| 1 | | - | <tr><td class="xsl" colspan="3"><p> </p> </td></tr></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center"></td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code> </code><code>AN ACT concerning regulation.</code> </td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code> </code><b><code>Be it enacted by the People of the State of Illinois, </code></b></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><b><code>represented in the General Assembly:</code></b> </td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code> </code><code>Section 5. </code><code>The Illinois Insurance Code is amended by </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>changing Section 356z.3a as follows:</code> </td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code> </code><code>(215 ILCS 5/356z.3a)</code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code> </code><code>Sec. 356z.3a. </code><code>Billing; emergency services; </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>nonparticipating providers.</code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code> </code><code>(a) As used in this Section:</code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Ancillary services" means:</code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) items and services related to emergency medicine, </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" > <code>anesthesiology, pathology, radiology, and neonatology that </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" > <code>are provided by any health care provider;</code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) items and services provided by assistant surgeons, </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" > <code>hospitalists, and intensivists;</code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(3) diagnostic services, including radiology and </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" > <code>laboratory services, except for advanced diagnostic </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" > <code>laboratory tests identified on the most current list </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>published by the United States Secretary of Health and </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>Human Services under 42 U.S.C. 300gg-132(b)(3);</code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(4) items and services provided by other specialty </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" > <code>practitioners as the United States Secretary of Health and </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" > <code>Human Services specifies through rulemaking under 42 </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 2 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" > <code>U.S.C. 300gg-132(b)(3);</code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(5) items and services provided by a nonparticipating </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" > <code>provider if there is no participating provider who can </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>furnish the item or service at the facility; and</code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(6) items and services provided by a nonparticipating </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>provider if there is no participating provider who will </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>furnish the item or service because a participating </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>provider has asserted the participating provider's rights </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" > <code>under the Health Care Right of Conscience Act. </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Cost sharing" means the amount an insured, beneficiary, </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>or enrollee is responsible for paying for a covered item or </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>service under the terms of the policy or certificate. "Cost </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>sharing" includes copayments, coinsurance, and amounts paid </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>toward deductibles, but does not include amounts paid towards </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>premiums, balance billing by out-of-network providers, or the </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>cost of items or services that are not covered under the policy </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>or certificate.</code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Emergency department of a hospital" means any hospital </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>department that provides emergency services, including a </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>hospital outpatient department.</code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Emergency medical condition" has the meaning ascribed to </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>that term in Section 10 of the Managed Care Reform and Patient </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>Rights Act.</code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Emergency medical screening examination" has the meaning </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>ascribed to that term in Section 10 of the Managed Care Reform </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>and Patient Rights Act.</code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 3 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Emergency services" means, with respect to an emergency </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>medical condition:</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) in general, an emergency medical screening </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>examination, including ancillary services routinely </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" > <code>available to the emergency department to evaluate such </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>emergency medical condition, and such further medical </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>examination and treatment as would be required to </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>stabilize the patient regardless of the department of the </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" > <code>hospital or other facility in which such further </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" > <code>examination or treatment is furnished; or</code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) additional items and services for which benefits </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" > <code>are provided or covered under the coverage and that are </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" > <code>furnished by a nonparticipating provider or </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" > <code>nonparticipating emergency facility regardless of the </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" > <code>department of the hospital or other facility in which such </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" > <code>items are furnished after the insured, beneficiary, or </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" > <code>enrollee is stabilized and as part of outpatient </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" > <code>observation or an inpatient or outpatient stay with </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>respect to the visit in which the services described in </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>paragraph (1) are furnished. Services after stabilization </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" > <code>cease to be emergency services only when all the </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" > <code>conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" > <code>regulations thereunder are met.</code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Freestanding Emergency Center" means a facility licensed </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>under Section 32.5 of the Emergency Medical Services (EMS) </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>Systems Act.</code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 4 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Health care facility" means, in the context of </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>non-emergency services, any of the following:</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) a hospital as defined in 42 U.S.C. 1395x(e);</code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) a hospital outpatient department;</code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(3) a critical access hospital certified under 42 </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>U.S.C. 1395i-4(e);</code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(4) an ambulatory surgical treatment center as defined </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>in the Ambulatory Surgical Treatment Center Act; or</code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(5) any recipient of a license under the Hospital </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" > <code>Licensing Act that is not otherwise described in this </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" > <code>definition.</code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Health care provider" means a provider as defined in </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>subsection (d) of Section 370g. "Health care provider" does </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>not include a provider of air ambulance or ground ambulance </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>services.</code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Health care services" has the meaning ascribed to that </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>term in subsection (a) of Section 370g.</code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Health insurance issuer" has the meaning ascribed to that </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>term in Section 5 of the Illinois Health Insurance Portability </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>and Accountability Act.</code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Nonparticipating emergency facility" means, with respect </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>to the furnishing of an item or service under a policy of group </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>or individual health insurance coverage, any of the following </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>facilities that does not have a contractual relationship </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>directly or indirectly with a health insurance issuer in </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>relation to the coverage:</code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 5 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) an emergency department of a hospital;</code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) a Freestanding Emergency Center;</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(3) an ambulatory surgical treatment center as defined </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>in the Ambulatory Surgical Treatment Center Act; or</code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(4) with respect to emergency services described in </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>paragraph (2) of the definition of "emergency services", a </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>hospital.</code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Nonparticipating provider" means, with respect to the </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>furnishing of an item or service under a policy of group or </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>individual health insurance coverage, any health care provider </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>who does not have a contractual relationship directly or </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>indirectly with a health insurance issuer in relation to the </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>coverage.</code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Participating emergency facility" means any of the </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>following facilities that has a contractual relationship </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>directly or indirectly with a health insurance issuer offering </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>group or individual health insurance coverage setting forth </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>the terms and conditions on which a relevant health care </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>service is provided to an insured, beneficiary, or enrollee </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>under the coverage:</code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) an emergency department of a hospital;</code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) a Freestanding Emergency Center;</code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(3) an ambulatory surgical treatment center as defined </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" > <code>in the Ambulatory Surgical Treatment Center Act; or</code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(4) with respect to emergency services described in </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" > <code>paragraph (2) of the definition of "emergency services", a </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 6 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" > <code>hospital.</code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code> </code><code>For purposes of this definition, a single case agreement </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>between an emergency facility and an issuer that is used to </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>address unique situations in which an insured, beneficiary, or </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>enrollee requires services that typically occur out-of-network </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>constitutes a contractual relationship and is limited to the </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>parties to the agreement.</code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Participating health care facility" means any health care </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>facility that has a contractual relationship directly or </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>indirectly with a health insurance issuer offering group or </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>individual health insurance coverage setting forth the terms </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>and conditions on which a relevant health care service is </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>provided to an insured, beneficiary, or enrollee under the </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>coverage. A single case agreement between an emergency </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>facility and an issuer that is used to address unique </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>situations in which an insured, beneficiary, or enrollee </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>requires services that typically occur out-of-network </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>constitutes a contractual relationship for purposes of this </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>definition and is limited to the parties to the agreement.</code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Participating provider" means any health care provider </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>that has a contractual relationship directly or indirectly </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>with a health insurance issuer offering group or individual </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>health insurance coverage setting forth the terms and </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>conditions on which a relevant health care service is provided </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>to an insured, beneficiary, or enrollee under the coverage.</code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Qualifying payment amount" has the meaning given to that </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 7 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>promulgated thereunder.</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Recognized amount" means the lesser of the amount </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>initially billed by the provider or the qualifying payment </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>amount.</code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Stabilize" means "stabilization" as defined in Section 10 </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>of the Managed Care Reform and Patient Rights Act.</code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Treating provider" means a health care provider who has </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>evaluated the individual.</code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Visit" means, with respect to health care services </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>furnished to an individual at a health care facility, health </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>care services furnished by a provider at the facility, as well </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>as equipment, devices, telehealth services, imaging services, </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>laboratory services, and preoperative and postoperative </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>services regardless of whether the provider furnishing such </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>services is at the facility. </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code> </code><code>(b) Emergency services. When a beneficiary, insured, or </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>enrollee receives emergency services from a nonparticipating </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>provider or a nonparticipating emergency facility, the health </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>insurance issuer shall ensure that the beneficiary, insured, </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>or enrollee shall incur no greater out-of-pocket costs than </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>the beneficiary, insured, or enrollee would have incurred with </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>a participating provider or a participating emergency </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>facility. Any cost-sharing requirements shall be applied as </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>though the emergency services had been received from a </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>participating provider or a participating facility. Cost </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 8 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>sharing shall be calculated based on the recognized amount for </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>the emergency services. If the cost sharing for the same item </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>or service furnished by a participating provider would have </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>been a flat-dollar copayment, that amount shall be the </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>cost-sharing amount unless the provider has billed a lesser </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>total amount. In no event shall the beneficiary, insured, </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>enrollee, or any group policyholder or plan sponsor be liable </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>to or billed by the health insurance issuer, the </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider, or the nonparticipating emergency </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>facility for any amount beyond the cost sharing calculated in </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>accordance with this subsection with respect to the emergency </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>services delivered. Administrative requirements or limitations </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>shall be no greater than those applicable to emergency </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>services received from a participating provider or a </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>participating emergency facility. </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code> </code><code>(b-5) Non-emergency services at participating health care </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>facilities. </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) When a beneficiary, insured, or enrollee utilizes </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>a participating health care facility and, due to any </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>reason, covered ancillary services are provided by a </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" > <code>nonparticipating provider during or resulting from the </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" > <code>visit, the health insurance issuer shall ensure that the </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" > <code>beneficiary, insured, or enrollee shall incur no greater </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" > <code>out-of-pocket costs than the beneficiary, insured, or </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" > <code>enrollee would have incurred with a participating provider </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" > <code>for the ancillary services. Any cost-sharing requirements </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 9 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" > <code>shall be applied as though the ancillary services had been </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" > <code>received from a participating provider. Cost sharing shall </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" > <code>be calculated based on the recognized amount for the </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>ancillary services. If the cost sharing for the same item </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" > <code>or service furnished by a participating provider would </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>have been a flat-dollar copayment, that amount shall be </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>the cost-sharing amount unless the provider has billed a </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>lesser total amount. In no event shall the beneficiary, </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" > <code>insured, enrollee, or any group policyholder or plan </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" > <code>sponsor be liable to or billed by the health insurance </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" > <code>issuer, the nonparticipating provider, or the </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" > <code>participating health care facility for any amount beyond </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" > <code>the cost sharing calculated in accordance with this </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" > <code>subsection with respect to the ancillary services </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" > <code>delivered. In addition to ancillary services, the </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" > <code>requirements of this paragraph shall also apply with </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" > <code>respect to covered items or services furnished as a result </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" > <code>of unforeseen, urgent medical needs that arise at the time </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>an item or service is furnished, regardless of whether the </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>nonparticipating provider satisfied the notice and consent </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" > <code>criteria under paragraph (2) of this subsection. </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) When a beneficiary, insured, or enrollee utilizes </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" > <code>a participating health care facility and receives </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" > <code>non-emergency covered health care services other than </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" > <code>those described in paragraph (1) of this subsection from a </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" > <code>nonparticipating provider during or resulting from the </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 10 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" > <code>visit, the health insurance issuer shall ensure that the </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" > <code>beneficiary, insured, or enrollee incurs no greater </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" > <code>out-of-pocket costs than the beneficiary, insured, or </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>enrollee would have incurred with a participating provider </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" > <code>unless the nonparticipating provider or the participating </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>health care facility on behalf of the nonparticipating </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>provider satisfies the notice and consent criteria </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>provided in 42 U.S.C. 300gg-132 and regulations </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" > <code>promulgated thereunder. If the notice and consent criteria </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" > <code>are not satisfied, then:</code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code> </code><code>(A) any cost-sharing requirements shall be applied </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" > <code>as though the health care services had been received </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" > <code>from a participating provider;</code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code> </code><code>(B) cost sharing shall be calculated based on the </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" > <code>recognized amount for the health care services; and</code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code> </code><code>(C) in no event shall the beneficiary, insured, </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" > <code>enrollee, or any group policyholder or plan sponsor be </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" > <code>liable to or billed by the health insurance issuer, </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>the nonparticipating provider, or the participating </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>health care facility for any amount beyond the cost </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" > <code>sharing calculated in accordance with this subsection </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" > <code>with respect to the health care services delivered. </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code> </code><code>(c) Notwithstanding any other provision of this Code, </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>except when the notice and consent criteria are satisfied for </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>the situation in paragraph (2) of subsection (b-5), any </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>benefits a beneficiary, insured, or enrollee receives for </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 11 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>services under the situations in subsection (b) or (b-5) are </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>assigned to the nonparticipating providers or the facility </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>acting on their behalf. Upon receipt of the provider's bill or </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>facility's bill, the health insurance issuer shall provide the </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider or the facility with a written </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>explanation of benefits that specifies the proposed </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>reimbursement and the applicable deductible, copayment, or </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>coinsurance amounts owed by the insured, beneficiary, or </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>enrollee. The health insurance issuer shall pay any </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>reimbursement subject to this Section directly to the </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider or the facility.</code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code> </code><code>(d) For bills assigned under subsection (c), the </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider or the facility may bill the health </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>insurance issuer for the services rendered, and the health </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>insurance issuer may pay the billed amount or attempt to </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>negotiate reimbursement with the nonparticipating provider or </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>the facility. Within 30 calendar days after the provider or </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>facility transmits the bill to the health insurance issuer, </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>the issuer shall send an initial payment or notice of denial of </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>payment with the written explanation of benefits to the </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>provider or facility. If attempts to negotiate reimbursement </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>for services provided by a nonparticipating provider do not </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>result in a resolution of the payment dispute within 30 days </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>after receipt of written explanation of benefits by the health </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>insurance issuer, then the health insurance issuer or </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider or the facility may initiate binding </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 12 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>arbitration to determine payment for services provided on a </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>per-bill or batched-bill basis, in accordance with Section </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>300gg-111 of the Public Health Service Act and the regulations </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>promulgated thereunder. The party requesting arbitration shall </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>notify the other party arbitration has been initiated and </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>state its final offer before arbitration. In response to this </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>notice, the nonrequesting party shall inform the requesting </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>party of its final offer before the arbitration occurs. </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>Arbitration shall be initiated by filing a request with the </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>Department of Insurance.</code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code> </code><code>(e) The Department of Insurance shall publish a list of </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>approved arbitrators or entities that shall provide binding </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>arbitration. These arbitrators shall be American Arbitration </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>Association or American Health Lawyers Association trained </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>arbitrators. Both parties must agree on an arbitrator from the </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>Department of Insurance's or its approved entity's list of </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>arbitrators. If no agreement can be reached, then a list of 5 </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>arbitrators shall be provided by the Department of Insurance </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>or the approved entity. From the list of 5 arbitrators, the </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>health insurance issuer can veto 2 arbitrators and the </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>provider or facility can veto 2 arbitrators. The remaining </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>arbitrator shall be the chosen arbitrator. This arbitration </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>shall consist of a review of the written submissions by both </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>parties. The arbitrator shall not establish a rebuttable </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>presumption that the qualifying payment amount should be the </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>total amount owed to the provider or facility by the </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 13 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>combination of the issuer and the insured, beneficiary, or </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>enrollee. Binding arbitration shall provide for a written </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>decision within 45 days after the request is filed with the </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>Department of Insurance. Both parties shall be bound by the </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>arbitrator's decision. The arbitrator's expenses and fees, </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>together with other expenses, not including attorney's fees, </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>incurred in the conduct of the arbitration, shall be paid as </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>provided in the decision.</code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code> </code><code>(f) (Blank).</code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code> </code><code>(g) Section 368a of this Act shall not apply during the </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>pendency of a decision under subsection (d). Upon the issuance </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>of the arbitrator's decision, Section 368a applies with </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>respect to the amount, if any, by which the arbitrator's </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>determination exceeds the issuer's initial payment under </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>subsection (c), or the entire amount of the arbitrator's </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>determination if initial payment was denied. Any interest </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>required to be paid to a provider under Section 368a shall not </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>accrue until after 30 days of an arbitrator's decision as </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>provided in subsection (d), but in no circumstances longer </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>than 150 days from the date the nonparticipating </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>facility-based provider billed for services rendered.</code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code> </code><code>(h) Nothing in this Section shall be interpreted to change </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>the prudent layperson provisions with respect to emergency </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>services under the Managed Care Reform and Patient Rights Act. </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code> </code><code>(i) Nothing in this Section shall preclude a health care </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>provider from billing a beneficiary, insured, or enrollee for </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 14 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>reasonable administrative fees, such as service fees for </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>checks returned for nonsufficient funds and missed </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>appointments.</code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code> </code><code>(j) Nothing in this Section shall preclude a beneficiary, </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>insured, or enrollee from assigning benefits to a </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider when the notice and consent criteria </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>are satisfied under paragraph (2) of subsection (b-5) or in </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>any other situation not described in subsection (b) or (b-5).</code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code> </code><code>(k) Except when the notice and consent criteria are </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>satisfied under paragraph (2) of subsection (b-5), if an </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>individual receives health care services under the situations </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>described in subsection (b) or (b-5), no referral requirement </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>or any other provision contained in the policy or certificate </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>of coverage shall deny coverage, reduce benefits, or otherwise </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>defeat the requirements of this Section for services that </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>would have been covered with a participating provider. </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>However, this subsection shall not be construed to preclude a </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>provider contract with a health insurance issuer, or with an </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>administrator or similar entity acting on the issuer's behalf, </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>from imposing requirements on the participating provider, </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>participating emergency facility, or participating health care </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>facility relating to the referral of covered individuals to </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>nonparticipating providers.</code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code> </code><code>(l) Except if the notice and consent criteria are </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>satisfied under paragraph (2) of subsection (b-5), </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>cost-sharing amounts calculated in conformity with this </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 15 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>Section shall count toward any deductible or out-of-pocket </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>maximum applicable to in-network coverage.</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code>(m) The Department has the authority to enforce the </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>requirements of this Section in the situations described in </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>subsections (b) and (b-5), and in any other situation for </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>regulations promulgated thereunder would prohibit an </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>individual from being billed or liable for emergency services </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>furnished by a nonparticipating provider or nonparticipating </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>emergency facility or for non-emergency health care services </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>furnished by a nonparticipating provider at a participating </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>health care facility.</code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code> </code><code>(n) This Section does not apply with respect to air </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>ambulance or ground ambulance services. This Section does not </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>apply to any policy of excepted benefits or to short-term, </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>limited-duration health insurance coverage. </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code> </code><u><code>(o) Notwithstanding any other provision of law to the </code></u></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><u><code>contrary, if a beneficiary, insured, or enrollee receives </code></u></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><u><code>neonatal intensive care from a nonparticipating provider or </code></u></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><u><code>nonparticipating facility, a health insurance issuer shall </code></u></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><u><code>ensure that the beneficiary, insured, or enrollee shall incur </code></u></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><u><code>no greater out-of-pocket costs than he or she would have </code></u></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><u><code>incurred with a participating provider or a participating </code></u></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><u><code>facility, as long as the nonparticipating provider or </code></u></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><u><code>nonparticipating facility bills the neonatal intensive care as </code></u></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><u><code>emergency services.</code></u><code> </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 16 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23; </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>103-440, eff. 1-1-24</code><code>.)</code> |
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| 1 | + | 104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 HB2464 Introduced , by Rep. Robert "Bob" Rita SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a Amends the Accident and Health Article of the Illinois Insurance Code. Provides that no health insurer may charge a patient out-of-network rates for neonatal care at any hospital. LRB104 10675 BAB 20754 b A BILL FOR 104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 HB2464 Introduced , by Rep. Robert "Bob" Rita SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a 215 ILCS 5/356z.3a Amends the Accident and Health Article of the Illinois Insurance Code. Provides that no health insurer may charge a patient out-of-network rates for neonatal care at any hospital. LRB104 10675 BAB 20754 b LRB104 10675 BAB 20754 b A BILL FOR |
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| 2 | + | 104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 HB2464 Introduced , by Rep. Robert "Bob" Rita SYNOPSIS AS INTRODUCED: |
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| 3 | + | 215 ILCS 5/356z.3a 215 ILCS 5/356z.3a |
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| 4 | + | 215 ILCS 5/356z.3a |
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| 5 | + | Amends the Accident and Health Article of the Illinois Insurance Code. Provides that no health insurer may charge a patient out-of-network rates for neonatal care at any hospital. |
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| 6 | + | LRB104 10675 BAB 20754 b LRB104 10675 BAB 20754 b |
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| 7 | + | LRB104 10675 BAB 20754 b |
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| 8 | + | A BILL FOR |
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| 9 | + | HB2464LRB104 10675 BAB 20754 b HB2464 LRB104 10675 BAB 20754 b |
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| 10 | + | HB2464 LRB104 10675 BAB 20754 b |
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| 11 | + | 1 AN ACT concerning regulation. |
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| 12 | + | 2 Be it enacted by the People of the State of Illinois, |
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| 13 | + | 3 represented in the General Assembly: |
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| 14 | + | 4 Section 5. The Illinois Insurance Code is amended by |
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| 15 | + | 5 changing Section 356z.3a as follows: |
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| 16 | + | 6 (215 ILCS 5/356z.3a) |
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| 17 | + | 7 Sec. 356z.3a. Billing; emergency services; |
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| 18 | + | 8 nonparticipating providers. |
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| 19 | + | 9 (a) As used in this Section: |
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| 20 | + | 10 "Ancillary services" means: |
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| 21 | + | 11 (1) items and services related to emergency medicine, |
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| 22 | + | 12 anesthesiology, pathology, radiology, and neonatology that |
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| 23 | + | 13 are provided by any health care provider; |
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| 24 | + | 14 (2) items and services provided by assistant surgeons, |
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| 25 | + | 15 hospitalists, and intensivists; |
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| 26 | + | 16 (3) diagnostic services, including radiology and |
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| 27 | + | 17 laboratory services, except for advanced diagnostic |
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| 28 | + | 18 laboratory tests identified on the most current list |
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| 29 | + | 19 published by the United States Secretary of Health and |
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| 30 | + | 20 Human Services under 42 U.S.C. 300gg-132(b)(3); |
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| 31 | + | 21 (4) items and services provided by other specialty |
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| 32 | + | 22 practitioners as the United States Secretary of Health and |
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| 33 | + | 23 Human Services specifies through rulemaking under 42 |
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| 34 | + | |
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| 35 | + | |
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| 36 | + | |
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| 37 | + | 104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 HB2464 Introduced , by Rep. Robert "Bob" Rita SYNOPSIS AS INTRODUCED: |
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| 38 | + | 215 ILCS 5/356z.3a 215 ILCS 5/356z.3a |
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| 39 | + | 215 ILCS 5/356z.3a |
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| 40 | + | Amends the Accident and Health Article of the Illinois Insurance Code. Provides that no health insurer may charge a patient out-of-network rates for neonatal care at any hospital. |
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| 41 | + | LRB104 10675 BAB 20754 b LRB104 10675 BAB 20754 b |
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| 42 | + | LRB104 10675 BAB 20754 b |
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| 43 | + | A BILL FOR |
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| 44 | + | |
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| 45 | + | |
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| 46 | + | |
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| 47 | + | |
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| 48 | + | |
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| 49 | + | 215 ILCS 5/356z.3a |
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| 50 | + | |
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| 51 | + | |
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| 52 | + | |
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| 53 | + | LRB104 10675 BAB 20754 b |
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| 54 | + | |
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| 55 | + | |
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| 56 | + | |
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| 57 | + | |
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| 58 | + | |
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| 59 | + | |
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| 60 | + | |
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| 61 | + | |
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| 62 | + | |
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| 63 | + | HB2464 LRB104 10675 BAB 20754 b |
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| 64 | + | |
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| 65 | + | |
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| 66 | + | HB2464- 2 -LRB104 10675 BAB 20754 b HB2464 - 2 - LRB104 10675 BAB 20754 b |
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| 67 | + | HB2464 - 2 - LRB104 10675 BAB 20754 b |
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| 68 | + | 1 U.S.C. 300gg-132(b)(3); |
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| 69 | + | 2 (5) items and services provided by a nonparticipating |
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| 70 | + | 3 provider if there is no participating provider who can |
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| 71 | + | 4 furnish the item or service at the facility; and |
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| 72 | + | 5 (6) items and services provided by a nonparticipating |
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| 73 | + | 6 provider if there is no participating provider who will |
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| 74 | + | 7 furnish the item or service because a participating |
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| 75 | + | 8 provider has asserted the participating provider's rights |
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| 76 | + | 9 under the Health Care Right of Conscience Act. |
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| 77 | + | 10 "Cost sharing" means the amount an insured, beneficiary, |
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| 78 | + | 11 or enrollee is responsible for paying for a covered item or |
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| 79 | + | 12 service under the terms of the policy or certificate. "Cost |
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| 80 | + | 13 sharing" includes copayments, coinsurance, and amounts paid |
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| 81 | + | 14 toward deductibles, but does not include amounts paid towards |
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| 82 | + | 15 premiums, balance billing by out-of-network providers, or the |
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| 83 | + | 16 cost of items or services that are not covered under the policy |
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| 84 | + | 17 or certificate. |
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| 85 | + | 18 "Emergency department of a hospital" means any hospital |
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| 86 | + | 19 department that provides emergency services, including a |
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| 87 | + | 20 hospital outpatient department. |
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| 88 | + | 21 "Emergency medical condition" has the meaning ascribed to |
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| 89 | + | 22 that term in Section 10 of the Managed Care Reform and Patient |
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| 90 | + | 23 Rights Act. |
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| 91 | + | 24 "Emergency medical screening examination" has the meaning |
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| 92 | + | 25 ascribed to that term in Section 10 of the Managed Care Reform |
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| 93 | + | 26 and Patient Rights Act. |
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| 94 | + | |
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| 95 | + | |
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| 96 | + | |
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| 97 | + | |
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| 98 | + | |
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| 99 | + | HB2464 - 2 - LRB104 10675 BAB 20754 b |
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| 100 | + | |
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| 101 | + | |
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| 102 | + | HB2464- 3 -LRB104 10675 BAB 20754 b HB2464 - 3 - LRB104 10675 BAB 20754 b |
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| 103 | + | HB2464 - 3 - LRB104 10675 BAB 20754 b |
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| 104 | + | 1 "Emergency services" means, with respect to an emergency |
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| 105 | + | 2 medical condition: |
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| 106 | + | 3 (1) in general, an emergency medical screening |
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| 107 | + | 4 examination, including ancillary services routinely |
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| 108 | + | 5 available to the emergency department to evaluate such |
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| 109 | + | 6 emergency medical condition, and such further medical |
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| 110 | + | 7 examination and treatment as would be required to |
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| 111 | + | 8 stabilize the patient regardless of the department of the |
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| 112 | + | 9 hospital or other facility in which such further |
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| 113 | + | 10 examination or treatment is furnished; or |
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| 114 | + | 11 (2) additional items and services for which benefits |
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| 115 | + | 12 are provided or covered under the coverage and that are |
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| 116 | + | 13 furnished by a nonparticipating provider or |
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| 117 | + | 14 nonparticipating emergency facility regardless of the |
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| 118 | + | 15 department of the hospital or other facility in which such |
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| 119 | + | 16 items are furnished after the insured, beneficiary, or |
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| 120 | + | 17 enrollee is stabilized and as part of outpatient |
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| 121 | + | 18 observation or an inpatient or outpatient stay with |
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| 122 | + | 19 respect to the visit in which the services described in |
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| 123 | + | 20 paragraph (1) are furnished. Services after stabilization |
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| 124 | + | 21 cease to be emergency services only when all the |
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| 125 | + | 22 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and |
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| 126 | + | 23 regulations thereunder are met. |
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| 127 | + | 24 "Freestanding Emergency Center" means a facility licensed |
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| 128 | + | 25 under Section 32.5 of the Emergency Medical Services (EMS) |
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| 129 | + | 26 Systems Act. |
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| 130 | + | |
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| 131 | + | |
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| 132 | + | |
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| 133 | + | |
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| 134 | + | |
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| 135 | + | HB2464 - 3 - LRB104 10675 BAB 20754 b |
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| 136 | + | |
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| 137 | + | |
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| 138 | + | HB2464- 4 -LRB104 10675 BAB 20754 b HB2464 - 4 - LRB104 10675 BAB 20754 b |
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| 139 | + | HB2464 - 4 - LRB104 10675 BAB 20754 b |
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| 140 | + | 1 "Health care facility" means, in the context of |
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| 141 | + | 2 non-emergency services, any of the following: |
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| 142 | + | 3 (1) a hospital as defined in 42 U.S.C. 1395x(e); |
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| 143 | + | 4 (2) a hospital outpatient department; |
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| 144 | + | 5 (3) a critical access hospital certified under 42 |
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| 145 | + | 6 U.S.C. 1395i-4(e); |
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| 146 | + | 7 (4) an ambulatory surgical treatment center as defined |
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| 147 | + | 8 in the Ambulatory Surgical Treatment Center Act; or |
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| 148 | + | 9 (5) any recipient of a license under the Hospital |
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| 149 | + | 10 Licensing Act that is not otherwise described in this |
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| 150 | + | 11 definition. |
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| 151 | + | 12 "Health care provider" means a provider as defined in |
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| 152 | + | 13 subsection (d) of Section 370g. "Health care provider" does |
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| 153 | + | 14 not include a provider of air ambulance or ground ambulance |
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| 154 | + | 15 services. |
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| 155 | + | 16 "Health care services" has the meaning ascribed to that |
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| 156 | + | 17 term in subsection (a) of Section 370g. |
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| 157 | + | 18 "Health insurance issuer" has the meaning ascribed to that |
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| 158 | + | 19 term in Section 5 of the Illinois Health Insurance Portability |
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| 159 | + | 20 and Accountability Act. |
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| 160 | + | 21 "Nonparticipating emergency facility" means, with respect |
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| 161 | + | 22 to the furnishing of an item or service under a policy of group |
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| 162 | + | 23 or individual health insurance coverage, any of the following |
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| 163 | + | 24 facilities that does not have a contractual relationship |
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| 164 | + | 25 directly or indirectly with a health insurance issuer in |
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| 165 | + | 26 relation to the coverage: |
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| 166 | + | |
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| 167 | + | |
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| 168 | + | |
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| 169 | + | |
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| 170 | + | |
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| 171 | + | HB2464 - 4 - LRB104 10675 BAB 20754 b |
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| 172 | + | |
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| 173 | + | |
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| 174 | + | HB2464- 5 -LRB104 10675 BAB 20754 b HB2464 - 5 - LRB104 10675 BAB 20754 b |
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| 175 | + | HB2464 - 5 - LRB104 10675 BAB 20754 b |
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| 176 | + | 1 (1) an emergency department of a hospital; |
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| 177 | + | 2 (2) a Freestanding Emergency Center; |
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| 178 | + | 3 (3) an ambulatory surgical treatment center as defined |
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| 179 | + | 4 in the Ambulatory Surgical Treatment Center Act; or |
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| 180 | + | 5 (4) with respect to emergency services described in |
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| 181 | + | 6 paragraph (2) of the definition of "emergency services", a |
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| 182 | + | 7 hospital. |
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| 183 | + | 8 "Nonparticipating provider" means, with respect to the |
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| 184 | + | 9 furnishing of an item or service under a policy of group or |
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| 185 | + | 10 individual health insurance coverage, any health care provider |
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| 186 | + | 11 who does not have a contractual relationship directly or |
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| 187 | + | 12 indirectly with a health insurance issuer in relation to the |
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| 188 | + | 13 coverage. |
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| 189 | + | 14 "Participating emergency facility" means any of the |
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| 190 | + | 15 following facilities that has a contractual relationship |
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| 191 | + | 16 directly or indirectly with a health insurance issuer offering |
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| 192 | + | 17 group or individual health insurance coverage setting forth |
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| 193 | + | 18 the terms and conditions on which a relevant health care |
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| 194 | + | 19 service is provided to an insured, beneficiary, or enrollee |
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| 195 | + | 20 under the coverage: |
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| 196 | + | 21 (1) an emergency department of a hospital; |
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| 197 | + | 22 (2) a Freestanding Emergency Center; |
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| 198 | + | 23 (3) an ambulatory surgical treatment center as defined |
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| 199 | + | 24 in the Ambulatory Surgical Treatment Center Act; or |
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| 200 | + | 25 (4) with respect to emergency services described in |
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| 201 | + | 26 paragraph (2) of the definition of "emergency services", a |
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| 202 | + | |
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| 203 | + | |
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| 204 | + | |
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| 205 | + | |
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| 206 | + | |
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| 207 | + | HB2464 - 5 - LRB104 10675 BAB 20754 b |
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| 208 | + | |
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| 209 | + | |
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| 210 | + | HB2464- 6 -LRB104 10675 BAB 20754 b HB2464 - 6 - LRB104 10675 BAB 20754 b |
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| 211 | + | HB2464 - 6 - LRB104 10675 BAB 20754 b |
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| 212 | + | 1 hospital. |
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| 213 | + | 2 For purposes of this definition, a single case agreement |
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| 214 | + | 3 between an emergency facility and an issuer that is used to |
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| 215 | + | 4 address unique situations in which an insured, beneficiary, or |
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| 216 | + | 5 enrollee requires services that typically occur out-of-network |
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| 217 | + | 6 constitutes a contractual relationship and is limited to the |
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| 218 | + | 7 parties to the agreement. |
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| 219 | + | 8 "Participating health care facility" means any health care |
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| 220 | + | 9 facility that has a contractual relationship directly or |
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| 221 | + | 10 indirectly with a health insurance issuer offering group or |
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| 222 | + | 11 individual health insurance coverage setting forth the terms |
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| 223 | + | 12 and conditions on which a relevant health care service is |
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| 224 | + | 13 provided to an insured, beneficiary, or enrollee under the |
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| 225 | + | 14 coverage. A single case agreement between an emergency |
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| 226 | + | 15 facility and an issuer that is used to address unique |
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| 227 | + | 16 situations in which an insured, beneficiary, or enrollee |
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| 228 | + | 17 requires services that typically occur out-of-network |
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| 229 | + | 18 constitutes a contractual relationship for purposes of this |
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| 230 | + | 19 definition and is limited to the parties to the agreement. |
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| 231 | + | 20 "Participating provider" means any health care provider |
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| 232 | + | 21 that has a contractual relationship directly or indirectly |
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| 233 | + | 22 with a health insurance issuer offering group or individual |
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| 234 | + | 23 health insurance coverage setting forth the terms and |
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| 235 | + | 24 conditions on which a relevant health care service is provided |
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| 236 | + | 25 to an insured, beneficiary, or enrollee under the coverage. |
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| 237 | + | 26 "Qualifying payment amount" has the meaning given to that |
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| 238 | + | |
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| 239 | + | |
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| 240 | + | |
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| 241 | + | |
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| 242 | + | |
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| 243 | + | HB2464 - 6 - LRB104 10675 BAB 20754 b |
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| 244 | + | |
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| 245 | + | |
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| 246 | + | HB2464- 7 -LRB104 10675 BAB 20754 b HB2464 - 7 - LRB104 10675 BAB 20754 b |
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| 247 | + | HB2464 - 7 - LRB104 10675 BAB 20754 b |
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| 248 | + | 1 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations |
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| 249 | + | 2 promulgated thereunder. |
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| 250 | + | 3 "Recognized amount" means the lesser of the amount |
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| 251 | + | 4 initially billed by the provider or the qualifying payment |
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| 252 | + | 5 amount. |
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| 253 | + | 6 "Stabilize" means "stabilization" as defined in Section 10 |
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| 254 | + | 7 of the Managed Care Reform and Patient Rights Act. |
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| 255 | + | 8 "Treating provider" means a health care provider who has |
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| 256 | + | 9 evaluated the individual. |
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| 257 | + | 10 "Visit" means, with respect to health care services |
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| 258 | + | 11 furnished to an individual at a health care facility, health |
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| 259 | + | 12 care services furnished by a provider at the facility, as well |
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| 260 | + | 13 as equipment, devices, telehealth services, imaging services, |
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| 261 | + | 14 laboratory services, and preoperative and postoperative |
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| 262 | + | 15 services regardless of whether the provider furnishing such |
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| 263 | + | 16 services is at the facility. |
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| 264 | + | 17 (b) Emergency services. When a beneficiary, insured, or |
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| 265 | + | 18 enrollee receives emergency services from a nonparticipating |
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| 266 | + | 19 provider or a nonparticipating emergency facility, the health |
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| 267 | + | 20 insurance issuer shall ensure that the beneficiary, insured, |
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| 268 | + | 21 or enrollee shall incur no greater out-of-pocket costs than |
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| 269 | + | 22 the beneficiary, insured, or enrollee would have incurred with |
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| 270 | + | 23 a participating provider or a participating emergency |
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| 271 | + | 24 facility. Any cost-sharing requirements shall be applied as |
|---|
| 272 | + | 25 though the emergency services had been received from a |
|---|
| 273 | + | 26 participating provider or a participating facility. Cost |
|---|
| 274 | + | |
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| 275 | + | |
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| 276 | + | |
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| 277 | + | |
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| 278 | + | |
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| 279 | + | HB2464 - 7 - LRB104 10675 BAB 20754 b |
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| 280 | + | |
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| 281 | + | |
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| 282 | + | HB2464- 8 -LRB104 10675 BAB 20754 b HB2464 - 8 - LRB104 10675 BAB 20754 b |
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| 283 | + | HB2464 - 8 - LRB104 10675 BAB 20754 b |
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| 284 | + | 1 sharing shall be calculated based on the recognized amount for |
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| 285 | + | 2 the emergency services. If the cost sharing for the same item |
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| 286 | + | 3 or service furnished by a participating provider would have |
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| 287 | + | 4 been a flat-dollar copayment, that amount shall be the |
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| 288 | + | 5 cost-sharing amount unless the provider has billed a lesser |
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| 289 | + | 6 total amount. In no event shall the beneficiary, insured, |
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| 290 | + | 7 enrollee, or any group policyholder or plan sponsor be liable |
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| 291 | + | 8 to or billed by the health insurance issuer, the |
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| 292 | + | 9 nonparticipating provider, or the nonparticipating emergency |
|---|
| 293 | + | 10 facility for any amount beyond the cost sharing calculated in |
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| 294 | + | 11 accordance with this subsection with respect to the emergency |
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| 295 | + | 12 services delivered. Administrative requirements or limitations |
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| 296 | + | 13 shall be no greater than those applicable to emergency |
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| 297 | + | 14 services received from a participating provider or a |
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| 298 | + | 15 participating emergency facility. |
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| 299 | + | 16 (b-5) Non-emergency services at participating health care |
|---|
| 300 | + | 17 facilities. |
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| 301 | + | 18 (1) When a beneficiary, insured, or enrollee utilizes |
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| 302 | + | 19 a participating health care facility and, due to any |
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| 303 | + | 20 reason, covered ancillary services are provided by a |
|---|
| 304 | + | 21 nonparticipating provider during or resulting from the |
|---|
| 305 | + | 22 visit, the health insurance issuer shall ensure that the |
|---|
| 306 | + | 23 beneficiary, insured, or enrollee shall incur no greater |
|---|
| 307 | + | 24 out-of-pocket costs than the beneficiary, insured, or |
|---|
| 308 | + | 25 enrollee would have incurred with a participating provider |
|---|
| 309 | + | 26 for the ancillary services. Any cost-sharing requirements |
|---|
| 310 | + | |
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| 311 | + | |
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| 312 | + | |
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| 313 | + | |
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| 314 | + | |
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| 315 | + | HB2464 - 8 - LRB104 10675 BAB 20754 b |
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| 316 | + | |
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| 317 | + | |
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| 318 | + | HB2464- 9 -LRB104 10675 BAB 20754 b HB2464 - 9 - LRB104 10675 BAB 20754 b |
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| 319 | + | HB2464 - 9 - LRB104 10675 BAB 20754 b |
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| 320 | + | 1 shall be applied as though the ancillary services had been |
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| 321 | + | 2 received from a participating provider. Cost sharing shall |
|---|
| 322 | + | 3 be calculated based on the recognized amount for the |
|---|
| 323 | + | 4 ancillary services. If the cost sharing for the same item |
|---|
| 324 | + | 5 or service furnished by a participating provider would |
|---|
| 325 | + | 6 have been a flat-dollar copayment, that amount shall be |
|---|
| 326 | + | 7 the cost-sharing amount unless the provider has billed a |
|---|
| 327 | + | 8 lesser total amount. In no event shall the beneficiary, |
|---|
| 328 | + | 9 insured, enrollee, or any group policyholder or plan |
|---|
| 329 | + | 10 sponsor be liable to or billed by the health insurance |
|---|
| 330 | + | 11 issuer, the nonparticipating provider, or the |
|---|
| 331 | + | 12 participating health care facility for any amount beyond |
|---|
| 332 | + | 13 the cost sharing calculated in accordance with this |
|---|
| 333 | + | 14 subsection with respect to the ancillary services |
|---|
| 334 | + | 15 delivered. In addition to ancillary services, the |
|---|
| 335 | + | 16 requirements of this paragraph shall also apply with |
|---|
| 336 | + | 17 respect to covered items or services furnished as a result |
|---|
| 337 | + | 18 of unforeseen, urgent medical needs that arise at the time |
|---|
| 338 | + | 19 an item or service is furnished, regardless of whether the |
|---|
| 339 | + | 20 nonparticipating provider satisfied the notice and consent |
|---|
| 340 | + | 21 criteria under paragraph (2) of this subsection. |
|---|
| 341 | + | 22 (2) When a beneficiary, insured, or enrollee utilizes |
|---|
| 342 | + | 23 a participating health care facility and receives |
|---|
| 343 | + | 24 non-emergency covered health care services other than |
|---|
| 344 | + | 25 those described in paragraph (1) of this subsection from a |
|---|
| 345 | + | 26 nonparticipating provider during or resulting from the |
|---|
| 346 | + | |
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| 347 | + | |
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| 348 | + | |
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| 349 | + | |
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| 350 | + | |
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| 351 | + | HB2464 - 9 - LRB104 10675 BAB 20754 b |
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| 352 | + | |
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| 353 | + | |
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| 354 | + | HB2464- 10 -LRB104 10675 BAB 20754 b HB2464 - 10 - LRB104 10675 BAB 20754 b |
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| 355 | + | HB2464 - 10 - LRB104 10675 BAB 20754 b |
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| 356 | + | 1 visit, the health insurance issuer shall ensure that the |
|---|
| 357 | + | 2 beneficiary, insured, or enrollee incurs no greater |
|---|
| 358 | + | 3 out-of-pocket costs than the beneficiary, insured, or |
|---|
| 359 | + | 4 enrollee would have incurred with a participating provider |
|---|
| 360 | + | 5 unless the nonparticipating provider or the participating |
|---|
| 361 | + | 6 health care facility on behalf of the nonparticipating |
|---|
| 362 | + | 7 provider satisfies the notice and consent criteria |
|---|
| 363 | + | 8 provided in 42 U.S.C. 300gg-132 and regulations |
|---|
| 364 | + | 9 promulgated thereunder. If the notice and consent criteria |
|---|
| 365 | + | 10 are not satisfied, then: |
|---|
| 366 | + | 11 (A) any cost-sharing requirements shall be applied |
|---|
| 367 | + | 12 as though the health care services had been received |
|---|
| 368 | + | 13 from a participating provider; |
|---|
| 369 | + | 14 (B) cost sharing shall be calculated based on the |
|---|
| 370 | + | 15 recognized amount for the health care services; and |
|---|
| 371 | + | 16 (C) in no event shall the beneficiary, insured, |
|---|
| 372 | + | 17 enrollee, or any group policyholder or plan sponsor be |
|---|
| 373 | + | 18 liable to or billed by the health insurance issuer, |
|---|
| 374 | + | 19 the nonparticipating provider, or the participating |
|---|
| 375 | + | 20 health care facility for any amount beyond the cost |
|---|
| 376 | + | 21 sharing calculated in accordance with this subsection |
|---|
| 377 | + | 22 with respect to the health care services delivered. |
|---|
| 378 | + | 23 (c) Notwithstanding any other provision of this Code, |
|---|
| 379 | + | 24 except when the notice and consent criteria are satisfied for |
|---|
| 380 | + | 25 the situation in paragraph (2) of subsection (b-5), any |
|---|
| 381 | + | 26 benefits a beneficiary, insured, or enrollee receives for |
|---|
| 382 | + | |
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| 383 | + | |
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| 384 | + | |
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| 385 | + | |
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| 386 | + | |
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| 387 | + | HB2464 - 10 - LRB104 10675 BAB 20754 b |
|---|
| 388 | + | |
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| 389 | + | |
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| 390 | + | HB2464- 11 -LRB104 10675 BAB 20754 b HB2464 - 11 - LRB104 10675 BAB 20754 b |
|---|
| 391 | + | HB2464 - 11 - LRB104 10675 BAB 20754 b |
|---|
| 392 | + | 1 services under the situations in subsection (b) or (b-5) are |
|---|
| 393 | + | 2 assigned to the nonparticipating providers or the facility |
|---|
| 394 | + | 3 acting on their behalf. Upon receipt of the provider's bill or |
|---|
| 395 | + | 4 facility's bill, the health insurance issuer shall provide the |
|---|
| 396 | + | 5 nonparticipating provider or the facility with a written |
|---|
| 397 | + | 6 explanation of benefits that specifies the proposed |
|---|
| 398 | + | 7 reimbursement and the applicable deductible, copayment, or |
|---|
| 399 | + | 8 coinsurance amounts owed by the insured, beneficiary, or |
|---|
| 400 | + | 9 enrollee. The health insurance issuer shall pay any |
|---|
| 401 | + | 10 reimbursement subject to this Section directly to the |
|---|
| 402 | + | 11 nonparticipating provider or the facility. |
|---|
| 403 | + | 12 (d) For bills assigned under subsection (c), the |
|---|
| 404 | + | 13 nonparticipating provider or the facility may bill the health |
|---|
| 405 | + | 14 insurance issuer for the services rendered, and the health |
|---|
| 406 | + | 15 insurance issuer may pay the billed amount or attempt to |
|---|
| 407 | + | 16 negotiate reimbursement with the nonparticipating provider or |
|---|
| 408 | + | 17 the facility. Within 30 calendar days after the provider or |
|---|
| 409 | + | 18 facility transmits the bill to the health insurance issuer, |
|---|
| 410 | + | 19 the issuer shall send an initial payment or notice of denial of |
|---|
| 411 | + | 20 payment with the written explanation of benefits to the |
|---|
| 412 | + | 21 provider or facility. If attempts to negotiate reimbursement |
|---|
| 413 | + | 22 for services provided by a nonparticipating provider do not |
|---|
| 414 | + | 23 result in a resolution of the payment dispute within 30 days |
|---|
| 415 | + | 24 after receipt of written explanation of benefits by the health |
|---|
| 416 | + | 25 insurance issuer, then the health insurance issuer or |
|---|
| 417 | + | 26 nonparticipating provider or the facility may initiate binding |
|---|
| 418 | + | |
|---|
| 419 | + | |
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| 420 | + | |
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| 421 | + | |
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| 422 | + | |
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| 423 | + | HB2464 - 11 - LRB104 10675 BAB 20754 b |
|---|
| 424 | + | |
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| 425 | + | |
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| 426 | + | HB2464- 12 -LRB104 10675 BAB 20754 b HB2464 - 12 - LRB104 10675 BAB 20754 b |
|---|
| 427 | + | HB2464 - 12 - LRB104 10675 BAB 20754 b |
|---|
| 428 | + | 1 arbitration to determine payment for services provided on a |
|---|
| 429 | + | 2 per-bill or batched-bill basis, in accordance with Section |
|---|
| 430 | + | 3 300gg-111 of the Public Health Service Act and the regulations |
|---|
| 431 | + | 4 promulgated thereunder. The party requesting arbitration shall |
|---|
| 432 | + | 5 notify the other party arbitration has been initiated and |
|---|
| 433 | + | 6 state its final offer before arbitration. In response to this |
|---|
| 434 | + | 7 notice, the nonrequesting party shall inform the requesting |
|---|
| 435 | + | 8 party of its final offer before the arbitration occurs. |
|---|
| 436 | + | 9 Arbitration shall be initiated by filing a request with the |
|---|
| 437 | + | 10 Department of Insurance. |
|---|
| 438 | + | 11 (e) The Department of Insurance shall publish a list of |
|---|
| 439 | + | 12 approved arbitrators or entities that shall provide binding |
|---|
| 440 | + | 13 arbitration. These arbitrators shall be American Arbitration |
|---|
| 441 | + | 14 Association or American Health Lawyers Association trained |
|---|
| 442 | + | 15 arbitrators. Both parties must agree on an arbitrator from the |
|---|
| 443 | + | 16 Department of Insurance's or its approved entity's list of |
|---|
| 444 | + | 17 arbitrators. If no agreement can be reached, then a list of 5 |
|---|
| 445 | + | 18 arbitrators shall be provided by the Department of Insurance |
|---|
| 446 | + | 19 or the approved entity. From the list of 5 arbitrators, the |
|---|
| 447 | + | 20 health insurance issuer can veto 2 arbitrators and the |
|---|
| 448 | + | 21 provider or facility can veto 2 arbitrators. The remaining |
|---|
| 449 | + | 22 arbitrator shall be the chosen arbitrator. This arbitration |
|---|
| 450 | + | 23 shall consist of a review of the written submissions by both |
|---|
| 451 | + | 24 parties. The arbitrator shall not establish a rebuttable |
|---|
| 452 | + | 25 presumption that the qualifying payment amount should be the |
|---|
| 453 | + | 26 total amount owed to the provider or facility by the |
|---|
| 454 | + | |
|---|
| 455 | + | |
|---|
| 456 | + | |
|---|
| 457 | + | |
|---|
| 458 | + | |
|---|
| 459 | + | HB2464 - 12 - LRB104 10675 BAB 20754 b |
|---|
| 460 | + | |
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| 461 | + | |
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| 462 | + | HB2464- 13 -LRB104 10675 BAB 20754 b HB2464 - 13 - LRB104 10675 BAB 20754 b |
|---|
| 463 | + | HB2464 - 13 - LRB104 10675 BAB 20754 b |
|---|
| 464 | + | 1 combination of the issuer and the insured, beneficiary, or |
|---|
| 465 | + | 2 enrollee. Binding arbitration shall provide for a written |
|---|
| 466 | + | 3 decision within 45 days after the request is filed with the |
|---|
| 467 | + | 4 Department of Insurance. Both parties shall be bound by the |
|---|
| 468 | + | 5 arbitrator's decision. The arbitrator's expenses and fees, |
|---|
| 469 | + | 6 together with other expenses, not including attorney's fees, |
|---|
| 470 | + | 7 incurred in the conduct of the arbitration, shall be paid as |
|---|
| 471 | + | 8 provided in the decision. |
|---|
| 472 | + | 9 (f) (Blank). |
|---|
| 473 | + | 10 (g) Section 368a of this Act shall not apply during the |
|---|
| 474 | + | 11 pendency of a decision under subsection (d). Upon the issuance |
|---|
| 475 | + | 12 of the arbitrator's decision, Section 368a applies with |
|---|
| 476 | + | 13 respect to the amount, if any, by which the arbitrator's |
|---|
| 477 | + | 14 determination exceeds the issuer's initial payment under |
|---|
| 478 | + | 15 subsection (c), or the entire amount of the arbitrator's |
|---|
| 479 | + | 16 determination if initial payment was denied. Any interest |
|---|
| 480 | + | 17 required to be paid to a provider under Section 368a shall not |
|---|
| 481 | + | 18 accrue until after 30 days of an arbitrator's decision as |
|---|
| 482 | + | 19 provided in subsection (d), but in no circumstances longer |
|---|
| 483 | + | 20 than 150 days from the date the nonparticipating |
|---|
| 484 | + | 21 facility-based provider billed for services rendered. |
|---|
| 485 | + | 22 (h) Nothing in this Section shall be interpreted to change |
|---|
| 486 | + | 23 the prudent layperson provisions with respect to emergency |
|---|
| 487 | + | 24 services under the Managed Care Reform and Patient Rights Act. |
|---|
| 488 | + | 25 (i) Nothing in this Section shall preclude a health care |
|---|
| 489 | + | 26 provider from billing a beneficiary, insured, or enrollee for |
|---|
| 490 | + | |
|---|
| 491 | + | |
|---|
| 492 | + | |
|---|
| 493 | + | |
|---|
| 494 | + | |
|---|
| 495 | + | HB2464 - 13 - LRB104 10675 BAB 20754 b |
|---|
| 496 | + | |
|---|
| 497 | + | |
|---|
| 498 | + | HB2464- 14 -LRB104 10675 BAB 20754 b HB2464 - 14 - LRB104 10675 BAB 20754 b |
|---|
| 499 | + | HB2464 - 14 - LRB104 10675 BAB 20754 b |
|---|
| 500 | + | 1 reasonable administrative fees, such as service fees for |
|---|
| 501 | + | 2 checks returned for nonsufficient funds and missed |
|---|
| 502 | + | 3 appointments. |
|---|
| 503 | + | 4 (j) Nothing in this Section shall preclude a beneficiary, |
|---|
| 504 | + | 5 insured, or enrollee from assigning benefits to a |
|---|
| 505 | + | 6 nonparticipating provider when the notice and consent criteria |
|---|
| 506 | + | 7 are satisfied under paragraph (2) of subsection (b-5) or in |
|---|
| 507 | + | 8 any other situation not described in subsection (b) or (b-5). |
|---|
| 508 | + | 9 (k) Except when the notice and consent criteria are |
|---|
| 509 | + | 10 satisfied under paragraph (2) of subsection (b-5), if an |
|---|
| 510 | + | 11 individual receives health care services under the situations |
|---|
| 511 | + | 12 described in subsection (b) or (b-5), no referral requirement |
|---|
| 512 | + | 13 or any other provision contained in the policy or certificate |
|---|
| 513 | + | 14 of coverage shall deny coverage, reduce benefits, or otherwise |
|---|
| 514 | + | 15 defeat the requirements of this Section for services that |
|---|
| 515 | + | 16 would have been covered with a participating provider. |
|---|
| 516 | + | 17 However, this subsection shall not be construed to preclude a |
|---|
| 517 | + | 18 provider contract with a health insurance issuer, or with an |
|---|
| 518 | + | 19 administrator or similar entity acting on the issuer's behalf, |
|---|
| 519 | + | 20 from imposing requirements on the participating provider, |
|---|
| 520 | + | 21 participating emergency facility, or participating health care |
|---|
| 521 | + | 22 facility relating to the referral of covered individuals to |
|---|
| 522 | + | 23 nonparticipating providers. |
|---|
| 523 | + | 24 (l) Except if the notice and consent criteria are |
|---|
| 524 | + | 25 satisfied under paragraph (2) of subsection (b-5), |
|---|
| 525 | + | 26 cost-sharing amounts calculated in conformity with this |
|---|
| 526 | + | |
|---|
| 527 | + | |
|---|
| 528 | + | |
|---|
| 529 | + | |
|---|
| 530 | + | |
|---|
| 531 | + | HB2464 - 14 - LRB104 10675 BAB 20754 b |
|---|
| 532 | + | |
|---|
| 533 | + | |
|---|
| 534 | + | HB2464- 15 -LRB104 10675 BAB 20754 b HB2464 - 15 - LRB104 10675 BAB 20754 b |
|---|
| 535 | + | HB2464 - 15 - LRB104 10675 BAB 20754 b |
|---|
| 536 | + | |
|---|
| 537 | + | |
|---|
| 538 | + | |
|---|
| 539 | + | |
|---|
| 540 | + | |
|---|
| 541 | + | HB2464 - 15 - LRB104 10675 BAB 20754 b |
|---|