Illinois 2023-2024 Regular Session

Illinois Senate Bill SB2295 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 SB2295 Introduced 2/10/2023, by Sen. Julie A. Morrison SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a Amends the Illinois Insurance Code. In provisions concerning billing for services provided by nonparticipating providers or facilities, provides that if attempts to negotiate reimbursement for services provided by a nonparticipating provider do not result in a resolution of the payment dispute within 30 days after receipt of written explanation of benefits by the health insurance issuer, then the health insurance issuer, nonparticipating provider, or the facility may initiate binding arbitration to determine payment for services provided on a per-bill or a batched-bill basis (instead of only a per-bill basis) in accordance with specified law. LRB103 24784 BMS 56584 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2295 Introduced 2/10/2023, by Sen. Julie A. Morrison SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a 215 ILCS 5/356z.3a Amends the Illinois Insurance Code. In provisions concerning billing for services provided by nonparticipating providers or facilities, provides that if attempts to negotiate reimbursement for services provided by a nonparticipating provider do not result in a resolution of the payment dispute within 30 days after receipt of written explanation of benefits by the health insurance issuer, then the health insurance issuer, nonparticipating provider, or the facility may initiate binding arbitration to determine payment for services provided on a per-bill or a batched-bill basis (instead of only a per-bill basis) in accordance with specified law. LRB103 24784 BMS 56584 b LRB103 24784 BMS 56584 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2295 Introduced 2/10/2023, by Sen. Julie A. Morrison 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 provisions concerning billing for services provided by nonparticipating providers or facilities, provides that if attempts to negotiate reimbursement for services provided by a nonparticipating provider do not result in a resolution of the payment dispute within 30 days after receipt of written explanation of benefits by the health insurance issuer, then the health insurance issuer, nonparticipating provider, or the facility may initiate binding arbitration to determine payment for services provided on a per-bill or a batched-bill basis (instead of only a per-bill basis) in accordance with specified law.
6	6	LRB103 24784 BMS 56584 b LRB103 24784 BMS 56584 b
7	7	LRB103 24784 BMS 56584 b
8	8	A BILL FOR
9	9	SB2295LRB103 24784 BMS 56584 b SB2295 LRB103 24784 BMS 56584 b
10	10	SB2295 LRB103 24784 BMS 56584 b
11	11	1 AN ACT concerning regulation.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Insurance Code is amended by
15	15	5 changing Section 356z.3a as follows:
16	16	6 (215 ILCS 5/356z.3a)
17	17	7 Sec. 356z.3a. Billing; emergency services;
18	18	8 nonparticipating providers.
19	19	9 (a) As used in this Section:
20	20	10 "Ancillary services" means:
21	21	11 (1) items and services related to emergency medicine,
22	22	12 anesthesiology, pathology, radiology, and neonatology that
23	23	13 are provided by any health care provider;
24	24	14 (2) items and services provided by assistant surgeons,
25	25	15 hospitalists, and intensivists;
26	26	16 (3) diagnostic services, including radiology and
27	27	17 laboratory services, except for advanced diagnostic
28	28	18 laboratory tests identified on the most current list
29	29	19 published by the United States Secretary of Health and
30	30	20 Human Services under 42 U.S.C. 300gg-132(b)(3);
31	31	21 (4) items and services provided by other specialty
32	32	22 practitioners as the United States Secretary of Health and
33	33	23 Human Services specifies through rulemaking under 42
34	34
35	35
36	36
37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2295 Introduced 2/10/2023, by Sen. Julie A. Morrison 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 provisions concerning billing for services provided by nonparticipating providers or facilities, provides that if attempts to negotiate reimbursement for services provided by a nonparticipating provider do not result in a resolution of the payment dispute within 30 days after receipt of written explanation of benefits by the health insurance issuer, then the health insurance issuer, nonparticipating provider, or the facility may initiate binding arbitration to determine payment for services provided on a per-bill or a batched-bill basis (instead of only a per-bill basis) in accordance with specified law.
41	41	LRB103 24784 BMS 56584 b LRB103 24784 BMS 56584 b
42	42	LRB103 24784 BMS 56584 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 24784 BMS 56584 b
54	54
55	55
56	56
57	57
58	58
59	59
60	60
61	61
62	62
63	63	SB2295 LRB103 24784 BMS 56584 b
64	64
65	65
66	66	SB2295- 2 -LRB103 24784 BMS 56584 b SB2295 - 2 - LRB103 24784 BMS 56584 b
67	67	SB2295 - 2 - LRB103 24784 BMS 56584 b
68	68	1 U.S.C. 300gg-132(b)(3);
69	69	2 (5) items and services provided by a nonparticipating
70	70	3 provider if there is no participating provider who can
71	71	4 furnish the item or service at the facility; and
72	72	5 (6) items and services provided by a nonparticipating
73	73	6 provider if there is no participating provider who will
74	74	7 furnish the item or service because a participating
75	75	8 provider has asserted the participating provider's rights
76	76	9 under the Health Care Right of Conscience Act.
77	77	10 "Cost sharing" means the amount an insured, beneficiary,
78	78	11 or enrollee is responsible for paying for a covered item or
79	79	12 service under the terms of the policy or certificate. "Cost
80	80	13 sharing" includes copayments, coinsurance, and amounts paid
81	81	14 toward deductibles, but does not include amounts paid towards
82	82	15 premiums, balance billing by out-of-network providers, or the
83	83	16 cost of items or services that are not covered under the policy
84	84	17 or certificate.
85	85	18 "Emergency department of a hospital" means any hospital
86	86	19 department that provides emergency services, including a
87	87	20 hospital outpatient department.
88	88	21 "Emergency medical condition" has the meaning ascribed to
89	89	22 that term in Section 10 of the Managed Care Reform and Patient
90	90	23 Rights Act.
91	91	24 "Emergency medical screening examination" has the meaning
92	92	25 ascribed to that term in Section 10 of the Managed Care Reform
93	93	26 and Patient Rights Act.
94	94
95	95
96	96
97	97
98	98
99	99	SB2295 - 2 - LRB103 24784 BMS 56584 b
100	100
101	101
102	102	SB2295- 3 -LRB103 24784 BMS 56584 b SB2295 - 3 - LRB103 24784 BMS 56584 b
103	103	SB2295 - 3 - LRB103 24784 BMS 56584 b
104	104	1 "Emergency services" means, with respect to an emergency
105	105	2 medical condition:
106	106	3 (1) in general, an emergency medical screening
107	107	4 examination, including ancillary services routinely
108	108	5 available to the emergency department to evaluate such
109	109	6 emergency medical condition, and such further medical
110	110	7 examination and treatment as would be required to
111	111	8 stabilize the patient regardless of the department of the
112	112	9 hospital or other facility in which such further
113	113	10 examination or treatment is furnished; or
114	114	11 (2) additional items and services for which benefits
115	115	12 are provided or covered under the coverage and that are
116	116	13 furnished by a nonparticipating provider or
117	117	14 nonparticipating emergency facility regardless of the
118	118	15 department of the hospital or other facility in which such
119	119	16 items are furnished after the insured, beneficiary, or
120	120	17 enrollee is stabilized and as part of outpatient
121	121	18 observation or an inpatient or outpatient stay with
122	122	19 respect to the visit in which the services described in
123	123	20 paragraph (1) are furnished. Services after stabilization
124	124	21 cease to be emergency services only when all the
125	125	22 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
126	126	23 regulations thereunder are met.
127	127	24 "Freestanding Emergency Center" means a facility licensed
128	128	25 under Section 32.5 of the Emergency Medical Services (EMS)
129	129	26 Systems Act.
130	130
131	131
132	132
133	133
134	134
135	135	SB2295 - 3 - LRB103 24784 BMS 56584 b
136	136
137	137
138	138	SB2295- 4 -LRB103 24784 BMS 56584 b SB2295 - 4 - LRB103 24784 BMS 56584 b
139	139	SB2295 - 4 - LRB103 24784 BMS 56584 b
140	140	1 "Health care facility" means, in the context of
141	141	2 non-emergency services, any of the following:
142	142	3 (1) a hospital as defined in 42 U.S.C. 1395x(e);
143	143	4 (2) a hospital outpatient department;
144	144	5 (3) a critical access hospital certified under 42
145	145	6 U.S.C. 1395i-4(e);
146	146	7 (4) an ambulatory surgical treatment center as defined
147	147	8 in the Ambulatory Surgical Treatment Center Act; or
148	148	9 (5) any recipient of a license under the Hospital
149	149	10 Licensing Act that is not otherwise described in this
150	150	11 definition.
151	151	12 "Health care provider" means a provider as defined in
152	152	13 subsection (d) of Section 370g. "Health care provider" does
153	153	14 not include a provider of air ambulance or ground ambulance
154	154	15 services.
155	155	16 "Health care services" has the meaning ascribed to that
156	156	17 term in subsection (a) of Section 370g.
157	157	18 "Health insurance issuer" has the meaning ascribed to that
158	158	19 term in Section 5 of the Illinois Health Insurance Portability
159	159	20 and Accountability Act.
160	160	21 "Nonparticipating emergency facility" means, with respect
161	161	22 to the furnishing of an item or service under a policy of group
162	162	23 or individual health insurance coverage, any of the following
163	163	24 facilities that does not have a contractual relationship
164	164	25 directly or indirectly with a health insurance issuer in
165	165	26 relation to the coverage:
166	166
167	167
168	168
169	169
170	170
171	171	SB2295 - 4 - LRB103 24784 BMS 56584 b
172	172
173	173
174	174	SB2295- 5 -LRB103 24784 BMS 56584 b SB2295 - 5 - LRB103 24784 BMS 56584 b
175	175	SB2295 - 5 - LRB103 24784 BMS 56584 b
176	176	1 (1) an emergency department of a hospital;
177	177	2 (2) a Freestanding Emergency Center;
178	178	3 (3) an ambulatory surgical treatment center as defined
179	179	4 in the Ambulatory Surgical Treatment Center Act; or
180	180	5 (4) with respect to emergency services described in
181	181	6 paragraph (2) of the definition of "emergency services", a
182	182	7 hospital.
183	183	8 "Nonparticipating provider" means, with respect to the
184	184	9 furnishing of an item or service under a policy of group or
185	185	10 individual health insurance coverage, any health care provider
186	186	11 who does not have a contractual relationship directly or
187	187	12 indirectly with a health insurance issuer in relation to the
188	188	13 coverage.
189	189	14 "Participating emergency facility" means any of the
190	190	15 following facilities that has a contractual relationship
191	191	16 directly or indirectly with a health insurance issuer offering
192	192	17 group or individual health insurance coverage setting forth
193	193	18 the terms and conditions on which a relevant health care
194	194	19 service is provided to an insured, beneficiary, or enrollee
195	195	20 under the coverage:
196	196	21 (1) an emergency department of a hospital;
197	197	22 (2) a Freestanding Emergency Center;
198	198	23 (3) an ambulatory surgical treatment center as defined
199	199	24 in the Ambulatory Surgical Treatment Center Act; or
200	200	25 (4) with respect to emergency services described in
201	201	26 paragraph (2) of the definition of "emergency services", a
202	202
203	203
204	204
205	205
206	206
207	207	SB2295 - 5 - LRB103 24784 BMS 56584 b
208	208
209	209
210	210	SB2295- 6 -LRB103 24784 BMS 56584 b SB2295 - 6 - LRB103 24784 BMS 56584 b
211	211	SB2295 - 6 - LRB103 24784 BMS 56584 b
212	212	1 hospital.
213	213	2 For purposes of this definition, a single case agreement
214	214	3 between an emergency facility and an issuer that is used to
215	215	4 address unique situations in which an insured, beneficiary, or
216	216	5 enrollee requires services that typically occur out-of-network
217	217	6 constitutes a contractual relationship and is limited to the
218	218	7 parties to the agreement.
219	219	8 "Participating health care facility" means any health care
220	220	9 facility that has a contractual relationship directly or
221	221	10 indirectly with a health insurance issuer offering group or
222	222	11 individual health insurance coverage setting forth the terms
223	223	12 and conditions on which a relevant health care service is
224	224	13 provided to an insured, beneficiary, or enrollee under the
225	225	14 coverage. A single case agreement between an emergency
226	226	15 facility and an issuer that is used to address unique
227	227	16 situations in which an insured, beneficiary, or enrollee
228	228	17 requires services that typically occur out-of-network
229	229	18 constitutes a contractual relationship for purposes of this
230	230	19 definition and is limited to the parties to the agreement.
231	231	20 "Participating provider" means any health care provider
232	232	21 that has a contractual relationship directly or indirectly
233	233	22 with a health insurance issuer offering group or individual
234	234	23 health insurance coverage setting forth the terms and
235	235	24 conditions on which a relevant health care service is provided
236	236	25 to an insured, beneficiary, or enrollee under the coverage.
237	237	26 "Qualifying payment amount" has the meaning given to that
238	238
239	239
240	240
241	241
242	242
243	243	SB2295 - 6 - LRB103 24784 BMS 56584 b
244	244
245	245
246	246	SB2295- 7 -LRB103 24784 BMS 56584 b SB2295 - 7 - LRB103 24784 BMS 56584 b
247	247	SB2295 - 7 - LRB103 24784 BMS 56584 b
248	248	1 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
249	249	2 promulgated thereunder.
250	250	3 "Recognized amount" means the lesser of the amount
251	251	4 initially billed by the provider or the qualifying payment
252	252	5 amount.
253	253	6 "Stabilize" means "stabilization" as defined in Section 10
254	254	7 of the Managed Care Reform and Patient Rights Act.
255	255	8 "Treating provider" means a health care provider who has
256	256	9 evaluated the individual.
257	257	10 "Visit" means, with respect to health care services
258	258	11 furnished to an individual at a health care facility, health
259	259	12 care services furnished by a provider at the facility, as well
260	260	13 as equipment, devices, telehealth services, imaging services,
261	261	14 laboratory services, and preoperative and postoperative
262	262	15 services regardless of whether the provider furnishing such
263	263	16 services is at the facility.
264	264	17 (b) Emergency services. When a beneficiary, insured, or
265	265	18 enrollee receives emergency services from a nonparticipating
266	266	19 provider or a nonparticipating emergency facility, the health
267	267	20 insurance issuer shall ensure that the beneficiary, insured,
268	268	21 or enrollee shall incur no greater out-of-pocket costs than
269	269	22 the beneficiary, insured, or enrollee would have incurred with
270	270	23 a participating provider or a participating emergency
271	271	24 facility. Any cost-sharing requirements shall be applied as
272	272	25 though the emergency services had been received from a
273	273	26 participating provider or a participating facility. Cost
274	274
275	275
276	276
277	277
278	278
279	279	SB2295 - 7 - LRB103 24784 BMS 56584 b
280	280
281	281
282	282	SB2295- 8 -LRB103 24784 BMS 56584 b SB2295 - 8 - LRB103 24784 BMS 56584 b
283	283	SB2295 - 8 - LRB103 24784 BMS 56584 b
284	284	1 sharing shall be calculated based on the recognized amount for
285	285	2 the emergency services. If the cost sharing for the same item
286	286	3 or service furnished by a participating provider would have
287	287	4 been a flat-dollar copayment, that amount shall be the
288	288	5 cost-sharing amount unless the provider has billed a lesser
289	289	6 total amount. In no event shall the beneficiary, insured,
290	290	7 enrollee, or any group policyholder or plan sponsor be liable
291	291	8 to or billed by the health insurance issuer, the
292	292	9 nonparticipating provider, or the nonparticipating emergency
293	293	10 facility for any amount beyond the cost sharing calculated in
294	294	11 accordance with this subsection with respect to the emergency
295	295	12 services delivered. Administrative requirements or limitations
296	296	13 shall be no greater than those applicable to emergency
297	297	14 services received from a participating provider or a
298	298	15 participating emergency facility.
299	299	16 (b-5) Non-emergency services at participating health care
300	300	17 facilities.
301	301	18 (1) When a beneficiary, insured, or enrollee utilizes
302	302	19 a participating health care facility and, due to any
303	303	20 reason, covered ancillary services are provided by a
304	304	21 nonparticipating provider during or resulting from the
305	305	22 visit, the health insurance issuer shall ensure that the
306	306	23 beneficiary, insured, or enrollee shall incur no greater
307	307	24 out-of-pocket costs than the beneficiary, insured, or
308	308	25 enrollee would have incurred with a participating provider
309	309	26 for the ancillary services. Any cost-sharing requirements
310	310
311	311
312	312
313	313
314	314
315	315	SB2295 - 8 - LRB103 24784 BMS 56584 b
316	316
317	317
318	318	SB2295- 9 -LRB103 24784 BMS 56584 b SB2295 - 9 - LRB103 24784 BMS 56584 b
319	319	SB2295 - 9 - LRB103 24784 BMS 56584 b
320	320	1 shall be applied as though the ancillary services had been
321	321	2 received from a participating provider. Cost sharing shall
322	322	3 be calculated based on the recognized amount for the
323	323	4 ancillary services. If the cost sharing for the same item
324	324	5 or service furnished by a participating provider would
325	325	6 have been a flat-dollar copayment, that amount shall be
326	326	7 the cost-sharing amount unless the provider has billed a
327	327	8 lesser total amount. In no event shall the beneficiary,
328	328	9 insured, enrollee, or any group policyholder or plan
329	329	10 sponsor be liable to or billed by the health insurance
330	330	11 issuer, the nonparticipating provider, or the
331	331	12 participating health care facility for any amount beyond
332	332	13 the cost sharing calculated in accordance with this
333	333	14 subsection with respect to the ancillary services
334	334	15 delivered. In addition to ancillary services, the
335	335	16 requirements of this paragraph shall also apply with
336	336	17 respect to covered items or services furnished as a result
337	337	18 of unforeseen, urgent medical needs that arise at the time
338	338	19 an item or service is furnished, regardless of whether the
339	339	20 nonparticipating provider satisfied the notice and consent
340	340	21 criteria under paragraph (2) of this subsection.
341	341	22 (2) When a beneficiary, insured, or enrollee utilizes
342	342	23 a participating health care facility and receives
343	343	24 non-emergency covered health care services other than
344	344	25 those described in paragraph (1) of this subsection from a
345	345	26 nonparticipating provider during or resulting from the
346	346
347	347
348	348
349	349
350	350
351	351	SB2295 - 9 - LRB103 24784 BMS 56584 b
352	352
353	353
354	354	SB2295- 10 -LRB103 24784 BMS 56584 b SB2295 - 10 - LRB103 24784 BMS 56584 b
355	355	SB2295 - 10 - LRB103 24784 BMS 56584 b
356	356	1 visit, the health insurance issuer shall ensure that the
357	357	2 beneficiary, insured, or enrollee incurs no greater
358	358	3 out-of-pocket costs than the beneficiary, insured, or
359	359	4 enrollee would have incurred with a participating provider
360	360	5 unless the nonparticipating provider or the participating
361	361	6 health care facility on behalf of the nonparticipating
362	362	7 provider satisfies the notice and consent criteria
363	363	8 provided in 42 U.S.C. 300gg-132 and regulations
364	364	9 promulgated thereunder. If the notice and consent criteria
365	365	10 are not satisfied, then:
366	366	11 (A) any cost-sharing requirements shall be applied
367	367	12 as though the health care services had been received
368	368	13 from a participating provider;
369	369	14 (B) cost sharing shall be calculated based on the
370	370	15 recognized amount for the health care services; and
371	371	16 (C) in no event shall the beneficiary, insured,
372	372	17 enrollee, or any group policyholder or plan sponsor be
373	373	18 liable to or billed by the health insurance issuer,
374	374	19 the nonparticipating provider, or the participating
375	375	20 health care facility for any amount beyond the cost
376	376	21 sharing calculated in accordance with this subsection
377	377	22 with respect to the health care services delivered.
378	378	23 (c) Notwithstanding any other provision of this Code,
379	379	24 except when the notice and consent criteria are satisfied for
380	380	25 the situation in paragraph (2) of subsection (b-5), any
381	381	26 benefits a beneficiary, insured, or enrollee receives for
382	382
383	383
384	384
385	385
386	386
387	387	SB2295 - 10 - LRB103 24784 BMS 56584 b
388	388
389	389
390	390	SB2295- 11 -LRB103 24784 BMS 56584 b SB2295 - 11 - LRB103 24784 BMS 56584 b
391	391	SB2295 - 11 - LRB103 24784 BMS 56584 b
392	392	1 services under the situations in subsection (b) or (b-5) are
393	393	2 assigned to the nonparticipating providers or the facility
394	394	3 acting on their behalf. Upon receipt of the provider's bill or
395	395	4 facility's bill, the health insurance issuer shall provide the
396	396	5 nonparticipating provider or the facility with a written
397	397	6 explanation of benefits that specifies the proposed
398	398	7 reimbursement and the applicable deductible, copayment, or
399	399	8 coinsurance amounts owed by the insured, beneficiary, or
400	400	9 enrollee. The health insurance issuer shall pay any
401	401	10 reimbursement subject to this Section directly to the
402	402	11 nonparticipating provider or the facility.
403	403	12 (d) For bills assigned under subsection (c), the
404	404	13 nonparticipating provider or the facility may bill the health
405	405	14 insurance issuer for the services rendered, and the health
406	406	15 insurance issuer may pay the billed amount or attempt to
407	407	16 negotiate reimbursement with the nonparticipating provider or
408	408	17 the facility. Within 30 calendar days after the provider or
409	409	18 facility transmits the bill to the health insurance issuer,
410	410	19 the issuer shall send an initial payment or notice of denial of
411	411	20 payment with the written explanation of benefits to the
412	412	21 provider or facility. If attempts to negotiate reimbursement
413	413	22 for services provided by a nonparticipating provider do not
414	414	23 result in a resolution of the payment dispute within 30 days
415	415	24 after receipt of written explanation of benefits by the health
416	416	25 insurance issuer, then the health insurance issuer or
417	417	26 nonparticipating provider or the facility may initiate binding
418	418
419	419
420	420
421	421
422	422
423	423	SB2295 - 11 - LRB103 24784 BMS 56584 b
424	424
425	425
426	426	SB2295- 12 -LRB103 24784 BMS 56584 b SB2295 - 12 - LRB103 24784 BMS 56584 b
427	427	SB2295 - 12 - LRB103 24784 BMS 56584 b
428	428	1 arbitration to determine payment for services provided on a
429	429	2 per-bill or batched-bill basis, in accordance with Section
430	430	3 300gg-111 of the federal Public Health Service Act and the
431	431	4 regulations promulgated thereunder. The party requesting
432	432	5 arbitration shall notify the other party arbitration has been
433	433	6 initiated and state its final offer before arbitration. In
434	434	7 response to this notice, the nonrequesting party shall inform
435	435	8 the requesting party of its final offer before the arbitration
436	436	9 occurs. Arbitration shall be initiated by filing a request
437	437	10 with the Department of Insurance.
438	438	11 (e) The Department of Insurance shall publish a list of
439	439	12 approved arbitrators or entities that shall provide binding
440	440	13 arbitration. These arbitrators shall be American Arbitration
441	441	14 Association or American Health Lawyers Association trained
442	442	15 arbitrators. Both parties must agree on an arbitrator from the
443	443	16 Department of Insurance's or its approved entity's list of
444	444	17 arbitrators. If no agreement can be reached, then a list of 5
445	445	18 arbitrators shall be provided by the Department of Insurance
446	446	19 or the approved entity. From the list of 5 arbitrators, the
447	447	20 health insurance issuer can veto 2 arbitrators and the
448	448	21 provider or facility can veto 2 arbitrators. The remaining
449	449	22 arbitrator shall be the chosen arbitrator. This arbitration
450	450	23 shall consist of a review of the written submissions by both
451	451	24 parties. The arbitrator shall not establish a rebuttable
452	452	25 presumption that the qualifying payment amount should be the
453	453	26 total amount owed to the provider or facility by the
454	454
455	455
456	456
457	457
458	458
459	459	SB2295 - 12 - LRB103 24784 BMS 56584 b
460	460
461	461
462	462	SB2295- 13 -LRB103 24784 BMS 56584 b SB2295 - 13 - LRB103 24784 BMS 56584 b
463	463	SB2295 - 13 - LRB103 24784 BMS 56584 b
464	464	1 combination of the issuer and the insured, beneficiary, or
465	465	2 enrollee. Binding arbitration shall provide for a written
466	466	3 decision within 45 days after the request is filed with the
467	467	4 Department of Insurance. Both parties shall be bound by the
468	468	5 arbitrator's decision. The arbitrator's expenses and fees,
469	469	6 together with other expenses, not including attorney's fees,
470	470	7 incurred in the conduct of the arbitration, shall be paid as
471	471	8 provided in the decision.
472	472	9 (f) (Blank).
473	473	10 (g) Section 368a of this Act shall not apply during the
474	474	11 pendency of a decision under subsection (d). Upon the issuance
475	475	12 of the arbitrator's decision, Section 368a applies with
476	476	13 respect to the amount, if any, by which the arbitrator's
477	477	14 determination exceeds the issuer's initial payment under
478	478	15 subsection (c), or the entire amount of the arbitrator's
479	479	16 determination if initial payment was denied. Any interest
480	480	17 required to be paid to a provider under Section 368a shall not
481	481	18 accrue until after 30 days of an arbitrator's decision as
482	482	19 provided in subsection (d), but in no circumstances longer
483	483	20 than 150 days from the date the nonparticipating
484	484	21 facility-based provider billed for services rendered.
485	485	22 (h) Nothing in this Section shall be interpreted to change
486	486	23 the prudent layperson provisions with respect to emergency
487	487	24 services under the Managed Care Reform and Patient Rights Act.
488	488	25 (i) Nothing in this Section shall preclude a health care
489	489	26 provider from billing a beneficiary, insured, or enrollee for
490	490
491	491
492	492
493	493
494	494
495	495	SB2295 - 13 - LRB103 24784 BMS 56584 b
496	496
497	497
498	498	SB2295- 14 -LRB103 24784 BMS 56584 b SB2295 - 14 - LRB103 24784 BMS 56584 b
499	499	SB2295 - 14 - LRB103 24784 BMS 56584 b
500	500	1 reasonable administrative fees, such as service fees for
501	501	2 checks returned for nonsufficient funds and missed
502	502	3 appointments.
503	503	4 (j) Nothing in this Section shall preclude a beneficiary,
504	504	5 insured, or enrollee from assigning benefits to a
505	505	6 nonparticipating provider when the notice and consent criteria
506	506	7 are satisfied under paragraph (2) of subsection (b-5) or in
507	507	8 any other situation not described in subsection (b) or (b-5).
508	508	9 (k) Except when the notice and consent criteria are
509	509	10 satisfied under paragraph (2) of subsection (b-5), if an
510	510	11 individual receives health care services under the situations
511	511	12 described in subsection (b) or (b-5), no referral requirement
512	512	13 or any other provision contained in the policy or certificate
513	513	14 of coverage shall deny coverage, reduce benefits, or otherwise
514	514	15 defeat the requirements of this Section for services that
515	515	16 would have been covered with a participating provider.
516	516	17 However, this subsection shall not be construed to preclude a
517	517	18 provider contract with a health insurance issuer, or with an
518	518	19 administrator or similar entity acting on the issuer's behalf,
519	519	20 from imposing requirements on the participating provider,
520	520	21 participating emergency facility, or participating health care
521	521	22 facility relating to the referral of covered individuals to
522	522	23 nonparticipating providers.
523	523	24 (l) Except if the notice and consent criteria are
524	524	25 satisfied under paragraph (2) of subsection (b-5),
525	525	26 cost-sharing amounts calculated in conformity with this
526	526
527	527
528	528
529	529
530	530
531	531	SB2295 - 14 - LRB103 24784 BMS 56584 b
532	532
533	533
534	534	SB2295- 15 -LRB103 24784 BMS 56584 b SB2295 - 15 - LRB103 24784 BMS 56584 b
535	535	SB2295 - 15 - LRB103 24784 BMS 56584 b
536	536	1 Section shall count toward any deductible or out-of-pocket
537	537	2 maximum applicable to in-network coverage.
538	538	3 (m) The Department has the authority to enforce the
539	539	4 requirements of this Section in the situations described in
540	540	5 subsections (b) and (b-5), and in any other situation for
541	541	6 which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
542	542	7 regulations promulgated thereunder would prohibit an
543	543	8 individual from being billed or liable for emergency services
544	544	9 furnished by a nonparticipating provider or nonparticipating
545	545	10 emergency facility or for non-emergency health care services
546	546	11 furnished by a nonparticipating provider at a participating
547	547	12 health care facility.
548	548	13 (n) This Section does not apply with respect to air
549	549	14 ambulance or ground ambulance services. This Section does not
550	550	15 apply to any policy of excepted benefits or to short-term,
551	551	16 limited-duration health insurance coverage.
552	552	17 (Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
553	553
554	554
555	555
556	556
557	557
558	558	SB2295 - 15 - LRB103 24784 BMS 56584 b