rendered.
	451	+	22 (h) Nothing in this Section shall be interpreted to change
	452	+	23 the prudent layperson provisions with respect to emergency
	453	+	24 services under the Managed Care Reform and Patient Rights Act.
	454	+	25 (i) Nothing in this Section shall preclude a health care
	455	+	26 provider from billing a beneficiary, insured, or enrollee for
	456	+
	457	+
	458	+
	459	+
	460	+
	461	+	HB3030 Enrolled - 13 - LRB103 05013 BMS 56587 b
	462	+
	463	+
	464	+	HB3030 Enrolled- 14 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 14 - LRB103 05013 BMS 56587 b
	465	+	HB3030 Enrolled - 14 - LRB103 05013 BMS 56587 b
	466	+	1 reasonable administrative fees, such as service fees for
	467	+	2 checks returned for nonsufficient funds and missed
	468	+	3 appointments.
	469	+	4 (j) Nothing in this Section shall preclude a beneficiary,
	470	+	5 insured, or enrollee from assigning benefits to a
	471	+	6 nonparticipating provider when the notice and consent criteria
	472	+	7 are satisfied under paragraph (2) of subsection (b-5) or in
	473	+	8 any other situation not described in subsection (b) or (b-5).
	474	+	9 (k) Except when the notice and consent criteria are
	475	+	10 satisfied under paragraph (2) of subsection (b-5), if an
	476	+	11 individual receives health care services under the situations
	477	+	12 described in subsection (b) or (b-5), no referral requirement
	478	+	13 or any other provision contained in the policy or certificate
	479	+	14 of coverage shall deny coverage, reduce benefits, or otherwise
	480	+	15 defeat the requirements of this Section for services that
	481	+	16 would have been covered with a participating provider.
	482	+	17 However, this subsection shall not be construed to preclude a
	483	+	18 provider contract with a health insurance issuer, or with an
	484	+	19 administrator or similar entity acting on the issuer's behalf,
	485	+	20 from imposing requirements on the participating provider,
	486	+	21 participating emergency facility, or participating health care
	487	+	22 facility relating to the referral of covered individuals to
	488	+	23 nonparticipating providers.
	489	+	24 (l) Except if the notice and consent criteria are
	490	+	25 satisfied under paragraph (2) of subsection (b-5),
	491	+	26 cost-sharing amounts calculated in conformity with this
	492	+
	493	+
	494	+
	495	+
	496	+
	497	+	HB3030 Enrolled - 14 - LRB103 05013 BMS 56587 b
	498	+
	499	+
	500	+	HB3030 Enrolled- 15 -LRB103 05013 BMS 56587 b HB3030 Enrolled - 15 - LRB103 05013 BMS 56587 b
	501	+	HB3030 Enrolled - 15 - LRB103 05013 BMS 56587 b
	502	+	1 Section shall count toward any deductible or out-of-pocket
	503	+	2 maximum applicable to in-network coverage.
	504	+	3 (m) The Department has the authority to enforce the
	505	+	4 requirements of this Section in the situations described in
	506	+	5 subsections (b) and (b-5), and in any other situation for
	507	+	6 which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
	508	+	7 regulations promulgated thereunder would prohibit an
	509	+	8 individual from being billed or liable for emergency services
	510	+	9 furnished by a nonparticipating provider or nonparticipating
	511	+	10 emergency facility or for non-emergency health care services
	512	+	11 furnished by a nonparticipating provider at a participating
	513	+	12 health care facility.
	514	+	13 (n) This Section does not apply with respect to air
	515	+	14 ambulance or ground ambulance services. This Section does not
	516	+	15 apply to any policy of excepted benefits or to short-term,
	517	+	16 limited-duration health insurance coverage.
	518	+	17 (Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
	519	+
	520	+
	521	+
	522	+
	523	+
	524	+	HB3030 Enrolled - 15 - LRB103 05013 BMS 56587 b