Illinois 2025-2026 Regular Session

Illinois House Bill HB2464 Compare Versions

OldNewDifferences
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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>AN ACT concerning regulation.</code> </td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>(215 ILCS 5/356z.3a)</code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>"Ancillary services" means:</code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>(2) a hospital outpatient department;</code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>(2) a Freestanding Emergency Center;</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>(2) a Freestanding Emergency Center;</code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</code><code>(f) (Blank).</code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>&nbsp;&nbsp;&nbsp;&nbsp;</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>
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
2+104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2464 Introduced , by Rep. Robert "Bob" Rita SYNOPSIS AS INTRODUCED:
3+215 ILCS 5/356z.3a 215 ILCS 5/356z.3a
4+215 ILCS 5/356z.3a
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.
6+LRB104 10675 BAB 20754 b LRB104 10675 BAB 20754 b
7+ LRB104 10675 BAB 20754 b
8+A BILL FOR
9+HB2464LRB104 10675 BAB 20754 b HB2464 LRB104 10675 BAB 20754 b
10+ HB2464 LRB104 10675 BAB 20754 b
11+1 AN ACT concerning regulation.
12+2 Be it enacted by the People of the State of Illinois,
13+3 represented in the General Assembly:
14+4 Section 5. The Illinois Insurance Code is amended by
15+5 changing Section 356z.3a as follows:
16+6 (215 ILCS 5/356z.3a)
17+7 Sec. 356z.3a. Billing; emergency services;
18+8 nonparticipating providers.
19+9 (a) As used in this Section:
20+10 "Ancillary services" means:
21+11 (1) items and services related to emergency medicine,
22+12 anesthesiology, pathology, radiology, and neonatology that
23+13 are provided by any health care provider;
24+14 (2) items and services provided by assistant surgeons,
25+15 hospitalists, and intensivists;
26+16 (3) diagnostic services, including radiology and
27+17 laboratory services, except for advanced diagnostic
28+18 laboratory tests identified on the most current list
29+19 published by the United States Secretary of Health and
30+20 Human Services under 42 U.S.C. 300gg-132(b)(3);
31+21 (4) items and services provided by other specialty
32+22 practitioners as the United States Secretary of Health and
33+23 Human Services specifies through rulemaking under 42
34+
35+
36+
37+104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2464 Introduced , by Rep. Robert "Bob" Rita SYNOPSIS AS INTRODUCED:
38+215 ILCS 5/356z.3a 215 ILCS 5/356z.3a
39+215 ILCS 5/356z.3a
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.
41+LRB104 10675 BAB 20754 b LRB104 10675 BAB 20754 b
42+ LRB104 10675 BAB 20754 b
43+A BILL FOR
44+
45+
46+
47+
48+
49+215 ILCS 5/356z.3a
50+
51+
52+
53+ LRB104 10675 BAB 20754 b
54+
55+
56+
57+
58+
59+
60+
61+
62+
63+ HB2464 LRB104 10675 BAB 20754 b
64+
65+
66+HB2464- 2 -LRB104 10675 BAB 20754 b HB2464 - 2 - LRB104 10675 BAB 20754 b
67+ HB2464 - 2 - LRB104 10675 BAB 20754 b
68+1 U.S.C. 300gg-132(b)(3);
69+2 (5) items and services provided by a nonparticipating
70+3 provider if there is no participating provider who can
71+4 furnish the item or service at the facility; and
72+5 (6) items and services provided by a nonparticipating
73+6 provider if there is no participating provider who will
74+7 furnish the item or service because a participating
75+8 provider has asserted the participating provider's rights
76+9 under the Health Care Right of Conscience Act.
77+10 "Cost sharing" means the amount an insured, beneficiary,
78+11 or enrollee is responsible for paying for a covered item or
79+12 service under the terms of the policy or certificate. "Cost
80+13 sharing" includes copayments, coinsurance, and amounts paid
81+14 toward deductibles, but does not include amounts paid towards
82+15 premiums, balance billing by out-of-network providers, or the
83+16 cost of items or services that are not covered under the policy
84+17 or certificate.
85+18 "Emergency department of a hospital" means any hospital
86+19 department that provides emergency services, including a
87+20 hospital outpatient department.
88+21 "Emergency medical condition" has the meaning ascribed to
89+22 that term in Section 10 of the Managed Care Reform and Patient
90+23 Rights Act.
91+24 "Emergency medical screening examination" has the meaning
92+25 ascribed to that term in Section 10 of the Managed Care Reform
93+26 and Patient Rights Act.
94+
95+
96+
97+
98+
99+ HB2464 - 2 - LRB104 10675 BAB 20754 b
100+
101+
102+HB2464- 3 -LRB104 10675 BAB 20754 b HB2464 - 3 - LRB104 10675 BAB 20754 b
103+ HB2464 - 3 - LRB104 10675 BAB 20754 b
104+1 "Emergency services" means, with respect to an emergency
105+2 medical condition:
106+3 (1) in general, an emergency medical screening
107+4 examination, including ancillary services routinely
108+5 available to the emergency department to evaluate such
109+6 emergency medical condition, and such further medical
110+7 examination and treatment as would be required to
111+8 stabilize the patient regardless of the department of the
112+9 hospital or other facility in which such further
113+10 examination or treatment is furnished; or
114+11 (2) additional items and services for which benefits
115+12 are provided or covered under the coverage and that are
116+13 furnished by a nonparticipating provider or
117+14 nonparticipating emergency facility regardless of the
118+15 department of the hospital or other facility in which such
119+16 items are furnished after the insured, beneficiary, or
120+17 enrollee is stabilized and as part of outpatient
121+18 observation or an inpatient or outpatient stay with
122+19 respect to the visit in which the services described in
123+20 paragraph (1) are furnished. Services after stabilization
124+21 cease to be emergency services only when all the
125+22 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
126+23 regulations thereunder are met.
127+24 "Freestanding Emergency Center" means a facility licensed
128+25 under Section 32.5 of the Emergency Medical Services (EMS)
129+26 Systems Act.
130+
131+
132+
133+
134+
135+ HB2464 - 3 - LRB104 10675 BAB 20754 b
136+
137+
138+HB2464- 4 -LRB104 10675 BAB 20754 b HB2464 - 4 - LRB104 10675 BAB 20754 b
139+ HB2464 - 4 - LRB104 10675 BAB 20754 b
140+1 "Health care facility" means, in the context of
141+2 non-emergency services, any of the following:
142+3 (1) a hospital as defined in 42 U.S.C. 1395x(e);
143+4 (2) a hospital outpatient department;
144+5 (3) a critical access hospital certified under 42
145+6 U.S.C. 1395i-4(e);
146+7 (4) an ambulatory surgical treatment center as defined
147+8 in the Ambulatory Surgical Treatment Center Act; or
148+9 (5) any recipient of a license under the Hospital
149+10 Licensing Act that is not otherwise described in this
150+11 definition.
151+12 "Health care provider" means a provider as defined in
152+13 subsection (d) of Section 370g. "Health care provider" does
153+14 not include a provider of air ambulance or ground ambulance
154+15 services.
155+16 "Health care services" has the meaning ascribed to that
156+17 term in subsection (a) of Section 370g.
157+18 "Health insurance issuer" has the meaning ascribed to that
158+19 term in Section 5 of the Illinois Health Insurance Portability
159+20 and Accountability Act.
160+21 "Nonparticipating emergency facility" means, with respect
161+22 to the furnishing of an item or service under a policy of group
162+23 or individual health insurance coverage, any of the following
163+24 facilities that does not have a contractual relationship
164+25 directly or indirectly with a health insurance issuer in
165+26 relation to the coverage:
166+
167+
168+
169+
170+
171+ HB2464 - 4 - LRB104 10675 BAB 20754 b
172+
173+
174+HB2464- 5 -LRB104 10675 BAB 20754 b HB2464 - 5 - LRB104 10675 BAB 20754 b
175+ HB2464 - 5 - LRB104 10675 BAB 20754 b
176+1 (1) an emergency department of a hospital;
177+2 (2) a Freestanding Emergency Center;
178+3 (3) an ambulatory surgical treatment center as defined
179+4 in the Ambulatory Surgical Treatment Center Act; or
180+5 (4) with respect to emergency services described in
181+6 paragraph (2) of the definition of "emergency services", a
182+7 hospital.
183+8 "Nonparticipating provider" means, with respect to the
184+9 furnishing of an item or service under a policy of group or
185+10 individual health insurance coverage, any health care provider
186+11 who does not have a contractual relationship directly or
187+12 indirectly with a health insurance issuer in relation to the
188+13 coverage.
189+14 "Participating emergency facility" means any of the
190+15 following facilities that has a contractual relationship
191+16 directly or indirectly with a health insurance issuer offering
192+17 group or individual health insurance coverage setting forth
193+18 the terms and conditions on which a relevant health care
194+19 service is provided to an insured, beneficiary, or enrollee
195+20 under the coverage:
196+21 (1) an emergency department of a hospital;
197+22 (2) a Freestanding Emergency Center;
198+23 (3) an ambulatory surgical treatment center as defined
199+24 in the Ambulatory Surgical Treatment Center Act; or
200+25 (4) with respect to emergency services described in
201+26 paragraph (2) of the definition of "emergency services", a
202+
203+
204+
205+
206+
207+ HB2464 - 5 - LRB104 10675 BAB 20754 b
208+
209+
210+HB2464- 6 -LRB104 10675 BAB 20754 b HB2464 - 6 - LRB104 10675 BAB 20754 b
211+ HB2464 - 6 - LRB104 10675 BAB 20754 b
212+1 hospital.
213+2 For purposes of this definition, a single case agreement
214+3 between an emergency facility and an issuer that is used to
215+4 address unique situations in which an insured, beneficiary, or
216+5 enrollee requires services that typically occur out-of-network
217+6 constitutes a contractual relationship and is limited to the
218+7 parties to the agreement.
219+8 "Participating health care facility" means any health care
220+9 facility that has a contractual relationship directly or
221+10 indirectly with a health insurance issuer offering group or
222+11 individual health insurance coverage setting forth the terms
223+12 and conditions on which a relevant health care service is
224+13 provided to an insured, beneficiary, or enrollee under the
225+14 coverage. A single case agreement between an emergency
226+15 facility and an issuer that is used to address unique
227+16 situations in which an insured, beneficiary, or enrollee
228+17 requires services that typically occur out-of-network
229+18 constitutes a contractual relationship for purposes of this
230+19 definition and is limited to the parties to the agreement.
231+20 "Participating provider" means any health care provider
232+21 that has a contractual relationship directly or indirectly
233+22 with a health insurance issuer offering group or individual
234+23 health insurance coverage setting forth the terms and
235+24 conditions on which a relevant health care service is provided
236+25 to an insured, beneficiary, or enrollee under the coverage.
237+26 "Qualifying payment amount" has the meaning given to that
238+
239+
240+
241+
242+
243+ HB2464 - 6 - LRB104 10675 BAB 20754 b
244+
245+
246+HB2464- 7 -LRB104 10675 BAB 20754 b HB2464 - 7 - LRB104 10675 BAB 20754 b
247+ HB2464 - 7 - LRB104 10675 BAB 20754 b
248+1 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
249+2 promulgated thereunder.
250+3 "Recognized amount" means the lesser of the amount
251+4 initially billed by the provider or the qualifying payment
252+5 amount.
253+6 "Stabilize" means "stabilization" as defined in Section 10
254+7 of the Managed Care Reform and Patient Rights Act.
255+8 "Treating provider" means a health care provider who has
256+9 evaluated the individual.
257+10 "Visit" means, with respect to health care services
258+11 furnished to an individual at a health care facility, health
259+12 care services furnished by a provider at the facility, as well
260+13 as equipment, devices, telehealth services, imaging services,
261+14 laboratory services, and preoperative and postoperative
262+15 services regardless of whether the provider furnishing such
263+16 services is at the facility.
264+17 (b) Emergency services. When a beneficiary, insured, or
265+18 enrollee receives emergency services from a nonparticipating
266+19 provider or a nonparticipating emergency facility, the health
267+20 insurance issuer shall ensure that the beneficiary, insured,
268+21 or enrollee shall incur no greater out-of-pocket costs than
269+22 the beneficiary, insured, or enrollee would have incurred with
270+23 a participating provider or a participating emergency
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+
275+
276+
277+
278+
279+ HB2464 - 7 - LRB104 10675 BAB 20754 b
280+
281+
282+HB2464- 8 -LRB104 10675 BAB 20754 b HB2464 - 8 - LRB104 10675 BAB 20754 b
283+ HB2464 - 8 - LRB104 10675 BAB 20754 b
284+1 sharing shall be calculated based on the recognized amount for
285+2 the emergency services. If the cost sharing for the same item
286+3 or service furnished by a participating provider would have
287+4 been a flat-dollar copayment, that amount shall be the
288+5 cost-sharing amount unless the provider has billed a lesser
289+6 total amount. In no event shall the beneficiary, insured,
290+7 enrollee, or any group policyholder or plan sponsor be liable
291+8 to or billed by the health insurance issuer, the
292+9 nonparticipating provider, or the nonparticipating emergency
293+10 facility for any amount beyond the cost sharing calculated in
294+11 accordance with this subsection with respect to the emergency
295+12 services delivered. Administrative requirements or limitations
296+13 shall be no greater than those applicable to emergency
297+14 services received from a participating provider or a
298+15 participating emergency facility.
299+16 (b-5) Non-emergency services at participating health care
300+17 facilities.
301+18 (1) When a beneficiary, insured, or enrollee utilizes
302+19 a participating health care facility and, due to any
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+
311+
312+
313+
314+
315+ HB2464 - 8 - LRB104 10675 BAB 20754 b
316+
317+
318+HB2464- 9 -LRB104 10675 BAB 20754 b HB2464 - 9 - LRB104 10675 BAB 20754 b
319+ HB2464 - 9 - LRB104 10675 BAB 20754 b
320+1 shall be applied as though the ancillary services had been
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+
347+
348+
349+
350+
351+ HB2464 - 9 - LRB104 10675 BAB 20754 b
352+
353+
354+HB2464- 10 -LRB104 10675 BAB 20754 b HB2464 - 10 - LRB104 10675 BAB 20754 b
355+ HB2464 - 10 - LRB104 10675 BAB 20754 b
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+
383+
384+
385+
386+
387+ HB2464 - 10 - LRB104 10675 BAB 20754 b
388+
389+
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+
420+
421+
422+
423+ HB2464 - 11 - LRB104 10675 BAB 20754 b
424+
425+
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+
461+
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