<tr><td class="xsl" colspan="3"><p> </p> </td></tr></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center"></td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code> </code><code>AN ACT concerning regulation.</code> </td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code> </code><b><code>Be it enacted by the People of the State of Illinois, </code></b></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><b><code>represented in the General Assembly:</code></b> </td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code> </code><code>Section 5. </code><code>The Illinois Insurance Code is amended by </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>changing Section 356z.3a as follows:</code> </td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code> </code><code>(215 ILCS 5/356z.3a)</code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code> </code><code>Sec. 356z.3a. </code><code>Billing; emergency services; </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>nonparticipating providers.</code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code> </code><code>(a) As used in this Section:</code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Ancillary services" means:</code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) items and services related to emergency medicine, </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" > <code>anesthesiology, pathology, radiology, and neonatology that </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" > <code>are provided by any health care provider;</code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) items and services provided by assistant surgeons, </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" > <code>hospitalists, and intensivists;</code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(3) diagnostic services, including radiology and </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" > <code>laboratory services, except for advanced diagnostic </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" > <code>laboratory tests identified on the most current list </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>published by the United States Secretary of Health and </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>Human Services under 42 U.S.C. 300gg-132(b)(3);</code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(4) items and services provided by other specialty </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" > <code>practitioners as the United States Secretary of Health and </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" > <code>Human Services specifies through rulemaking under 42 </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 2 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" > <code>U.S.C. 300gg-132(b)(3);</code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(5) items and services provided by a nonparticipating </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" > <code>provider if there is no participating provider who can </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>furnish the item or service at the facility; and</code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(6) items and services provided by a nonparticipating </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>provider if there is no participating provider who will </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>furnish the item or service because a participating </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>provider has asserted the participating provider's rights </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" > <code>under the Health Care Right of Conscience Act. </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Cost sharing" means the amount an insured, beneficiary, </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>or enrollee is responsible for paying for a covered item or </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>service under the terms of the policy or certificate. "Cost </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>sharing" includes copayments, coinsurance, and amounts paid </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>toward deductibles, but does not include amounts paid towards </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>premiums, balance billing by out-of-network providers, or the </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>cost of items or services that are not covered under the policy </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>or certificate.</code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Emergency department of a hospital" means any hospital </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>department that provides emergency services, including a </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>hospital outpatient department.</code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Emergency medical condition" has the meaning ascribed to </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>that term in Section 10 of the Managed Care Reform and Patient </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>Rights Act.</code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Emergency medical screening examination" has the meaning </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>ascribed to that term in Section 10 of the Managed Care Reform </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>and Patient Rights Act.</code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 3 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Emergency services" means, with respect to an emergency </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>medical condition:</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) in general, an emergency medical screening </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>examination, including ancillary services routinely </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" > <code>available to the emergency department to evaluate such </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>emergency medical condition, and such further medical </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>examination and treatment as would be required to </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>stabilize the patient regardless of the department of the </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" > <code>hospital or other facility in which such further </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" > <code>examination or treatment is furnished; or</code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) additional items and services for which benefits </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" > <code>are provided or covered under the coverage and that are </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" > <code>furnished by a nonparticipating provider or </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" > <code>nonparticipating emergency facility regardless of the </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" > <code>department of the hospital or other facility in which such </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" > <code>items are furnished after the insured, beneficiary, or </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" > <code>enrollee is stabilized and as part of outpatient </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" > <code>observation or an inpatient or outpatient stay with </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>respect to the visit in which the services described in </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>paragraph (1) are furnished. Services after stabilization </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" > <code>cease to be emergency services only when all the </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" > <code>conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" > <code>regulations thereunder are met.</code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Freestanding Emergency Center" means a facility licensed </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>under Section 32.5 of the Emergency Medical Services (EMS) </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>Systems Act.</code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 4 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Health care facility" means, in the context of </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>non-emergency services, any of the following:</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) a hospital as defined in 42 U.S.C. 1395x(e);</code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) a hospital outpatient department;</code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(3) a critical access hospital certified under 42 </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>U.S.C. 1395i-4(e);</code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(4) an ambulatory surgical treatment center as defined </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>in the Ambulatory Surgical Treatment Center Act; or</code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(5) any recipient of a license under the Hospital </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" > <code>Licensing Act that is not otherwise described in this </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" > <code>definition.</code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Health care provider" means a provider as defined in </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>subsection (d) of Section 370g. "Health care provider" does </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>not include a provider of air ambulance or ground ambulance </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>services.</code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Health care services" has the meaning ascribed to that </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>term in subsection (a) of Section 370g.</code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Health insurance issuer" has the meaning ascribed to that </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>term in Section 5 of the Illinois Health Insurance Portability </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>and Accountability Act.</code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Nonparticipating emergency facility" means, with respect </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>to the furnishing of an item or service under a policy of group </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>or individual health insurance coverage, any of the following </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>facilities that does not have a contractual relationship </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>directly or indirectly with a health insurance issuer in </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>relation to the coverage:</code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 5 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) an emergency department of a hospital;</code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) a Freestanding Emergency Center;</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(3) an ambulatory surgical treatment center as defined </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>in the Ambulatory Surgical Treatment Center Act; or</code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(4) with respect to emergency services described in </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>paragraph (2) of the definition of "emergency services", a </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>hospital.</code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Nonparticipating provider" means, with respect to the </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>furnishing of an item or service under a policy of group or </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>individual health insurance coverage, any health care provider </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>who does not have a contractual relationship directly or </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>indirectly with a health insurance issuer in relation to the </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>coverage.</code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Participating emergency facility" means any of the </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>following facilities that has a contractual relationship </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>directly or indirectly with a health insurance issuer offering </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>group or individual health insurance coverage setting forth </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>the terms and conditions on which a relevant health care </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>service is provided to an insured, beneficiary, or enrollee </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>under the coverage:</code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) an emergency department of a hospital;</code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) a Freestanding Emergency Center;</code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(3) an ambulatory surgical treatment center as defined </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" > <code>in the Ambulatory Surgical Treatment Center Act; or</code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(4) with respect to emergency services described in </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" > <code>paragraph (2) of the definition of "emergency services", a </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 6 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" > <code>hospital.</code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code> </code><code>For purposes of this definition, a single case agreement </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>between an emergency facility and an issuer that is used to </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>address unique situations in which an insured, beneficiary, or </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>enrollee requires services that typically occur out-of-network </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>constitutes a contractual relationship and is limited to the </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>parties to the agreement.</code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Participating health care facility" means any health care </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>facility that has a contractual relationship directly or </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>indirectly with a health insurance issuer offering group or </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>individual health insurance coverage setting forth the terms </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>and conditions on which a relevant health care service is </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>provided to an insured, beneficiary, or enrollee under the </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>coverage. A single case agreement between an emergency </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>facility and an issuer that is used to address unique </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>situations in which an insured, beneficiary, or enrollee </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>requires services that typically occur out-of-network </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>constitutes a contractual relationship for purposes of this </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>definition and is limited to the parties to the agreement.</code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Participating provider" means any health care provider </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>that has a contractual relationship directly or indirectly </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>with a health insurance issuer offering group or individual </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>health insurance coverage setting forth the terms and </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>conditions on which a relevant health care service is provided </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>to an insured, beneficiary, or enrollee under the coverage.</code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Qualifying payment amount" has the meaning given to that </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 7 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>promulgated thereunder.</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Recognized amount" means the lesser of the amount </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>initially billed by the provider or the qualifying payment </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>amount.</code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Stabilize" means "stabilization" as defined in Section 10 </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>of the Managed Care Reform and Patient Rights Act.</code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Treating provider" means a health care provider who has </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>evaluated the individual.</code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code> </code><code>"Visit" means, with respect to health care services </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>furnished to an individual at a health care facility, health </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>care services furnished by a provider at the facility, as well </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>as equipment, devices, telehealth services, imaging services, </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>laboratory services, and preoperative and postoperative </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>services regardless of whether the provider furnishing such </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>services is at the facility. </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code> </code><code>(b) Emergency services. When a beneficiary, insured, or </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>enrollee receives emergency services from a nonparticipating </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>provider or a nonparticipating emergency facility, the health </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>insurance issuer shall ensure that the beneficiary, insured, </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>or enrollee shall incur no greater out-of-pocket costs than </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>the beneficiary, insured, or enrollee would have incurred with </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>a participating provider or a participating emergency </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>facility. Any cost-sharing requirements shall be applied as </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>though the emergency services had been received from a </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>participating provider or a participating facility. Cost </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 8 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>sharing shall be calculated based on the recognized amount for </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>the emergency services. If the cost sharing for the same item </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>or service furnished by a participating provider would have </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>been a flat-dollar copayment, that amount shall be the </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>cost-sharing amount unless the provider has billed a lesser </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>total amount. In no event shall the beneficiary, insured, </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>enrollee, or any group policyholder or plan sponsor be liable </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>to or billed by the health insurance issuer, the </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider, or the nonparticipating emergency </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>facility for any amount beyond the cost sharing calculated in </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>accordance with this subsection with respect to the emergency </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>services delivered. Administrative requirements or limitations </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>shall be no greater than those applicable to emergency </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>services received from a participating provider or a </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>participating emergency facility. </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code> </code><code>(b-5) Non-emergency services at participating health care </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>facilities. </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(1) When a beneficiary, insured, or enrollee utilizes </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>a participating health care facility and, due to any </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>reason, covered ancillary services are provided by a </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" > <code>nonparticipating provider during or resulting from the </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" > <code>visit, the health insurance issuer shall ensure that the </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" > <code>beneficiary, insured, or enrollee shall incur no greater </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" > <code>out-of-pocket costs than the beneficiary, insured, or </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" > <code>enrollee would have incurred with a participating provider </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" > <code>for the ancillary services. Any cost-sharing requirements </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 9 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" > <code>shall be applied as though the ancillary services had been </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" > <code>received from a participating provider. Cost sharing shall </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" > <code>be calculated based on the recognized amount for the </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>ancillary services. If the cost sharing for the same item </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" > <code>or service furnished by a participating provider would </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>have been a flat-dollar copayment, that amount shall be </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>the cost-sharing amount unless the provider has billed a </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>lesser total amount. In no event shall the beneficiary, </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" > <code>insured, enrollee, or any group policyholder or plan </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" > <code>sponsor be liable to or billed by the health insurance </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" > <code>issuer, the nonparticipating provider, or the </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" > <code>participating health care facility for any amount beyond </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" > <code>the cost sharing calculated in accordance with this </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" > <code>subsection with respect to the ancillary services </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" > <code>delivered. In addition to ancillary services, the </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" > <code>requirements of this paragraph shall also apply with </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" > <code>respect to covered items or services furnished as a result </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" > <code>of unforeseen, urgent medical needs that arise at the time </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>an item or service is furnished, regardless of whether the </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>nonparticipating provider satisfied the notice and consent </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" > <code>criteria under paragraph (2) of this subsection. </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code>(2) When a beneficiary, insured, or enrollee utilizes </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" > <code>a participating health care facility and receives </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" > <code>non-emergency covered health care services other than </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" > <code>those described in paragraph (1) of this subsection from a </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" > <code>nonparticipating provider during or resulting from the </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 10 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" > <code>visit, the health insurance issuer shall ensure that the </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" > <code>beneficiary, insured, or enrollee incurs no greater </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" > <code>out-of-pocket costs than the beneficiary, insured, or </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" > <code>enrollee would have incurred with a participating provider </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" > <code>unless the nonparticipating provider or the participating </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" > <code>health care facility on behalf of the nonparticipating </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" > <code>provider satisfies the notice and consent criteria </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" > <code>provided in 42 U.S.C. 300gg-132 and regulations </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" > <code>promulgated thereunder. If the notice and consent criteria </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" > <code>are not satisfied, then:</code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code> </code><code>(A) any cost-sharing requirements shall be applied </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" > <code>as though the health care services had been received </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" > <code>from a participating provider;</code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code> </code><code>(B) cost sharing shall be calculated based on the </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" > <code>recognized amount for the health care services; and</code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code> </code><code> </code><code> </code><code>(C) in no event shall the beneficiary, insured, </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" > <code>enrollee, or any group policyholder or plan sponsor be </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" > <code>liable to or billed by the health insurance issuer, </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" > <code>the nonparticipating provider, or the participating </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" > <code>health care facility for any amount beyond the cost </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" > <code>sharing calculated in accordance with this subsection </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" > <code>with respect to the health care services delivered. </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code> </code><code>(c) Notwithstanding any other provision of this Code, </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>except when the notice and consent criteria are satisfied for </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>the situation in paragraph (2) of subsection (b-5), any </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>benefits a beneficiary, insured, or enrollee receives for </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 11 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>services under the situations in subsection (b) or (b-5) are </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>assigned to the nonparticipating providers or the facility </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>acting on their behalf. Upon receipt of the provider's bill or </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>facility's bill, the health insurance issuer shall provide the </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider or the facility with a written </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>explanation of benefits that specifies the proposed </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>reimbursement and the applicable deductible, copayment, or </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>coinsurance amounts owed by the insured, beneficiary, or </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>enrollee. The health insurance issuer shall pay any </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>reimbursement subject to this Section directly to the </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider or the facility.</code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code> </code><code>(d) For bills assigned under subsection (c), the </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider or the facility may bill the health </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>insurance issuer for the services rendered, and the health </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>insurance issuer may pay the billed amount or attempt to </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>negotiate reimbursement with the nonparticipating provider or </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>the facility. Within 30 calendar days after the provider or </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>facility transmits the bill to the health insurance issuer, </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>the issuer shall send an initial payment or notice of denial of </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>payment with the written explanation of benefits to the </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>provider or facility. If attempts to negotiate reimbursement </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>for services provided by a nonparticipating provider do not </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>result in a resolution of the payment dispute within 30 days </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>after receipt of written explanation of benefits by the health </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>insurance issuer, then the health insurance issuer or </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider or the facility may initiate binding </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 12 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>arbitration to determine payment for services provided on a </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>per-bill or batched-bill basis, in accordance with Section </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>300gg-111 of the Public Health Service Act and the regulations </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>promulgated thereunder. The party requesting arbitration shall </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>notify the other party arbitration has been initiated and </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>state its final offer before arbitration. In response to this </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>notice, the nonrequesting party shall inform the requesting </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>party of its final offer before the arbitration occurs. </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>Arbitration shall be initiated by filing a request with the </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>Department of Insurance.</code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code> </code><code>(e) The Department of Insurance shall publish a list of </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>approved arbitrators or entities that shall provide binding </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>arbitration. These arbitrators shall be American Arbitration </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>Association or American Health Lawyers Association trained </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>arbitrators. Both parties must agree on an arbitrator from the </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>Department of Insurance's or its approved entity's list of </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>arbitrators. If no agreement can be reached, then a list of 5 </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>arbitrators shall be provided by the Department of Insurance </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>or the approved entity. From the list of 5 arbitrators, the </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>health insurance issuer can veto 2 arbitrators and the </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>provider or facility can veto 2 arbitrators. The remaining </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>arbitrator shall be the chosen arbitrator. This arbitration </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>shall consist of a review of the written submissions by both </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>parties. The arbitrator shall not establish a rebuttable </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>presumption that the qualifying payment amount should be the </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>total amount owed to the provider or facility by the </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 13 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>combination of the issuer and the insured, beneficiary, or </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>enrollee. Binding arbitration shall provide for a written </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>decision within 45 days after the request is filed with the </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>Department of Insurance. Both parties shall be bound by the </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>arbitrator's decision. The arbitrator's expenses and fees, </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>together with other expenses, not including attorney's fees, </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>incurred in the conduct of the arbitration, shall be paid as </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>provided in the decision.</code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code> </code><code>(f) (Blank).</code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code> </code><code>(g) Section 368a of this Act shall not apply during the </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>pendency of a decision under subsection (d). Upon the issuance </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>of the arbitrator's decision, Section 368a applies with </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>respect to the amount, if any, by which the arbitrator's </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>determination exceeds the issuer's initial payment under </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>subsection (c), or the entire amount of the arbitrator's </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>determination if initial payment was denied. Any interest </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>required to be paid to a provider under Section 368a shall not </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>accrue until after 30 days of an arbitrator's decision as </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>provided in subsection (d), but in no circumstances longer </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>than 150 days from the date the nonparticipating </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>facility-based provider billed for services rendered.</code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code> </code><code>(h) Nothing in this Section shall be interpreted to change </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>the prudent layperson provisions with respect to emergency </code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code>services under the Managed Care Reform and Patient Rights Act. </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code> </code><code>(i) Nothing in this Section shall preclude a health care </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>provider from billing a beneficiary, insured, or enrollee for </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 14 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>reasonable administrative fees, such as service fees for </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>checks returned for nonsufficient funds and missed </code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code>appointments.</code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code> </code><code>(j) Nothing in this Section shall preclude a beneficiary, </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>insured, or enrollee from assigning benefits to a </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>nonparticipating provider when the notice and consent criteria </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>are satisfied under paragraph (2) of subsection (b-5) or in </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>any other situation not described in subsection (b) or (b-5).</code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code> </code><code>(k) Except when the notice and consent criteria are </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>satisfied under paragraph (2) of subsection (b-5), if an </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>individual receives health care services under the situations </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>described in subsection (b) or (b-5), no referral requirement </code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code>or any other provision contained in the policy or certificate </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>of coverage shall deny coverage, reduce benefits, or otherwise </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>defeat the requirements of this Section for services that </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>would have been covered with a participating provider. </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code>However, this subsection shall not be construed to preclude a </code></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><code>provider contract with a health insurance issuer, or with an </code></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><code>administrator or similar entity acting on the issuer's behalf, </code></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><code>from imposing requirements on the participating provider, </code></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><code>participating emergency facility, or participating health care </code></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><code>facility relating to the referral of covered individuals to </code></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><code>nonparticipating providers.</code></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><code> </code><code>(l) Except if the notice and consent criteria are </code></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><code>satisfied under paragraph (2) of subsection (b-5), </code></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><code>cost-sharing amounts calculated in conformity with this </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 15 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>Section shall count toward any deductible or out-of-pocket </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>maximum applicable to in-network coverage.</code></td></tr><tr><td class="number">3</td><td class="junk"></td><td class="xsl" ><code> </code><code>(m) The Department has the authority to enforce the </code></td></tr><tr><td class="number">4</td><td class="junk"></td><td class="xsl" ><code>requirements of this Section in the situations described in </code></td></tr><tr><td class="number">5</td><td class="junk"></td><td class="xsl" ><code>subsections (b) and (b-5), and in any other situation for </code></td></tr><tr><td class="number">6</td><td class="junk"></td><td class="xsl" ><code>which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and </code></td></tr><tr><td class="number">7</td><td class="junk"></td><td class="xsl" ><code>regulations promulgated thereunder would prohibit an </code></td></tr><tr><td class="number">8</td><td class="junk"></td><td class="xsl" ><code>individual from being billed or liable for emergency services </code></td></tr><tr><td class="number">9</td><td class="junk"></td><td class="xsl" ><code>furnished by a nonparticipating provider or nonparticipating </code></td></tr><tr><td class="number">10</td><td class="junk"></td><td class="xsl" ><code>emergency facility or for non-emergency health care services </code></td></tr><tr><td class="number">11</td><td class="junk"></td><td class="xsl" ><code>furnished by a nonparticipating provider at a participating </code></td></tr><tr><td class="number">12</td><td class="junk"></td><td class="xsl" ><code>health care facility.</code></td></tr><tr><td class="number">13</td><td class="junk"></td><td class="xsl" ><code> </code><code>(n) This Section does not apply with respect to air </code></td></tr><tr><td class="number">14</td><td class="junk"></td><td class="xsl" ><code>ambulance or ground ambulance services. This Section does not </code></td></tr><tr><td class="number">15</td><td class="junk"></td><td class="xsl" ><code>apply to any policy of excepted benefits or to short-term, </code></td></tr><tr><td class="number">16</td><td class="junk"></td><td class="xsl" ><code>limited-duration health insurance coverage. </code></td></tr><tr><td class="number">17</td><td class="junk"></td><td class="xsl" ><code> </code><u><code>(o) Notwithstanding any other provision of law to the </code></u></td></tr><tr><td class="number">18</td><td class="junk"></td><td class="xsl" ><u><code>contrary, if a beneficiary, insured, or enrollee receives </code></u></td></tr><tr><td class="number">19</td><td class="junk"></td><td class="xsl" ><u><code>neonatal intensive care from a nonparticipating provider or </code></u></td></tr><tr><td class="number">20</td><td class="junk"></td><td class="xsl" ><u><code>nonparticipating facility, a health insurance issuer shall </code></u></td></tr><tr><td class="number">21</td><td class="junk"></td><td class="xsl" ><u><code>ensure that the beneficiary, insured, or enrollee shall incur </code></u></td></tr><tr><td class="number">22</td><td class="junk"></td><td class="xsl" ><u><code>no greater out-of-pocket costs than he or she would have </code></u></td></tr><tr><td class="number">23</td><td class="junk"></td><td class="xsl" ><u><code>incurred with a participating provider or a participating </code></u></td></tr><tr><td class="number">24</td><td class="junk"></td><td class="xsl" ><u><code>facility, as long as the nonparticipating provider or </code></u></td></tr><tr><td class="number">25</td><td class="junk"></td><td class="xsl" ><u><code>nonparticipating facility bills the neonatal intensive care as </code></u></td></tr><tr><td class="number">26</td><td class="junk"></td><td class="xsl" ><u><code>emergency services.</code></u><code> </code></td></tr></table><table class="xsl" width="650"><tr><td class="lineNum" colspan="3"><p> </p><p> </p></td></tr><tr><td class="xsl" colspan="3"><table class="xsl" width="100%"><colgroup width="5%"></colgroup><colgroup width="5%"></colgroup><colgroup width="30%"></colgroup><colgroup width="20%"></colgroup><colgroup width="40%"></colgroup><tr><td class="number"></td><td class="junk"></td><td class="xsl" align="left">HB2464 Engrossed</td><td class="xsl" align="center">- 16 -</td><td class="xsl" align="right">LRB104 10675 BAB 20754 b</td></tr></table></td></tr><tr><td class="xsl"> </td></tr><tr><td class="number">1</td><td class="junk"></td><td class="xsl" ><code>(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23; </code></td></tr><tr><td class="number">2</td><td class="junk"></td><td class="xsl" ><code>103-440, eff. 1-1-24</code><code>.)</code>