Illinois 2023-2024 Regular Session

Illinois House Bill HB4931 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 HB4931 Introduced , by Rep. Margaret Croke SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a Amends the Illinois Insurance Code. In a provision concerning billing for services provided by nonparticipating providers or facilities, provides that when calculating an enrollee's contribution to the annual limitation on cost sharing set forth under specified federal law, a health insurance issuer or its subcontractors shall include expenditures for any item or health care service covered under the policy issued to the enrollee by the health insurance issuer or its subcontractors if that item or health care service is included within a category of essential health benefits and regardless of whether the health insurance issuer or its subcontractors classify that item or service as an essential health benefit. Effective immediately. LRB103 35342 RPS 65406 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4931 Introduced , by Rep. Margaret Croke SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a 215 ILCS 5/356z.3a Amends the Illinois Insurance Code. In a provision concerning billing for services provided by nonparticipating providers or facilities, provides that when calculating an enrollee's contribution to the annual limitation on cost sharing set forth under specified federal law, a health insurance issuer or its subcontractors shall include expenditures for any item or health care service covered under the policy issued to the enrollee by the health insurance issuer or its subcontractors if that item or health care service is included within a category of essential health benefits and regardless of whether the health insurance issuer or its subcontractors classify that item or service as an essential health benefit. Effective immediately. LRB103 35342 RPS 65406 b LRB103 35342 RPS 65406 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4931 Introduced , by Rep. Margaret Croke 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. In a provision concerning billing for services provided by nonparticipating providers or facilities, provides that when calculating an enrollee's contribution to the annual limitation on cost sharing set forth under specified federal law, a health insurance issuer or its subcontractors shall include expenditures for any item or health care service covered under the policy issued to the enrollee by the health insurance issuer or its subcontractors if that item or health care service is included within a category of essential health benefits and regardless of whether the health insurance issuer or its subcontractors classify that item or service as an essential health benefit. Effective immediately.
6	6	LRB103 35342 RPS 65406 b LRB103 35342 RPS 65406 b
7	7	LRB103 35342 RPS 65406 b
8	8	A BILL FOR
9	9	HB4931LRB103 35342 RPS 65406 b HB4931 LRB103 35342 RPS 65406 b
10	10	HB4931 LRB103 35342 RPS 65406 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 (Text of Section before amendment by P.A. 103-440)
18	18	8 Sec. 356z.3a. Billing; emergency services;
19	19	9 nonparticipating providers.
20	20	10 (a) As used in this Section:
21	21	11 "Ancillary services" means:
22	22	12 (1) items and services related to emergency medicine,
23	23	13 anesthesiology, pathology, radiology, and neonatology that
24	24	14 are provided by any health care provider;
25	25	15 (2) items and services provided by assistant surgeons,
26	26	16 hospitalists, and intensivists;
27	27	17 (3) diagnostic services, including radiology and
28	28	18 laboratory services, except for advanced diagnostic
29	29	19 laboratory tests identified on the most current list
30	30	20 published by the United States Secretary of Health and
31	31	21 Human Services under 42 U.S.C. 300gg-132(b)(3);
32	32	22 (4) items and services provided by other specialty
33	33	23 practitioners as the United States Secretary of Health and
34	34
35	35
36	36
37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4931 Introduced , by Rep. Margaret Croke 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. In a provision concerning billing for services provided by nonparticipating providers or facilities, provides that when calculating an enrollee's contribution to the annual limitation on cost sharing set forth under specified federal law, a health insurance issuer or its subcontractors shall include expenditures for any item or health care service covered under the policy issued to the enrollee by the health insurance issuer or its subcontractors if that item or health care service is included within a category of essential health benefits and regardless of whether the health insurance issuer or its subcontractors classify that item or service as an essential health benefit. Effective immediately.
41	41	LRB103 35342 RPS 65406 b LRB103 35342 RPS 65406 b
42	42	LRB103 35342 RPS 65406 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 35342 RPS 65406 b
54	54
55	55
56	56
57	57
58	58
59	59
60	60
61	61
62	62
63	63	HB4931 LRB103 35342 RPS 65406 b
64	64
65	65
66	66	HB4931- 2 -LRB103 35342 RPS 65406 b HB4931 - 2 - LRB103 35342 RPS 65406 b
67	67	HB4931 - 2 - LRB103 35342 RPS 65406 b
68	68	1 Human Services specifies through rulemaking under 42
69	69	2 U.S.C. 300gg-132(b)(3);
70	70	3 (5) items and services provided by a nonparticipating
71	71	4 provider if there is no participating provider who can
72	72	5 furnish the item or service at the facility; and
73	73	6 (6) items and services provided by a nonparticipating
74	74	7 provider if there is no participating provider who will
75	75	8 furnish the item or service because a participating
76	76	9 provider has asserted the participating provider's rights
77	77	10 under the Health Care Right of Conscience Act.
78	78	11 "Cost sharing" means the amount an insured, beneficiary,
79	79	12 or enrollee is responsible for paying for a covered item or
80	80	13 service under the terms of the policy or certificate. "Cost
81	81	14 sharing" includes copayments, coinsurance, and amounts paid
82	82	15 toward deductibles, but does not include amounts paid towards
83	83	16 premiums, balance billing by out-of-network providers, or the
84	84	17 cost of items or services that are not covered under the policy
85	85	18 or certificate.
86	86	19 "Emergency department of a hospital" means any hospital
87	87	20 department that provides emergency services, including a
88	88	21 hospital outpatient department.
89	89	22 "Emergency medical condition" has the meaning ascribed to
90	90	23 that term in Section 10 of the Managed Care Reform and Patient
91	91	24 Rights Act.
92	92	25 "Emergency medical screening examination" has the meaning
93	93	26 ascribed to that term in Section 10 of the Managed Care Reform
94	94
95	95
96	96
97	97
98	98
99	99	HB4931 - 2 - LRB103 35342 RPS 65406 b
100	100
101	101
102	102	HB4931- 3 -LRB103 35342 RPS 65406 b HB4931 - 3 - LRB103 35342 RPS 65406 b
103	103	HB4931 - 3 - LRB103 35342 RPS 65406 b
104	104	1 and Patient Rights Act.
105	105	2 "Emergency services" means, with respect to an emergency
106	106	3 medical condition:
107	107	4 (1) in general, an emergency medical screening
108	108	5 examination, including ancillary services routinely
109	109	6 available to the emergency department to evaluate such
110	110	7 emergency medical condition, and such further medical
111	111	8 examination and treatment as would be required to
112	112	9 stabilize the patient regardless of the department of the
113	113	10 hospital or other facility in which such further
114	114	11 examination or treatment is furnished; or
115	115	12 (2) additional items and services for which benefits
116	116	13 are provided or covered under the coverage and that are
117	117	14 furnished by a nonparticipating provider or
118	118	15 nonparticipating emergency facility regardless of the
119	119	16 department of the hospital or other facility in which such
120	120	17 items are furnished after the insured, beneficiary, or
121	121	18 enrollee is stabilized and as part of outpatient
122	122	19 observation or an inpatient or outpatient stay with
123	123	20 respect to the visit in which the services described in
124	124	21 paragraph (1) are furnished. Services after stabilization
125	125	22 cease to be emergency services only when all the
126	126	23 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
127	127	24 regulations thereunder are met.
128	128	25 "Freestanding Emergency Center" means a facility licensed
129	129	26 under Section 32.5 of the Emergency Medical Services (EMS)
130	130
131	131
132	132
133	133
134	134
135	135	HB4931 - 3 - LRB103 35342 RPS 65406 b
136	136
137	137
138	138	HB4931- 4 -LRB103 35342 RPS 65406 b HB4931 - 4 - LRB103 35342 RPS 65406 b
139	139	HB4931 - 4 - LRB103 35342 RPS 65406 b
140	140	1 Systems Act.
141	141	2 "Health care facility" means, in the context of
142	142	3 non-emergency services, any of the following:
143	143	4 (1) a hospital as defined in 42 U.S.C. 1395x(e);
144	144	5 (2) a hospital outpatient department;
145	145	6 (3) a critical access hospital certified under 42
146	146	7 U.S.C. 1395i-4(e);
147	147	8 (4) an ambulatory surgical treatment center as defined
148	148	9 in the Ambulatory Surgical Treatment Center Act; or
149	149	10 (5) any recipient of a license under the Hospital
150	150	11 Licensing Act that is not otherwise described in this
151	151	12 definition.
152	152	13 "Health care provider" means a provider as defined in
153	153	14 subsection (d) of Section 370g. "Health care provider" does
154	154	15 not include a provider of air ambulance or ground ambulance
155	155	16 services.
156	156	17 "Health care services" has the meaning ascribed to that
157	157	18 term in subsection (a) of Section 370g.
158	158	19 "Health insurance issuer" has the meaning ascribed to that
159	159	20 term in Section 5 of the Illinois Health Insurance Portability
160	160	21 and Accountability Act.
161	161	22 "Nonparticipating emergency facility" means, with respect
162	162	23 to the furnishing of an item or service under a policy of group
163	163	24 or individual health insurance coverage, any of the following
164	164	25 facilities that does not have a contractual relationship
165	165	26 directly or indirectly with a health insurance issuer in
166	166
167	167
168	168
169	169
170	170
171	171	HB4931 - 4 - LRB103 35342 RPS 65406 b
172	172
173	173
174	174	HB4931- 5 -LRB103 35342 RPS 65406 b HB4931 - 5 - LRB103 35342 RPS 65406 b
175	175	HB4931 - 5 - LRB103 35342 RPS 65406 b
176	176	1 relation to the coverage:
177	177	2 (1) an emergency department of a hospital;
178	178	3 (2) a Freestanding Emergency Center;
179	179	4 (3) an ambulatory surgical treatment center as defined
180	180	5 in the Ambulatory Surgical Treatment Center Act; or
181	181	6 (4) with respect to emergency services described in
182	182	7 paragraph (2) of the definition of "emergency services", a
183	183	8 hospital.
184	184	9 "Nonparticipating provider" means, with respect to the
185	185	10 furnishing of an item or service under a policy of group or
186	186	11 individual health insurance coverage, any health care provider
187	187	12 who does not have a contractual relationship directly or
188	188	13 indirectly with a health insurance issuer in relation to the
189	189	14 coverage.
190	190	15 "Participating emergency facility" means any of the
191	191	16 following facilities that has a contractual relationship
192	192	17 directly or indirectly with a health insurance issuer offering
193	193	18 group or individual health insurance coverage setting forth
194	194	19 the terms and conditions on which a relevant health care
195	195	20 service is provided to an insured, beneficiary, or enrollee
196	196	21 under the coverage:
197	197	22 (1) an emergency department of a hospital;
198	198	23 (2) a Freestanding Emergency Center;
199	199	24 (3) an ambulatory surgical treatment center as defined
200	200	25 in the Ambulatory Surgical Treatment Center Act; or
201	201	26 (4) with respect to emergency services described in
202	202
203	203
204	204
205	205
206	206
207	207	HB4931 - 5 - LRB103 35342 RPS 65406 b
208	208
209	209
210	210	HB4931- 6 -LRB103 35342 RPS 65406 b HB4931 - 6 - LRB103 35342 RPS 65406 b
211	211	HB4931 - 6 - LRB103 35342 RPS 65406 b
212	212	1 paragraph (2) of the definition of "emergency services", a
213	213	2 hospital.
214	214	3 For purposes of this definition, a single case agreement
215	215	4 between an emergency facility and an issuer that is used to
216	216	5 address unique situations in which an insured, beneficiary, or
217	217	6 enrollee requires services that typically occur out-of-network
218	218	7 constitutes a contractual relationship and is limited to the
219	219	8 parties to the agreement.
220	220	9 "Participating health care facility" means any health care
221	221	10 facility that has a contractual relationship directly or
222	222	11 indirectly with a health insurance issuer offering group or
223	223	12 individual health insurance coverage setting forth the terms
224	224	13 and conditions on which a relevant health care service is
225	225	14 provided to an insured, beneficiary, or enrollee under the
226	226	15 coverage. A single case agreement between an emergency
227	227	16 facility and an issuer that is used to address unique
228	228	17 situations in which an insured, beneficiary, or enrollee
229	229	18 requires services that typically occur out-of-network
230	230	19 constitutes a contractual relationship for purposes of this
231	231	20 definition and is limited to the parties to the agreement.
232	232	21 "Participating provider" means any health care provider
233	233	22 that has a contractual relationship directly or indirectly
234	234	23 with a health insurance issuer offering group or individual
235	235	24 health insurance coverage setting forth the terms and
236	236	25 conditions on which a relevant health care service is provided
237	237	26 to an insured, beneficiary, or enrollee under the coverage.
238	238
239	239
240	240
241	241
242	242
243	243	HB4931 - 6 - LRB103 35342 RPS 65406 b
244	244
245	245
246	246	HB4931- 7 -LRB103 35342 RPS 65406 b HB4931 - 7 - LRB103 35342 RPS 65406 b
247	247	HB4931 - 7 - LRB103 35342 RPS 65406 b
248	248	1 "Qualifying payment amount" has the meaning given to that
249	249	2 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
250	250	3 promulgated thereunder.
251	251	4 "Recognized amount" means the lesser of the amount
252	252	5 initially billed by the provider or the qualifying payment
253	253	6 amount.
254	254	7 "Stabilize" means "stabilization" as defined in Section 10
255	255	8 of the Managed Care Reform and Patient Rights Act.
256	256	9 "Treating provider" means a health care provider who has
257	257	10 evaluated the individual.
258	258	11 "Visit" means, with respect to health care services
259	259	12 furnished to an individual at a health care facility, health
260	260	13 care services furnished by a provider at the facility, as well
261	261	14 as equipment, devices, telehealth services, imaging services,
262	262	15 laboratory services, and preoperative and postoperative
263	263	16 services regardless of whether the provider furnishing such
264	264	17 services is at the facility.
265	265	18 (b) Emergency services. When a beneficiary, insured, or
266	266	19 enrollee receives emergency services from a nonparticipating
267	267	20 provider or a nonparticipating emergency facility, the health
268	268	21 insurance issuer shall ensure that the beneficiary, insured,
269	269	22 or enrollee shall incur no greater out-of-pocket costs than
270	270	23 the beneficiary, insured, or enrollee would have incurred with
271	271	24 a participating provider or a participating emergency
272	272	25 facility. Any cost-sharing requirements shall be applied as
273	273	26 though the emergency services had been received from a
274	274
275	275
276	276
277	277
278	278
279	279	HB4931 - 7 - LRB103 35342 RPS 65406 b
280	280
281	281
282	282	HB4931- 8 -LRB103 35342 RPS 65406 b HB4931 - 8 - LRB103 35342 RPS 65406 b
283	283	HB4931 - 8 - LRB103 35342 RPS 65406 b
284	284	1 participating provider or a participating facility. Cost
285	285	2 sharing shall be calculated based on the recognized amount for
286	286	3 the emergency services. If the cost sharing for the same item
287	287	4 or service furnished by a participating provider would have
288	288	5 been a flat-dollar copayment, that amount shall be the
289	289	6 cost-sharing amount unless the provider has billed a lesser
290	290	7 total amount. In no event shall the beneficiary, insured,
291	291	8 enrollee, or any group policyholder or plan sponsor be liable
292	292	9 to or billed by the health insurance issuer, the
293	293	10 nonparticipating provider, or the nonparticipating emergency
294	294	11 facility for any amount beyond the cost sharing calculated in
295	295	12 accordance with this subsection with respect to the emergency
296	296	13 services delivered. Administrative requirements or limitations
297	297	14 shall be no greater than those applicable to emergency
298	298	15 services received from a participating provider or a
299	299	16 participating emergency facility.
300	300	17 (b-5) Non-emergency services at participating health care
301	301	18 facilities.
302	302	19 (1) When a beneficiary, insured, or enrollee utilizes
303	303	20 a participating health care facility and, due to any
304	304	21 reason, covered ancillary services are provided by a
305	305	22 nonparticipating provider during or resulting from the
306	306	23 visit, the health insurance issuer shall ensure that the
307	307	24 beneficiary, insured, or enrollee shall incur no greater
308	308	25 out-of-pocket costs than the beneficiary, insured, or
309	309	26 enrollee would have incurred with a participating provider
310	310
311	311
312	312
313	313
314	314
315	315	HB4931 - 8 - LRB103 35342 RPS 65406 b
316	316
317	317
318	318	HB4931- 9 -LRB103 35342 RPS 65406 b HB4931 - 9 - LRB103 35342 RPS 65406 b
319	319	HB4931 - 9 - LRB103 35342 RPS 65406 b
320	320	1 for the ancillary services. Any cost-sharing requirements
321	321	2 shall be applied as though the ancillary services had been
322	322	3 received from a participating provider. Cost sharing shall
323	323	4 be calculated based on the recognized amount for the
324	324	5 ancillary services. If the cost sharing for the same item
325	325	6 or service furnished by a participating provider would
326	326	7 have been a flat-dollar copayment, that amount shall be
327	327	8 the cost-sharing amount unless the provider has billed a
328	328	9 lesser total amount. In no event shall the beneficiary,
329	329	10 insured, enrollee, or any group policyholder or plan
330	330	11 sponsor be liable to or billed by the health insurance
331	331	12 issuer, the nonparticipating provider, or the
332	332	13 participating health care facility for any amount beyond
333	333	14 the cost sharing calculated in accordance with this
334	334	15 subsection with respect to the ancillary services
335	335	16 delivered. In addition to ancillary services, the
336	336	17 requirements of this paragraph shall also apply with
337	337	18 respect to covered items or services furnished as a result
338	338	19 of unforeseen, urgent medical needs that arise at the time
339	339	20 an item or service is furnished, regardless of whether the
340	340	21 nonparticipating provider satisfied the notice and consent
341	341	22 criteria under paragraph (2) of this subsection. When
342	342	23 calculating an enrollee's contribution to the annual
343	343	24 limitation on cost sharing set forth in 42 U.S.C. 18022(c)
344	344	25 and 42 U.S.C. 300gg-6(b), a health insurance issuer or its
345	345	26 subcontractors shall include expenditures for any item or
346	346
347	347
348	348
349	349
350	350
351	351	HB4931 - 9 - LRB103 35342 RPS 65406 b
352	352
353	353
354	354	HB4931- 10 -LRB103 35342 RPS 65406 b HB4931 - 10 - LRB103 35342 RPS 65406 b
355	355	HB4931 - 10 - LRB103 35342 RPS 65406 b
356	356	1 health care service covered under the policy issued to the
357	357	2 enrollee by the health insurance issuer or its
358	358	3 subcontractors if that item or health care service is
359	359	4 included within a category of essential health benefits,
360	360	5 as described in 42 U.S.C. 18022(b)(1), and regardless of
361	361	6 whether the health insurance issuer or its subcontractors
362	362	7 classify that item or service as an essential health
363	363	8 benefit.
364	364	9 (2) When a beneficiary, insured, or enrollee utilizes
365	365	10 a participating health care facility and receives
366	366	11 non-emergency covered health care services other than
367	367	12 those described in paragraph (1) of this subsection from a
368	368	13 nonparticipating provider during or resulting from the
369	369	14 visit, the health insurance issuer shall ensure that the
370	370	15 beneficiary, insured, or enrollee incurs no greater
371	371	16 out-of-pocket costs than the beneficiary, insured, or
372	372	17 enrollee would have incurred with a participating provider
373	373	18 unless the nonparticipating provider or the participating
374	374	19 health care facility on behalf of the nonparticipating
375	375	20 provider satisfies the notice and consent criteria
376	376	21 provided in 42 U.S.C. 300gg-132 and regulations
377	377	22 promulgated thereunder. If the notice and consent criteria
378	378	23 are not satisfied, then:
379	379	24 (A) any cost-sharing requirements shall be applied
380	380	25 as though the health care services had been received
381	381	26 from a participating provider;
382	382
383	383
384	384
385	385
386	386
387	387	HB4931 - 10 - LRB103 35342 RPS 65406 b
388	388
389	389
390	390	HB4931- 11 -LRB103 35342 RPS 65406 b HB4931 - 11 - LRB103 35342 RPS 65406 b
391	391	HB4931 - 11 - LRB103 35342 RPS 65406 b
392	392	1 (B) cost sharing shall be calculated based on the
393	393	2 recognized amount for the health care services; and
394	394	3 (C) in no event shall the beneficiary, insured,
395	395	4 enrollee, or any group policyholder or plan sponsor be
396	396	5 liable to or billed by the health insurance issuer,
397	397	6 the nonparticipating provider, or the participating
398	398	7 health care facility for any amount beyond the cost
399	399	8 sharing calculated in accordance with this subsection
400	400	9 with respect to the health care services delivered;
401	401	10 and .
402	402	11 (D) when calculating an enrollee's contribution to
403	403	12 the annual limitation on cost sharing set forth in 42
404	404	13 U.S.C. 18022(c) and 42 U.S.C. 300gg-6(b), a health
405	405	14 insurance issuer or its subcontractors shall include
406	406	15 expenditures for any item or health care service
407	407	16 covered under the policy issued to the enrollee by the
408	408	17 health insurance issuer or its subcontractors if that
409	409	18 item or health care service is included within a
410	410	19 category of essential health benefits, as described in
411	411	20 42 U.S.C. 18022(b)(1), and regardless of whether the
412	412	21 health insurance issuer or its subcontractors classify
413	413	22 that item or service as an essential health benefit.
414	414	23 (c) Notwithstanding any other provision of this Code,
415	415	24 except when the notice and consent criteria are satisfied for
416	416	25 the situation in paragraph (2) of subsection (b-5), any
417	417	26 benefits a beneficiary, insured, or enrollee receives for
418	418
419	419
420	420
421	421
422	422
423	423	HB4931 - 11 - LRB103 35342 RPS 65406 b
424	424
425	425
426	426	HB4931- 12 -LRB103 35342 RPS 65406 b HB4931 - 12 - LRB103 35342 RPS 65406 b
427	427	HB4931 - 12 - LRB103 35342 RPS 65406 b
428	428	1 services under the situations in subsection (b) or (b-5) are
429	429	2 assigned to the nonparticipating providers or the facility
430	430	3 acting on their behalf. Upon receipt of the provider's bill or
431	431	4 facility's bill, the health insurance issuer shall provide the
432	432	5 nonparticipating provider or the facility with a written
433	433	6 explanation of benefits that specifies the proposed
434	434	7 reimbursement and the applicable deductible, copayment, or
435	435	8 coinsurance amounts owed by the insured, beneficiary, or
436	436	9 enrollee. The health insurance issuer shall pay any
437	437	10 reimbursement subject to this Section directly to the
438	438	11 nonparticipating provider or the facility.
439	439	12 (d) For bills assigned under subsection (c), the
440	440	13 nonparticipating provider or the facility may bill the health
441	441	14 insurance issuer for the services rendered, and the health
442	442	15 insurance issuer may pay the billed amount or attempt to
443	443	16 negotiate reimbursement with the nonparticipating provider or
444	444	17 the facility. Within 30 calendar days after the provider or
445	445	18 facility transmits the bill to the health insurance issuer,
446	446	19 the issuer shall send an initial payment or notice of denial of
447	447	20 payment with the written explanation of benefits to the
448	448	21 provider or facility. If attempts to negotiate reimbursement
449	449	22 for services provided by a nonparticipating provider do not
450	450	23 result in a resolution of the payment dispute within 30 days
451	451	24 after receipt of written explanation of benefits by the health
452	452	25 insurance issuer, then the health insurance issuer or
453	453	26 nonparticipating provider or the facility may initiate binding
454	454
455	455
456	456
457	457
458	458
459	459	HB4931 - 12 - LRB103 35342 RPS 65406 b
460	460
461	461
462	462	HB4931- 13 -LRB103 35342 RPS 65406 b HB4931 - 13 - LRB103 35342 RPS 65406 b
463	463	HB4931 - 13 - LRB103 35342 RPS 65406 b
464	464	1 arbitration to determine payment for services provided on a
465	465	2 per-bill basis. The party requesting arbitration shall notify
466	466	3 the other party arbitration has been initiated and state its
467	467	4 final offer before arbitration. In response to this notice,
468	468	5 the nonrequesting party shall inform the requesting party of
469	469	6 its final offer before the arbitration occurs. Arbitration
470	470	7 shall be initiated by filing a request with the Department of
471	471	8 Insurance.
472	472	9 (e) The Department of Insurance shall publish a list of
473	473	10 approved arbitrators or entities that shall provide binding
474	474	11 arbitration. These arbitrators shall be American Arbitration
475	475	12 Association or American Health Lawyers Association trained
476	476	13 arbitrators. Both parties must agree on an arbitrator from the
477	477	14 Department of Insurance's or its approved entity's list of
478	478	15 arbitrators. If no agreement can be reached, then a list of 5
479	479	16 arbitrators shall be provided by the Department of Insurance
480	480	17 or the approved entity. From the list of 5 arbitrators, the
481	481	18 health insurance issuer can veto 2 arbitrators and the
482	482	19 provider or facility can veto 2 arbitrators. The remaining
483	483	20 arbitrator shall be the chosen arbitrator. This arbitration
484	484	21 shall consist of a review of the written submissions by both
485	485	22 parties. The arbitrator shall not establish a rebuttable
486	486	23 presumption that the qualifying payment amount should be the
487	487	24 total amount owed to the provider or facility by the
488	488	25 combination of the issuer and the insured, beneficiary, or
489	489	26 enrollee. Binding arbitration shall provide for a written
490	490
491	491
492	492
493	493
494	494
495	495	HB4931 - 13 - LRB103 35342 RPS 65406 b
496	496
497	497
498	498	HB4931- 14 -LRB103 35342 RPS 65406 b HB4931 - 14 - LRB103 35342 RPS 65406 b
499	499	HB4931 - 14 - LRB103 35342 RPS 65406 b
500	500	1 decision within 45 days after the request is filed with the
501	501	2 Department of Insurance. Both parties shall be bound by the
502	502	3 arbitrator's decision. The arbitrator's expenses and fees,
503	503	4 together with other expenses, not including attorney's fees,
504	504	5 incurred in the conduct of the arbitration, shall be paid as
505	505	6 provided in the decision.
506	506	7 (f) (Blank).
507	507	8 (g) Section 368a of this Act shall not apply during the
508	508	9 pendency of a decision under subsection (d). Upon the issuance
509	509	10 of the arbitrator's decision, Section 368a applies with
510	510	11 respect to the amount, if any, by which the arbitrator's
511	511	12 determination exceeds the issuer's initial payment under
512	512	13 subsection (c), or the entire amount of the arbitrator's
513	513	14 determination if initial payment was denied. Any interest
514	514	15 required to be paid to a provider under Section 368a shall not
515	515	16 accrue until after 30 days of an arbitrator's decision as
516	516	17 provided in subsection (d), but in no circumstances longer
517	517	18 than 150 days from the date the nonparticipating
518	518	19 facility-based provider billed for services rendered.
519	519	20 (h) Nothing in this Section shall be interpreted to change
520	520	21 the prudent layperson provisions with respect to emergency
521	521	22 services under the Managed Care Reform and Patient Rights Act.
522	522	23 (i) Nothing in this Section shall preclude a health care
523	523	24 provider from billing a beneficiary, insured, or enrollee for
524	524	25 reasonable administrative fees, such as service fees for
525	525	26 checks returned for nonsufficient funds and missed
526	526
527	527
528	528
529	529
530	530
531	531	HB4931 - 14 - LRB103 35342 RPS 65406 b
532	532
533	533
534	534	HB4931- 15 -LRB103 35342 RPS 65406 b HB4931 - 15 - LRB103 35342 RPS 65406 b
535	535	HB4931 - 15 - LRB103 35342 RPS 65406 b
536	536	1 appointments.
537	537	2 (j) Nothing in this Section shall preclude a beneficiary,
538	538	3 insured, or enrollee from assigning benefits to a
539	539	4 nonparticipating provider when the notice and consent criteria
540	540	5 are satisfied under paragraph (2) of subsection (b-5) or in
541	541	6 any other situation not described in subsection (b) or (b-5).
542	542	7 (k) Except when the notice and consent criteria are
543	543	8 satisfied under paragraph (2) of subsection (b-5), if an
544	544	9 individual receives health care services under the situations
545	545	10 described in subsection (b) or (b-5), no referral requirement
546	546	11 or any other provision contained in the policy or certificate
547	547	12 of coverage shall deny coverage, reduce benefits, or otherwise
548	548	13 defeat the requirements of this Section for services that
549	549	14 would have been covered with a participating provider.
550	550	15 However, this subsection shall not be construed to preclude a
551	551	16 provider contract with a health insurance issuer, or with an
552	552	17 administrator or similar entity acting on the issuer's behalf,
553	553	18 from imposing requirements on the participating provider,
554	554	19 participating emergency facility, or participating health care
555	555	20 facility relating to the referral of covered individuals to
556	556	21 nonparticipating providers.
557	557	22 (l) Except if the notice and consent criteria are
558	558	23 satisfied under paragraph (2) of subsection (b-5),
559	559	24 cost-sharing amounts calculated in conformity with this
560	560	25 Section shall count toward any deductible or out-of-pocket
561	561	26 maximum applicable to in-network coverage.
562	562
563	563
564	564
565	565
566	566
567	567	HB4931 - 15 - LRB103 35342 RPS 65406 b
568	568
569	569
570	570	HB4931- 16 -LRB103 35342 RPS 65406 b HB4931 - 16 - LRB103 35342 RPS 65406 b
571	571	HB4931 - 16 - LRB103 35342 RPS 65406 b
572	572	1 (m) The Department has the authority to enforce the
573	573	2 requirements of this Section in the situations described in
574	574	3 subsections (b) and (b-5), and in any other situation for
575	575	4 which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
576	576	5 regulations promulgated thereunder would prohibit an
577	577	6 individual from being billed or liable for emergency services
578	578	7 furnished by a nonparticipating provider or nonparticipating
579	579	8 emergency facility or for non-emergency health care services
580	580	9 furnished by a nonparticipating provider at a participating
581	581	10 health care facility.
582	582	11 (n) This Section does not apply with respect to air
583	583	12 ambulance or ground ambulance services. This Section does not
584	584	13 apply to any policy of excepted benefits or to short-term,
585	585	14 limited-duration health insurance coverage.
586	586	15 (Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
587	587	16 (Text of Section after amendment by P.A. 103-440)
588	588	17 Sec. 356z.3a. Billing; emergency services;
589	589	18 nonparticipating providers.
590	590	19 (a) As used in this Section:
591	591	20 "Ancillary services" means:
592	592	21 (1) items and services related to emergency medicine,
593	593	22 anesthesiology, pathology, radiology, and neonatology that
594	594	23 are provided by any health care provider;
595	595	24 (2) items and services provided by assistant surgeons,
596	596	25 hospitalists, and intensivists;
597	597
598	598
599	599
600	600
601	601
602	602	HB4931 - 16 - LRB103 35342 RPS 65406 b
603	603
604	604
605	605	HB4931- 17 -LRB103 35342 RPS 65406 b HB4931 - 17 - LRB103 35342 RPS 65406 b
606	606	HB4931 - 17 - LRB103 35342 RPS 65406 b
607	607	1 (3) diagnostic services, including radiology and
608	608	2 laboratory services, except for advanced diagnostic
609	609	3 laboratory tests identified on the most current list
610	610	4 published by the United States Secretary of Health and
611	611	5 Human Services under 42 U.S.C. 300gg-132(b)(3);
612	612	6 (4) items and services provided by other specialty
613	613	7 practitioners as the United States Secretary of Health and
614	614	8 Human Services specifies through rulemaking under 42
615	615	9 U.S.C. 300gg-132(b)(3);
616	616	10 (5) items and services provided by a nonparticipating
617	617	11 provider if there is no participating provider who can
618	618	12 furnish the item or service at the facility; and
619	619	13 (6) items and services provided by a nonparticipating
620	620	14 provider if there is no participating provider who will
621	621	15 furnish the item or service because a participating
622	622	16 provider has asserted the participating provider's rights
623	623	17 under the Health Care Right of Conscience Act.
624	624	18 "Cost sharing" means the amount an insured, beneficiary,
625	625	19 or enrollee is responsible for paying for a covered item or
626	626	20 service under the terms of the policy or certificate. "Cost
627	627	21 sharing" includes copayments, coinsurance, and amounts paid
628	628	22 toward deductibles, but does not include amounts paid towards
629	629	23 premiums, balance billing by out-of-network providers, or the
630	630	24 cost of items or services that are not covered under the policy
631	631	25 or certificate.
632	632	26 "Emergency department of a hospital" means any hospital
633	633
634	634
635	635
636	636
637	637
638	638	HB4931 - 17 - LRB103 35342 RPS 65406 b
639	639
640	640
641	641	HB4931- 18 -LRB103 35342 RPS 65406 b HB4931 - 18 - LRB103 35342 RPS 65406 b
642	642	HB4931 - 18 - LRB103 35342 RPS 65406 b
643	643	1 department that provides emergency services, including a
644	644	2 hospital outpatient department.
645	645	3 "Emergency medical condition" has the meaning ascribed to
646	646	4 that term in Section 10 of the Managed Care Reform and Patient
647	647	5 Rights Act.
648	648	6 "Emergency medical screening examination" has the meaning
649	649	7 ascribed to that term in Section 10 of the Managed Care Reform
650	650	8 and Patient Rights Act.
651	651	9 "Emergency services" means, with respect to an emergency
652	652	10 medical condition:
653	653	11 (1) in general, an emergency medical screening
654	654	12 examination, including ancillary services routinely
655	655	13 available to the emergency department to evaluate such
656	656	14 emergency medical condition, and such further medical
657	657	15 examination and treatment as would be required to
658	658	16 stabilize the patient regardless of the department of the
659	659	17 hospital or other facility in which such further
660	660	18 examination or treatment is furnished; or
661	661	19 (2) additional items and services for which benefits
662	662	20 are provided or covered under the coverage and that are
663	663	21 furnished by a nonparticipating provider or
664	664	22 nonparticipating emergency facility regardless of the
665	665	23 department of the hospital or other facility in which such
666	666	24 items are furnished after the insured, beneficiary, or
667	667	25 enrollee is stabilized and as part of outpatient
668	668	26 observation or an inpatient or outpatient stay with
669	669
670	670
671	671
672	672
673	673
674	674	HB4931 - 18 - LRB103 35342 RPS 65406 b
675	675
676	676
677	677	HB4931- 19 -LRB103 35342 RPS 65406 b HB4931 - 19 - LRB103 35342 RPS 65406 b
678	678	HB4931 - 19 - LRB103 35342 RPS 65406 b
679	679	1 respect to the visit in which the services described in
680	680	2 paragraph (1) are furnished. Services after stabilization
681	681	3 cease to be emergency services only when all the
682	682	4 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
683	683	5 regulations thereunder are met.
684	684	6 "Freestanding Emergency Center" means a facility licensed
685	685	7 under Section 32.5 of the Emergency Medical Services (EMS)
686	686	8 Systems Act.
687	687	9 "Health care facility" means, in the context of
688	688	10 non-emergency services, any of the following:
689	689	11 (1) a hospital as defined in 42 U.S.C. 1395x(e);
690	690	12 (2) a hospital outpatient department;
691	691	13 (3) a critical access hospital certified under 42
692	692	14 U.S.C. 1395i-4(e);
693	693	15 (4) an ambulatory surgical treatment center as defined
694	694	16 in the Ambulatory Surgical Treatment Center Act; or
695	695	17 (5) any recipient of a license under the Hospital
696	696	18 Licensing Act that is not otherwise described in this
697	697	19 definition.
698	698	20 "Health care provider" means a provider as defined in
699	699	21 subsection (d) of Section 370g. "Health care provider" does
700	700	22 not include a provider of air ambulance or ground ambulance
701	701	23 services.
702	702	24 "Health care services" has the meaning ascribed to that
703	703	25 term in subsection (a) of Section 370g.
704	704	26 "Health insurance issuer" has the meaning ascribed to that
705	705
706	706
707	707
708	708
709	709
710	710	HB4931 - 19 - LRB103 35342 RPS 65406 b
711	711
712	712
713	713	HB4931- 20 -LRB103 35342 RPS 65406 b HB4931 - 20 - LRB103 35342 RPS 65406 b
714	714	HB4931 - 20 - LRB103 35342 RPS 65406 b
715	715	1 term in Section 5 of the Illinois Health Insurance Portability
716	716	2 and Accountability Act.
717	717	3 "Nonparticipating emergency facility" means, with respect
718	718	4 to the furnishing of an item or service under a policy of group
719	719	5 or individual health insurance coverage, any of the following
720	720	6 facilities that does not have a contractual relationship
721	721	7 directly or indirectly with a health insurance issuer in
722	722	8 relation to the coverage:
723	723	9 (1) an emergency department of a hospital;
724	724	10 (2) a Freestanding Emergency Center;
725	725	11 (3) an ambulatory surgical treatment center as defined
726	726	12 in the Ambulatory Surgical Treatment Center Act; or
727	727	13 (4) with respect to emergency services described in
728	728	14 paragraph (2) of the definition of "emergency services", a
729	729	15 hospital.
730	730	16 "Nonparticipating provider" means, with respect to the
731	731	17 furnishing of an item or service under a policy of group or
732	732	18 individual health insurance coverage, any health care provider
733	733	19 who does not have a contractual relationship directly or
734	734	20 indirectly with a health insurance issuer in relation to the
735	735	21 coverage.
736	736	22 "Participating emergency facility" means any of the
737	737	23 following facilities that has a contractual relationship
738	738	24 directly or indirectly with a health insurance issuer offering
739	739	25 group or individual health insurance coverage setting forth
740	740	26 the terms and conditions on which a relevant health care
741	741
742	742
743	743
744	744
745	745
746	746	HB4931 - 20 - LRB103 35342 RPS 65406 b
747	747
748	748
749	749	HB4931- 21 -LRB103 35342 RPS 65406 b HB4931 - 21 - LRB103 35342 RPS 65406 b
750	750	HB4931 - 21 - LRB103 35342 RPS 65406 b
751	751	1 service is provided to an insured, beneficiary, or enrollee
752	752	2 under the coverage:
753	753	3 (1) an emergency department of a hospital;
754	754	4 (2) a Freestanding Emergency Center;
755	755	5 (3) an ambulatory surgical treatment center as defined
756	756	6 in the Ambulatory Surgical Treatment Center Act; or
757	757	7 (4) with respect to emergency services described in
758	758	8 paragraph (2) of the definition of "emergency services", a
759	759	9 hospital.
760	760	10 For purposes of this definition, a single case agreement
761	761	11 between an emergency facility and an issuer that is used to
762	762	12 address unique situations in which an insured, beneficiary, or
763	763	13 enrollee requires services that typically occur out-of-network
764	764	14 constitutes a contractual relationship and is limited to the
765	765	15 parties to the agreement.
766	766	16 "Participating health care facility" means any health care
767	767	17 facility that has a contractual relationship directly or
768	768	18 indirectly with a health insurance issuer offering group or
769	769	19 individual health insurance coverage setting forth the terms
770	770	20 and conditions on which a relevant health care service is
771	771	21 provided to an insured, beneficiary, or enrollee under the
772	772	22 coverage. A single case agreement between an emergency
773	773	23 facility and an issuer that is used to address unique
774	774	24 situations in which an insured, beneficiary, or enrollee
775	775	25 requires services that typically occur out-of-network
776	776	26 constitutes a contractual relationship for purposes of this
777	777
778	778
779	779
780	780
781	781
782	782	HB4931 - 21 - LRB103 35342 RPS 65406 b
783	783
784	784
785	785	HB4931- 22 -LRB103 35342 RPS 65406 b HB4931 - 22 - LRB103 35342 RPS 65406 b
786	786	HB4931 - 22 - LRB103 35342 RPS 65406 b
787	787	1 definition and is limited to the parties to the agreement.
788	788	2 "Participating provider" means any health care provider
789	789	3 that has a contractual relationship directly or indirectly
790	790	4 with a health insurance issuer offering group or individual
791	791	5 health insurance coverage setting forth the terms and
792	792	6 conditions on which a relevant health care service is provided
793	793	7 to an insured, beneficiary, or enrollee under the coverage.
794	794	8 "Qualifying payment amount" has the meaning given to that
795	795	9 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
796	796	10 promulgated thereunder.
797	797	11 "Recognized amount" means the lesser of the amount
798	798	12 initially billed by the provider or the qualifying payment
799	799	13 amount.
800	800	14 "Stabilize" means "stabilization" as defined in Section 10
801	801	15 of the Managed Care Reform and Patient Rights Act.
802	802	16 "Treating provider" means a health care provider who has
803	803	17 evaluated the individual.
804	804	18 "Visit" means, with respect to health care services
805	805	19 furnished to an individual at a health care facility, health
806	806	20 care services furnished by a provider at the facility, as well
807	807	21 as equipment, devices, telehealth services, imaging services,
808	808	22 laboratory services, and preoperative and postoperative
809	809	23 services regardless of whether the provider furnishing such
810	810	24 services is at the facility.
811	811	25 (b) Emergency services. When a beneficiary, insured, or
812	812	26 enrollee receives emergency services from a nonparticipating
813	813
814	814
815	815
816	816
817	817
818	818	HB4931 - 22 - LRB103 35342 RPS 65406 b
819	819
820	820
821	821	HB4931- 23 -LRB103 35342 RPS 65406 b HB4931 - 23 - LRB103 35342 RPS 65406 b
822	822	HB4931 - 23 - LRB103 35342 RPS 65406 b
823	823	1 provider or a nonparticipating emergency facility, the health
824	824	2 insurance issuer shall ensure that the beneficiary, insured,
825	825	3 or enrollee shall incur no greater out-of-pocket costs than
826	826	4 the beneficiary, insured, or enrollee would have incurred with
827	827	5 a participating provider or a participating emergency
828	828	6 facility. Any cost-sharing requirements shall be applied as
829	829	7 though the emergency services had been received from a
830	830	8 participating provider or a participating facility. Cost
831	831	9 sharing shall be calculated based on the recognized amount for
832	832	10 the emergency services. If the cost sharing for the same item
833	833	11 or service furnished by a participating provider would have
834	834	12 been a flat-dollar copayment, that amount shall be the
835	835	13 cost-sharing amount unless the provider has billed a lesser
836	836	14 total amount. In no event shall the beneficiary, insured,
837	837	15 enrollee, or any group policyholder or plan sponsor be liable
838	838	16 to or billed by the health insurance issuer, the
839	839	17 nonparticipating provider, or the nonparticipating emergency
840	840	18 facility for any amount beyond the cost sharing calculated in
841	841	19 accordance with this subsection with respect to the emergency
842	842	20 services delivered. Administrative requirements or limitations
843	843	21 shall be no greater than those applicable to emergency
844	844	22 services received from a participating provider or a
845	845	23 participating emergency facility.
846	846	24 (b-5) Non-emergency services at participating health care
847	847	25 facilities.
848	848	26 (1) When a beneficiary, insured, or enrollee utilizes
849	849
850	850
851	851
852	852
853	853
854	854	HB4931 - 23 - LRB103 35342 RPS 65406 b
855	855
856	856
857	857	HB4931- 24 -LRB103 35342 RPS 65406 b HB4931 - 24 - LRB103 35342 RPS 65406 b
858	858	HB4931 - 24 - LRB103 35342 RPS 65406 b
859	859	1 a participating health care facility and, due to any
860	860	2 reason, covered ancillary services are provided by a
861	861	3 nonparticipating provider during or resulting from the
862	862	4 visit, the health insurance issuer shall ensure that the
863	863	5 beneficiary, insured, or enrollee shall incur no greater
864	864	6 out-of-pocket costs than the beneficiary, insured, or
865	865	7 enrollee would have incurred with a participating provider
866	866	8 for the ancillary services. Any cost-sharing requirements
867	867	9 shall be applied as though the ancillary services had been
868	868	10 received from a participating provider. Cost sharing shall
869	869	11 be calculated based on the recognized amount for the
870	870	12 ancillary services. If the cost sharing for the same item
871	871	13 or service furnished by a participating provider would
872	872	14 have been a flat-dollar copayment, that amount shall be
873	873	15 the cost-sharing amount unless the provider has billed a
874	874	16 lesser total amount. In no event shall the beneficiary,
875	875	17 insured, enrollee, or any group policyholder or plan
876	876	18 sponsor be liable to or billed by the health insurance
877	877	19 issuer, the nonparticipating provider, or the
878	878	20 participating health care facility for any amount beyond
879	879	21 the cost sharing calculated in accordance with this
880	880	22 subsection with respect to the ancillary services
881	881	23 delivered. In addition to ancillary services, the
882	882	24 requirements of this paragraph shall also apply with
883	883	25 respect to covered items or services furnished as a result
884	884	26 of unforeseen, urgent medical needs that arise at the time
885	885
886	886
887	887
888	888
889	889
890	890	HB4931 - 24 - LRB103 35342 RPS 65406 b
891	891
892	892
893	893	HB4931- 25 -LRB103 35342 RPS 65406 b HB4931 - 25 - LRB103 35342 RPS 65406 b
894	894	HB4931 - 25 - LRB103 35342 RPS 65406 b
895	895	1 an item or service is furnished, regardless of whether the
896	896	2 nonparticipating provider satisfied the notice and consent
897	897	3 criteria under paragraph (2) of this subsection. When
898	898	4 calculating an enrollee's contribution to the annual
899	899	5 limitation on cost sharing set forth in 42 U.S.C. 18022(c)
900	900	6 and 42 U.S.C. 300gg-6(b), a health insurance issuer or its
901	901	7 subcontractors shall include expenditures for any item or
902	902	8 health care service covered under the policy issued to the
903	903	9 enrollee by the health insurance issuer or its
904	904	10 subcontractors if that item or health care service is
905	905	11 included within a category of essential health benefits,
906	906	12 as described in 42 U.S.C. 18022(b)(1), and regardless of
907	907	13 whether the health insurance issuer or its subcontractors
908	908	14 classify that item or service as an essential health
909	909	15 benefit.
910	910	16 (2) When a beneficiary, insured, or enrollee utilizes
911	911	17 a participating health care facility and receives
912	912	18 non-emergency covered health care services other than
913	913	19 those described in paragraph (1) of this subsection from a
914	914	20 nonparticipating provider during or resulting from the
915	915	21 visit, the health insurance issuer shall ensure that the
916	916	22 beneficiary, insured, or enrollee incurs no greater
917	917	23 out-of-pocket costs than the beneficiary, insured, or
918	918	24 enrollee would have incurred with a participating provider
919	919	25 unless the nonparticipating provider or the participating
920	920	26 health care facility on behalf of the nonparticipating
921	921
922	922
923	923
924	924
925	925
926	926	HB4931 - 25 - LRB103 35342 RPS 65406 b
927	927
928	928
929	929	HB4931- 26 -LRB103 35342 RPS 65406 b HB4931 - 26 - LRB103 35342 RPS 65406 b
930	930	HB4931 - 26 - LRB103 35342 RPS 65406 b
931	931	1 provider satisfies the notice and consent criteria
932	932	2 provided in 42 U.S.C. 300gg-132 and regulations
933	933	3 promulgated thereunder. If the notice and consent criteria
934	934	4 are not satisfied, then:
935	935	5 (A) any cost-sharing requirements shall be applied
936	936	6 as though the health care services had been received
937	937	7 from a participating provider;
938	938	8 (B) cost sharing shall be calculated based on the
939	939	9 recognized amount for the health care services; and
940	940	10 (C) in no event shall the beneficiary, insured,
941	941	11 enrollee, or any group policyholder or plan sponsor be
942	942	12 liable to or billed by the health insurance issuer,
943	943	13 the nonparticipating provider, or the participating
944	944	14 health care facility for any amount beyond the cost
945	945	15 sharing calculated in accordance with this subsection
946	946	16 with respect to the health care services delivered;
947	947	17 and .
948	948	18 (D) when calculating an enrollee's contribution to
949	949	19 the annual limitation on cost sharing set forth in 42
950	950	20 U.S.C. 18022(c) and 42 U.S.C. 300gg-6(b), a health
951	951	21 insurance issuer or its subcontractors shall include
952	952	22 expenditures for any item or health care service
953	953	23 covered under the policy issued to the enrollee by the
954	954	24 health insurance issuer or its subcontractors if that
955	955	25 item or health care service is included within a
956	956	26 category of essential health benefits, as described in
957	957
958	958
959	959
960	960
961	961
962	962	HB4931 - 26 - LRB103 35342 RPS 65406 b
963	963
964	964
965	965	HB4931- 27 -LRB103 35342 RPS 65406 b HB4931 - 27 - LRB103 35342 RPS 65406 b
966	966	HB4931 - 27 - LRB103 35342 RPS 65406 b
967	967	1 42 U.S.C. 18022(b)(1), and regardless of whether the
968	968	2 health insurance issuer or its subcontractors classify
969	969	3 that item or service as an essential health benefit.
970	970	4 (c) Notwithstanding any other provision of this Code,
971	971	5 except when the notice and consent criteria are satisfied for
972	972	6 the situation in paragraph (2) of subsection (b-5), any
973	973	7 benefits a beneficiary, insured, or enrollee receives for
974	974	8 services under the situations in subsection (b) or (b-5) are
975	975	9 assigned to the nonparticipating providers or the facility
976	976	10 acting on their behalf. Upon receipt of the provider's bill or
977	977	11 facility's bill, the health insurance issuer shall provide the
978	978	12 nonparticipating provider or the facility with a written
979	979	13 explanation of benefits that specifies the proposed
980	980	14 reimbursement and the applicable deductible, copayment, or
981	981	15 coinsurance amounts owed by the insured, beneficiary, or
982	982	16 enrollee. The health insurance issuer shall pay any
983	983	17 reimbursement subject to this Section directly to the
984	984	18 nonparticipating provider or the facility.
985	985	19 (d) For bills assigned under subsection (c), the
986	986	20 nonparticipating provider or the facility may bill the health
987	987	21 insurance issuer for the services rendered, and the health
988	988	22 insurance issuer may pay the billed amount or attempt to
989	989	23 negotiate reimbursement with the nonparticipating provider or
990	990	24 the facility. Within 30 calendar days after the provider or
991	991	25 facility transmits the bill to the health insurance issuer,
992	992	26 the issuer shall send an initial payment or notice of denial of
993	993
994	994
995	995
996	996
997	997
998	998	HB4931 - 27 - LRB103 35342 RPS 65406 b
999	999
1000	1000
1001	1001	HB4931- 28 -LRB103 35342 RPS 65406 b HB4931 - 28 - LRB103 35342 RPS 65406 b
1002	1002	HB4931 - 28 - LRB103 35342 RPS 65406 b
1003	1003	1 payment with the written explanation of benefits to the
1004	1004	2 provider or facility. If attempts to negotiate reimbursement
1005	1005	3 for services provided by a nonparticipating provider do not
1006	1006	4 result in a resolution of the payment dispute within 30 days
1007	1007	5 after receipt of written explanation of benefits by the health
1008	1008	6 insurance issuer, then the health insurance issuer or
1009	1009	7 nonparticipating provider or the facility may initiate binding
1010	1010	8 arbitration to determine payment for services provided on a
1011	1011	9 per-bill or batched-bill basis, in accordance with Section
1012	1012	10 300gg-111 of the Public Health Service Act and the regulations
1013	1013	11 promulgated thereunder. The party requesting arbitration shall
1014	1014	12 notify the other party arbitration has been initiated and
1015	1015	13 state its final offer before arbitration. In response to this
1016	1016	14 notice, the nonrequesting party shall inform the requesting
1017	1017	15 party of its final offer before the arbitration occurs.
1018	1018	16 Arbitration shall be initiated by filing a request with the
1019	1019	17 Department of Insurance.
1020	1020	18 (e) The Department of Insurance shall publish a list of
1021	1021	19 approved arbitrators or entities that shall provide binding
1022	1022	20 arbitration. These arbitrators shall be American Arbitration
1023	1023	21 Association or American Health Lawyers Association trained
1024	1024	22 arbitrators. Both parties must agree on an arbitrator from the
1025	1025	23 Department of Insurance's or its approved entity's list of
1026	1026	24 arbitrators. If no agreement can be reached, then a list of 5
1027	1027	25 arbitrators shall be provided by the Department of Insurance
1028	1028	26 or the approved entity. From the list of 5 arbitrators, the
1029	1029
1030	1030
1031	1031
1032	1032
1033	1033
1034	1034	HB4931 - 28 - LRB103 35342 RPS 65406 b
1035	1035
1036	1036
1037	1037	HB4931- 29 -LRB103 35342 RPS 65406 b HB4931 - 29 - LRB103 35342 RPS 65406 b
1038	1038	HB4931 - 29 - LRB103 35342 RPS 65406 b
1039	1039	1 health insurance issuer can veto 2 arbitrators and the
1040	1040	2 provider or facility can veto 2 arbitrators. The remaining
1041	1041	3 arbitrator shall be the chosen arbitrator. This arbitration
1042	1042	4 shall consist of a review of the written submissions by both
1043	1043	5 parties. The arbitrator shall not establish a rebuttable
1044	1044	6 presumption that the qualifying payment amount should be the
1045	1045	7 total amount owed to the provider or facility by the
1046	1046	8 combination of the issuer and the insured, beneficiary, or
1047	1047	9 enrollee. Binding arbitration shall provide for a written
1048	1048	10 decision within 45 days after the request is filed with the
1049	1049	11 Department of Insurance. Both parties shall be bound by the
1050	1050	12 arbitrator's decision. The arbitrator's expenses and fees,
1051	1051	13 together with other expenses, not including attorney's fees,
1052	1052	14 incurred in the conduct of the arbitration, shall be paid as
1053	1053	15 provided in the decision.
1054	1054	16 (f) (Blank).
1055	1055	17 (g) Section 368a of this Act shall not apply during the
1056	1056	18 pendency of a decision under subsection (d). Upon the issuance
1057	1057	19 of the arbitrator's decision, Section 368a applies with
1058	1058	20 respect to the amount, if any, by which the arbitrator's
1059	1059	21 determination exceeds the issuer's initial payment under
1060	1060	22 subsection (c), or the entire amount of the arbitrator's
1061	1061	23 determination if initial payment was denied. Any interest
1062	1062	24 required to be paid to a provider under Section 368a shall not
1063	1063	25 accrue until after 30 days of an arbitrator's decision as
1064	1064	26 provided in subsection (d), but in no circumstances longer
1065	1065
1066	1066
1067	1067
1068	1068
1069	1069
1070	1070	HB4931 - 29 - LRB103 35342 RPS 65406 b
1071	1071
1072	1072
1073	1073	HB4931- 30 -LRB103 35342 RPS 65406 b HB4931 - 30 - LRB103 35342 RPS 65406 b
1074	1074	HB4931 - 30 - LRB103 35342 RPS 65406 b
1075	1075	1 than 150 days from the date the nonparticipating
1076	1076	2 facility-based provider billed for services rendered.
1077	1077	3 (h) Nothing in this Section shall be interpreted to change
1078	1078	4 the prudent layperson provisions with respect to emergency
1079	1079	5 services under the Managed Care Reform and Patient Rights Act.
1080	1080	6 (i) Nothing in this Section shall preclude a health care
1081	1081	7 provider from billing a beneficiary, insured, or enrollee for
1082	1082	8 reasonable administrative fees, such as service fees for
1083	1083	9 checks returned for nonsufficient funds and missed
1084	1084	10 appointments.
1085	1085	11 (j) Nothing in this Section shall preclude a beneficiary,
1086	1086	12 insured, or enrollee from assigning benefits to a
1087	1087	13 nonparticipating provider when the notice and consent criteria
1088	1088	14 are satisfied under paragraph (2) of subsection (b-5) or in
1089	1089	15 any other situation not described in subsection (b) or (b-5).
1090	1090	16 (k) Except when the notice and consent criteria are
1091	1091	17 satisfied under paragraph (2) of subsection (b-5), if an
1092	1092	18 individual receives health care services under the situations
1093	1093	19 described in subsection (b) or (b-5), no referral requirement
1094	1094	20 or any other provision contained in the policy or certificate
1095	1095	21 of coverage shall deny coverage, reduce benefits, or otherwise
1096	1096	22 defeat the requirements of this Section for services that
1097	1097	23 would have been covered with a participating provider.
1098	1098	24 However, this subsection shall not be construed to preclude a
1099	1099	25 provider contract with a health insurance issuer, or with an
1100	1100	26 administrator or similar entity acting on the issuer's behalf,
1101	1101
1102	1102
1103	1103
1104	1104
1105	1105
1106	1106	HB4931 - 30 - LRB103 35342 RPS 65406 b
1107	1107
1108	1108
1109	1109	HB4931- 31 -LRB103 35342 RPS 65406 b HB4931 - 31 - LRB103 35342 RPS 65406 b
1110	1110	HB4931 - 31 - LRB103 35342 RPS 65406 b
1111	1111	1 from imposing requirements on the participating provider,
1112	1112	2 participating emergency facility, or participating health care
1113	1113	3 facility relating to the referral of covered individuals to
1114	1114	4 nonparticipating providers.
1115	1115	5 (l) Except if the notice and consent criteria are
1116	1116	6 satisfied under paragraph (2) of subsection (b-5),
1117	1117	7 cost-sharing amounts calculated in conformity with this
1118	1118	8 Section shall count toward any deductible or out-of-pocket
1119	1119	9 maximum applicable to in-network coverage.
1120	1120	10 (m) The Department has the authority to enforce the
1121	1121	11 requirements of this Section in the situations described in
1122	1122	12 subsections (b) and (b-5), and in any other situation for
1123	1123	13 which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
1124	1124	14 regulations promulgated thereunder would prohibit an
1125	1125	15 individual from being billed or liable for emergency services
1126	1126	16 furnished by a nonparticipating provider or nonparticipating
1127	1127	17 emergency facility or for non-emergency health care services
1128	1128	18 furnished by a nonparticipating provider at a participating
1129	1129	19 health care facility.
1130	1130	20 (n) This Section does not apply with respect to air
1131	1131	21 ambulance or ground ambulance services. This Section does not
1132	1132	22 apply to any policy of excepted benefits or to short-term,
1133	1133	23 limited-duration health insurance coverage.
1134	1134	24 (Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23;
1135	1135	25 103-440, eff. 1-1-24.)
1136	1136
1137	1137
1138	1138
1139	1139
1140	1140
1141	1141	HB4931 - 31 - LRB103 35342 RPS 65406 b
1142	1142
1143	1143
1144	1144	HB4931- 32 -LRB103 35342 RPS 65406 b HB4931 - 32 - LRB103 35342 RPS 65406 b
1145	1145	HB4931 - 32 - LRB103 35342 RPS 65406 b
1146	1146	1 Section 95. No acceleration or delay. Where this Act makes
1147	1147	2 changes in a statute that is represented in this Act by text
1148	1148	3 that is not yet or no longer in effect (for example, a Section
1149	1149	4 represented by multiple versions), the use of that text does
1150	1150	5 not accelerate or delay the taking effect of (i) the changes
1151	1151	6 made by this Act or (ii) provisions derived from any other
1152	1152	7 Public Act.
1153	1153
1154	1154
1155	1155
1156	1156
1157	1157
1158	1158	HB4931 - 32 - LRB103 35342 RPS 65406 b