Illinois 2025-2026 Regular Session

Illinois Senate Bill SB1471 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB1471 Introduced 1/31/2025, by Sen. Linda Holmes SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a215 ILCS 5/370g from Ch. 73, par. 982g215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8 Amends the Illinois Insurance Code. Provides that nothing in the provisions shall require an ambulance provider to bill a beneficiary, insured, enrollee, or health insurance issuer when prohibited by any other law, rule, ordinance, contract, or agreement. Limits home rule powers. Changes the definition of "emergency services" and "health care provider". Amends the Health Maintenance Organization Act. Removes language providing that upon reasonable demand by a provider of emergency transportation by ambulance, a health maintenance organization shall promptly pay to the provider, subject to coverage limitations stated in the contract or evidence of coverage, the charges for emergency transportation by ambulance provided to an enrollee in a health care plan arranged for by the health maintenance organization. LRB104 09860 BAB 19928 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB1471 Introduced 1/31/2025, by Sen. Linda Holmes SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.3a215 ILCS 5/370g from Ch. 73, par. 982g215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8 215 ILCS 5/356z.3a 215 ILCS 5/370g from Ch. 73, par. 982g 215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8 Amends the Illinois Insurance Code. Provides that nothing in the provisions shall require an ambulance provider to bill a beneficiary, insured, enrollee, or health insurance issuer when prohibited by any other law, rule, ordinance, contract, or agreement. Limits home rule powers. Changes the definition of "emergency services" and "health care provider". Amends the Health Maintenance Organization Act. Removes language providing that upon reasonable demand by a provider of emergency transportation by ambulance, a health maintenance organization shall promptly pay to the provider, subject to coverage limitations stated in the contract or evidence of coverage, the charges for emergency transportation by ambulance provided to an enrollee in a health care plan arranged for by the health maintenance organization. LRB104 09860 BAB 19928 b LRB104 09860 BAB 19928 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB1471 Introduced 1/31/2025, by Sen. Linda Holmes SYNOPSIS AS INTRODUCED:
3	3	215 ILCS 5/356z.3a215 ILCS 5/370g from Ch. 73, par. 982g215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8 215 ILCS 5/356z.3a 215 ILCS 5/370g from Ch. 73, par. 982g 215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8
4	4	215 ILCS 5/356z.3a
5	5	215 ILCS 5/370g from Ch. 73, par. 982g
6	6	215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8
7	7	Amends the Illinois Insurance Code. Provides that nothing in the provisions shall require an ambulance provider to bill a beneficiary, insured, enrollee, or health insurance issuer when prohibited by any other law, rule, ordinance, contract, or agreement. Limits home rule powers. Changes the definition of "emergency services" and "health care provider". Amends the Health Maintenance Organization Act. Removes language providing that upon reasonable demand by a provider of emergency transportation by ambulance, a health maintenance organization shall promptly pay to the provider, subject to coverage limitations stated in the contract or evidence of coverage, the charges for emergency transportation by ambulance provided to an enrollee in a health care plan arranged for by the health maintenance organization.
8	8	LRB104 09860 BAB 19928 b LRB104 09860 BAB 19928 b
9	9	LRB104 09860 BAB 19928 b
10	10	A BILL FOR
11	11	SB1471LRB104 09860 BAB 19928 b SB1471 LRB104 09860 BAB 19928 b
12	12	SB1471 LRB104 09860 BAB 19928 b
13	13	1 AN ACT concerning regulation.
14	14	2 Be it enacted by the People of the State of Illinois,
15	15	3 represented in the General Assembly:
16	16	4 Section 5. The Illinois Insurance Code is amended by
17	17	5 changing Sections 356z.3a and 370g as follows:
18	18	6 (215 ILCS 5/356z.3a)
19	19	7 Sec. 356z.3a. Billing; emergency services;
20	20	8 nonparticipating providers.
21	21	9 (a) As used in this Section:
22	22	10 "Ancillary services" means:
23	23	11 (1) items and services related to emergency medicine,
24	24	12 anesthesiology, pathology, radiology, and neonatology that
25	25	13 are provided by any health care provider;
26	26	14 (2) items and services provided by assistant surgeons,
27	27	15 hospitalists, and intensivists;
28	28	16 (3) diagnostic services, including radiology and
29	29	17 laboratory services, except for advanced diagnostic
30	30	18 laboratory tests identified on the most current list
31	31	19 published by the United States Secretary of Health and
32	32	20 Human Services under 42 U.S.C. 300gg-132(b)(3);
33	33	21 (4) items and services provided by other specialty
34	34	22 practitioners as the United States Secretary of Health and
35	35	23 Human Services specifies through rulemaking under 42
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39	39	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB1471 Introduced 1/31/2025, by Sen. Linda Holmes SYNOPSIS AS INTRODUCED:
40	40	215 ILCS 5/356z.3a215 ILCS 5/370g from Ch. 73, par. 982g215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8 215 ILCS 5/356z.3a 215 ILCS 5/370g from Ch. 73, par. 982g 215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8
41	41	215 ILCS 5/356z.3a
42	42	215 ILCS 5/370g from Ch. 73, par. 982g
43	43	215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8
44	44	Amends the Illinois Insurance Code. Provides that nothing in the provisions shall require an ambulance provider to bill a beneficiary, insured, enrollee, or health insurance issuer when prohibited by any other law, rule, ordinance, contract, or agreement. Limits home rule powers. Changes the definition of "emergency services" and "health care provider". Amends the Health Maintenance Organization Act. Removes language providing that upon reasonable demand by a provider of emergency transportation by ambulance, a health maintenance organization shall promptly pay to the provider, subject to coverage limitations stated in the contract or evidence of coverage, the charges for emergency transportation by ambulance provided to an enrollee in a health care plan arranged for by the health maintenance organization.
45	45	LRB104 09860 BAB 19928 b LRB104 09860 BAB 19928 b
46	46	LRB104 09860 BAB 19928 b
47	47	A BILL FOR
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53	53	215 ILCS 5/356z.3a
54	54	215 ILCS 5/370g from Ch. 73, par. 982g
55	55	215 ILCS 125/4-15 from Ch. 111 1/2, par. 1409.8
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74	74	1 U.S.C. 300gg-132(b)(3);
75	75	2 (5) items and services provided by a nonparticipating
76	76	3 provider if there is no participating provider who can
77	77	4 furnish the item or service at the facility; and
78	78	5 (6) items and services provided by a nonparticipating
79	79	6 provider if there is no participating provider who will
80	80	7 furnish the item or service because a participating
81	81	8 provider has asserted the participating provider's rights
82	82	9 under the Health Care Right of Conscience Act.
83	83	10 "Cost sharing" means the amount an insured, beneficiary,
84	84	11 or enrollee is responsible for paying for a covered item or
85	85	12 service under the terms of the policy or certificate. "Cost
86	86	13 sharing" includes copayments, coinsurance, and amounts paid
87	87	14 toward deductibles, but does not include amounts paid towards
88	88	15 premiums, balance billing by out-of-network providers, or the
89	89	16 cost of items or services that are not covered under the policy
90	90	17 or certificate.
91	91	18 "Emergency department of a hospital" means any hospital
92	92	19 department that provides emergency services, including a
93	93	20 hospital outpatient department.
94	94	21 "Emergency medical condition" has the meaning ascribed to
95	95	22 that term in Section 10 of the Managed Care Reform and Patient
96	96	23 Rights Act.
97	97	24 "Emergency medical screening examination" has the meaning
98	98	25 ascribed to that term in Section 10 of the Managed Care Reform
99	99	26 and Patient Rights Act.
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110	110	1 "Emergency services" means, with respect to an emergency
111	111	2 medical condition:
112	112	3 (1) in general, any health care service provided to a
113	113	4 person to evaluate or treat a condition that requires
114	114	5 immediate unscheduled medical care, an emergency medical
115	115	6 screening examination, including ancillary services
116	116	7 routinely available to the emergency department to
117	117	8 evaluate such emergency medical condition, and such
118	118	9 further medical examination and treatment as would be
119	119	10 required to stabilize the patient regardless of the
120	120	11 department of the hospital, ground ambulance, or other
121	121	12 facility in which such further examination or treatment is
122	122	13 furnished, including any covered service for
123	123	14 transportation of a patient by a health care provider to a
124	124	15 participating or nonparticipating emergency facility for
125	125	16 an emergency medical condition; or
126	126	17 (2) additional items and services for which benefits
127	127	18 are provided or covered under the coverage and that are
128	128	19 furnished by a nonparticipating provider or
129	129	20 nonparticipating emergency facility regardless of the
130	130	21 department of the hospital or other facility in which such
131	131	22 items are furnished after the insured, beneficiary, or
132	132	23 enrollee is stabilized and as part of outpatient
133	133	24 observation or an inpatient or outpatient stay with
134	134	25 respect to the visit in which the services described in
135	135	26 paragraph (1) are furnished. Services after stabilization
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146	146	1 cease to be emergency services only when all the
147	147	2 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
148	148	3 regulations thereunder are met.
149	149	4 "Freestanding Emergency Center" means a facility licensed
150	150	5 under Section 32.5 of the Emergency Medical Services (EMS)
151	151	6 Systems Act.
152	152	7 "Health care facility" means, in the context of
153	153	8 non-emergency services, any of the following:
154	154	9 (1) a hospital as defined in 42 U.S.C. 1395x(e);
155	155	10 (2) a hospital outpatient department;
156	156	11 (3) a critical access hospital certified under 42
157	157	12 U.S.C. 1395i-4(e);
158	158	13 (4) an ambulatory surgical treatment center as defined
159	159	14 in the Ambulatory Surgical Treatment Center Act; or
160	160	15 (5) any recipient of a license under the Hospital
161	161	16 Licensing Act that is not otherwise described in this
162	162	17 definition.
163	163	18 "Health care provider" means a provider as defined in
164	164	19 subsection (d) of Section 370g. "Health care provider" does
165	165	20 not include a provider of air ambulance or ground ambulance
166	166	21 services.
167	167	22 "Health care services" has the meaning ascribed to that
168	168	23 term in subsection (a) of Section 370g.
169	169	24 "Health insurance issuer" has the meaning ascribed to that
170	170	25 term in Section 5 of the Illinois Health Insurance Portability
171	171	26 and Accountability Act.
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182	182	1 "Nonparticipating emergency facility" means, with respect
183	183	2 to the furnishing of an item or service under a policy of group
184	184	3 or individual health insurance coverage, any of the following
185	185	4 facilities that does not have a contractual relationship
186	186	5 directly or indirectly with a health insurance issuer in
187	187	6 relation to the coverage:
188	188	7 (1) an emergency department of a hospital;
189	189	8 (2) a Freestanding Emergency Center;
190	190	9 (3) an ambulatory surgical treatment center as defined
191	191	10 in the Ambulatory Surgical Treatment Center Act; or
192	192	11 (4) with respect to emergency services described in
193	193	12 paragraph (2) of the definition of "emergency services", a
194	194	13 hospital.
195	195	14 "Nonparticipating provider" means, with respect to the
196	196	15 furnishing of an item or service under a policy of group or
197	197	16 individual health insurance coverage, any health care provider
198	198	17 who does not have a contractual relationship directly or
199	199	18 indirectly with a health insurance issuer in relation to the
200	200	19 coverage.
201	201	20 "Participating emergency facility" means any of the
202	202	21 following facilities that has a contractual relationship
203	203	22 directly or indirectly with a health insurance issuer offering
204	204	23 group or individual health insurance coverage setting forth
205	205	24 the terms and conditions on which a relevant health care
206	206	25 service is provided to an insured, beneficiary, or enrollee
207	207	26 under the coverage:
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218	218	1 (1) an emergency department of a hospital;
219	219	2 (2) a Freestanding Emergency Center;
220	220	3 (3) an ambulatory surgical treatment center as defined
221	221	4 in the Ambulatory Surgical Treatment Center Act; or
222	222	5 (4) with respect to emergency services described in
223	223	6 paragraph (2) of the definition of "emergency services", a
224	224	7 hospital.
225	225	8 For purposes of this definition, a single case agreement
226	226	9 between an emergency facility and an issuer that is used to
227	227	10 address unique situations in which an insured, beneficiary, or
228	228	11 enrollee requires services that typically occur out-of-network
229	229	12 constitutes a contractual relationship and is limited to the
230	230	13 parties to the agreement.
231	231	14 "Participating health care facility" means any health care
232	232	15 facility that has a contractual relationship directly or
233	233	16 indirectly with a health insurance issuer offering group or
234	234	17 individual health insurance coverage setting forth the terms
235	235	18 and conditions on which a relevant health care service is
236	236	19 provided to an insured, beneficiary, or enrollee under the
237	237	20 coverage. A single case agreement between an emergency
238	238	21 facility and an issuer that is used to address unique
239	239	22 situations in which an insured, beneficiary, or enrollee
240	240	23 requires services that typically occur out-of-network
241	241	24 constitutes a contractual relationship for purposes of this
242	242	25 definition and is limited to the parties to the agreement.
243	243	26 "Participating provider" means any health care provider
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254	254	1 that has a contractual relationship directly or indirectly
255	255	2 with a health insurance issuer offering group or individual
256	256	3 health insurance coverage setting forth the terms and
257	257	4 conditions on which a relevant health care service is provided
258	258	5 to an insured, beneficiary, or enrollee under the coverage.
259	259	6 "Qualifying payment amount" has the meaning given to that
260	260	7 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
261	261	8 promulgated thereunder.
262	262	9 "Recognized amount" means the lesser of the amount
263	263	10 initially billed by the provider or the qualifying payment
264	264	11 amount.
265	265	12 "Stabilize" means "stabilization" as defined in Section 10
266	266	13 of the Managed Care Reform and Patient Rights Act.
267	267	14 "Treating provider" means a health care provider who has
268	268	15 evaluated the individual.
269	269	16 "Visit" means, with respect to health care services
270	270	17 furnished to an individual at a health care facility, health
271	271	18 care services furnished by a provider at the facility, as well
272	272	19 as equipment, devices, telehealth services, imaging services,
273	273	20 laboratory services, and preoperative and postoperative
274	274	21 services regardless of whether the provider furnishing such
275	275	22 services is at the facility.
276	276	23 (b) Emergency services. When a beneficiary, insured, or
277	277	24 enrollee receives emergency services from a nonparticipating
278	278	25 provider or a nonparticipating emergency facility, the health
279	279	26 insurance issuer shall ensure that the beneficiary, insured,
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290	290	1 or enrollee shall incur no greater out-of-pocket costs than
291	291	2 the beneficiary, insured, or enrollee would have incurred with
292	292	3 a participating provider or a participating emergency
293	293	4 facility. Any cost-sharing requirements shall be applied as
294	294	5 though the emergency services had been received from a
295	295	6 participating provider or a participating facility. Cost
296	296	7 sharing shall be calculated based on the recognized amount for
297	297	8 the emergency services. If the cost sharing for the same item
298	298	9 or service furnished by a participating provider would have
299	299	10 been a flat-dollar copayment, that amount shall be the
300	300	11 cost-sharing amount unless the provider has billed a lesser
301	301	12 total amount. In no event shall the beneficiary, insured,
302	302	13 enrollee, or any group policyholder or plan sponsor be liable
303	303	14 to or billed by the health insurance issuer, the
304	304	15 nonparticipating provider, or the nonparticipating emergency
305	305	16 facility for any amount beyond the cost sharing calculated in
306	306	17 accordance with this subsection with respect to the emergency
307	307	18 services delivered. Administrative requirements or limitations
308	308	19 shall be no greater than those applicable to emergency
309	309	20 services received from a participating provider or a
310	310	21 participating emergency facility.
311	311	22 (b-5) Non-emergency services at participating health care
312	312	23 facilities.
313	313	24 (1) When a beneficiary, insured, or enrollee utilizes
314	314	25 a participating health care facility and, due to any
315	315	26 reason, covered ancillary services are provided by a
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326	326	1 nonparticipating provider during or resulting from the
327	327	2 visit, the health insurance issuer shall ensure that the
328	328	3 beneficiary, insured, or enrollee shall incur no greater
329	329	4 out-of-pocket costs than the beneficiary, insured, or
330	330	5 enrollee would have incurred with a participating provider
331	331	6 for the ancillary services. Any cost-sharing requirements
332	332	7 shall be applied as though the ancillary services had been
333	333	8 received from a participating provider. Cost sharing shall
334	334	9 be calculated based on the recognized amount for the
335	335	10 ancillary services. If the cost sharing for the same item
336	336	11 or service furnished by a participating provider would
337	337	12 have been a flat-dollar copayment, that amount shall be
338	338	13 the cost-sharing amount unless the provider has billed a
339	339	14 lesser total amount. In no event shall the beneficiary,
340	340	15 insured, enrollee, or any group policyholder or plan
341	341	16 sponsor be liable to or billed by the health insurance
342	342	17 issuer, the nonparticipating provider, or the
343	343	18 participating health care facility for any amount beyond
344	344	19 the cost sharing calculated in accordance with this
345	345	20 subsection with respect to the ancillary services
346	346	21 delivered. In addition to ancillary services, the
347	347	22 requirements of this paragraph shall also apply with
348	348	23 respect to covered items or services furnished as a result
349	349	24 of unforeseen, urgent medical needs that arise at the time
350	350	25 an item or service is furnished, regardless of whether the
351	351	26 nonparticipating provider satisfied the notice and consent
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362	362	1 criteria under paragraph (2) of this subsection.
363	363	2 (2) When a beneficiary, insured, or enrollee utilizes
364	364	3 a participating health care facility and receives
365	365	4 non-emergency covered health care services other than
366	366	5 those described in paragraph (1) of this subsection from a
367	367	6 nonparticipating provider during or resulting from the
368	368	7 visit, the health insurance issuer shall ensure that the
369	369	8 beneficiary, insured, or enrollee incurs no greater
370	370	9 out-of-pocket costs than the beneficiary, insured, or
371	371	10 enrollee would have incurred with a participating provider
372	372	11 unless the nonparticipating provider or the participating
373	373	12 health care facility on behalf of the nonparticipating
374	374	13 provider satisfies the notice and consent criteria
375	375	14 provided in 42 U.S.C. 300gg-132 and regulations
376	376	15 promulgated thereunder. If the notice and consent criteria
377	377	16 are not satisfied, then:
378	378	17 (A) any cost-sharing requirements shall be applied
379	379	18 as though the health care services had been received
380	380	19 from a participating provider;
381	381	20 (B) cost sharing shall be calculated based on the
382	382	21 recognized amount for the health care services; and
383	383	22 (C) in no event shall the beneficiary, insured,
384	384	23 enrollee, or any group policyholder or plan sponsor be
385	385	24 liable to or billed by the health insurance issuer,
386	386	25 the nonparticipating provider, or the participating
387	387	26 health care facility for any amount beyond the cost
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398	398	1 sharing calculated in accordance with this subsection
399	399	2 with respect to the health care services delivered.
400	400	3 (c) Notwithstanding any other provision of this Code,
401	401	4 except when the notice and consent criteria are satisfied for
402	402	5 the situation in paragraph (2) of subsection (b-5), any
403	403	6 benefits a beneficiary, insured, or enrollee receives for
404	404	7 services under the situations in subsection (b) or (b-5) are
405	405	8 assigned to the nonparticipating providers or the facility
406	406	9 acting on their behalf. Upon receipt of the provider's bill or
407	407	10 facility's bill, the health insurance issuer shall provide the
408	408	11 nonparticipating provider or the facility with a written
409	409	12 explanation of benefits that specifies the proposed
410	410	13 reimbursement and the applicable deductible, copayment, or
411	411	14 coinsurance amounts owed by the insured, beneficiary, or
412	412	15 enrollee. The health insurance issuer shall pay any
413	413	16 reimbursement subject to this Section directly to the
414	414	17 nonparticipating provider or the facility.
415	415	18 (d) For bills assigned under subsection (c), the
416	416	19 nonparticipating provider or the facility may bill the health
417	417	20 insurance issuer for the services rendered, and the health
418	418	21 insurance issuer may pay the billed amount or attempt to
419	419	22 negotiate reimbursement with the nonparticipating provider or
420	420	23 the facility. Within 30 calendar days after the provider or
421	421	24 facility transmits the bill to the health insurance issuer,
422	422	25 the issuer shall send an initial payment or notice of denial of
423	423	26 payment with the written explanation of benefits to the
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434	434	1 provider or facility. If attempts to negotiate reimbursement
435	435	2 for services provided by a nonparticipating provider do not
436	436	3 result in a resolution of the payment dispute within 30 days
437	437	4 after receipt of written explanation of benefits by the health
438	438	5 insurance issuer, then the health insurance issuer or
439	439	6 nonparticipating provider or the facility may initiate binding
440	440	7 arbitration to determine payment for services provided on a
441	441	8 per-bill or batched-bill basis, in accordance with Section
442	442	9 300gg-111 of the Public Health Service Act and the regulations
443	443	10 promulgated thereunder. The party requesting arbitration shall
444	444	11 notify the other party arbitration has been initiated and
445	445	12 state its final offer before arbitration. In response to this
446	446	13 notice, the nonrequesting party shall inform the requesting
447	447	14 party of its final offer before the arbitration occurs.
448	448	15 Arbitration shall be initiated by filing a request with the
449	449	16 Department of Insurance.
450	450	17 (e) The Department of Insurance shall publish a list of
451	451	18 approved arbitrators or entities that shall provide binding
452	452	19 arbitration. These arbitrators shall be American Arbitration
453	453	20 Association or American Health Lawyers Association trained
454	454	21 arbitrators. Both parties must agree on an arbitrator from the
455	455	22 Department of Insurance's or its approved entity's list of
456	456	23 arbitrators. If no agreement can be reached, then a list of 5
457	457	24 arbitrators shall be provided by the Department of Insurance
458	458	25 or the approved entity. From the list of 5 arbitrators, the
459	459	26 health insurance issuer can veto 2 arbitrators and the
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470	470	1 provider or facility can veto 2 arbitrators. The remaining
471	471	2 arbitrator shall be the chosen arbitrator. This arbitration
472	472	3 shall consist of a review of the written submissions by both
473	473	4 parties. The arbitrator shall not establish a rebuttable
474	474	5 presumption that the qualifying payment amount should be the
475	475	6 total amount owed to the provider or facility by the
476	476	7 combination of the issuer and the insured, beneficiary, or
477	477	8 enrollee. Binding arbitration shall provide for a written
478	478	9 decision within 45 days after the request is filed with the
479	479	10 Department of Insurance. Both parties shall be bound by the
480	480	11 arbitrator's decision. The arbitrator's expenses and fees,
481	481	12 together with other expenses, not including attorney's fees,
482	482	13 incurred in the conduct of the arbitration, shall be paid as
483	483	14 provided in the decision.
484	484	15 (f) (Blank).
485	485	16 (g) Section 368a of this Act shall not apply during the
486	486	17 pendency of a decision under subsection (d). Upon the issuance
487	487	18 of the arbitrator's decision, Section 368a applies with
488	488	19 respect to the amount, if any, by which the arbitrator's
489	489	20 determination exceeds the issuer's initial payment under
490	490	21 subsection (c), or the entire amount of the arbitrator's
491	491	22 determination if initial payment was denied. Any interest
492	492	23 required to be paid to a provider under Section 368a shall not
493	493	24 accrue until after 30 days of an arbitrator's decision as
494	494	25 provided in subsection (d), but in no circumstances longer
495	495	26 than 150 days from the date the nonparticipating
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506	506	1 facility-based provider billed for services rendered.
507	507	2 (h) Nothing in this Section shall be interpreted to change
508	508	3 the prudent layperson provisions with respect to emergency
509	509	4 services under the Managed Care Reform and Patient Rights Act.
510	510	5 (i) Nothing in this Section shall preclude a health care
511	511	6 provider from billing a beneficiary, insured, or enrollee for
512	512	7 reasonable administrative fees, such as service fees for
513	513	8 checks returned for nonsufficient funds and missed
514	514	9 appointments.
515	515	10 (j) Nothing in this Section shall preclude a beneficiary,
516	516	11 insured, or enrollee from assigning benefits to a
517	517	12 nonparticipating provider when the notice and consent criteria
518	518	13 are satisfied under paragraph (2) of subsection (b-5) or in
519	519	14 any other situation not described in subsection (b) or (b-5).
520	520	15 (k) Except when the notice and consent criteria are
521	521	16 satisfied under paragraph (2) of subsection (b-5), if an
522	522	17 individual receives health care services under the situations
523	523	18 described in subsection (b) or (b-5), no referral requirement
524	524	19 or any other provision contained in the policy or certificate
525	525	20 of coverage shall deny coverage, reduce benefits, or otherwise
526	526	21 defeat the requirements of this Section for services that
527	527	22 would have been covered with a participating provider.
528	528	23 However, this subsection shall not be construed to preclude a
529	529	24 provider contract with a health insurance issuer, or with an
530	530	25 administrator or similar entity acting on the issuer's behalf,
531	531	26 from imposing requirements on the participating provider,
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542	542	1 participating emergency facility, or participating health care
543	543	2 facility relating to the referral of covered individuals to
544	544	3 nonparticipating providers.
545	545	4 (l) Except if the notice and consent criteria are
546	546	5 satisfied under paragraph (2) of subsection (b-5),
547	547	6 cost-sharing amounts calculated in conformity with this
548	548	7 Section shall count toward any deductible or out-of-pocket
549	549	8 maximum applicable to in-network coverage.
550	550	9 (m) The Department has the authority to enforce the
551	551	10 requirements of this Section in the situations described in
552	552	11 subsections (b) and (b-5), and in any other situation for
553	553	12 which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
554	554	13 regulations promulgated thereunder would prohibit an
555	555	14 individual from being billed or liable for emergency services
556	556	15 furnished by a nonparticipating provider or nonparticipating
557	557	16 emergency facility or for non-emergency health care services
558	558	17 furnished by a nonparticipating provider at a participating
559	559	18 health care facility.
560	560	19 (n) This Section does not apply with respect to air
561	561	20 ambulance or ground ambulance services. This Section does not
562	562	21 apply to any policy of excepted benefits or to short-term,
563	563	22 limited-duration health insurance coverage.
564	564	23 (o) Nothing in this Section shall require an ambulance
565	565	24 provider to bill a beneficiary, insured, enrollee, or health
566	566	25 insurance issuer when prohibited by any other law, rule,
567	567	26 ordinance, contract, or agreement. If an ambulance provider
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578	578	1 other than an air ambulance provider is a nonparticipating
579	579	2 provider when it furnishes emergency services under a contract
580	580	3 with a unit of local government of this State, and if the unit
581	581	4 of local government is permitted or required to bill a
582	582	5 beneficiary, insured, enrollee, or health insurance issuer for
583	583	6 the services furnished by the ambulance provider, this Section
584	584	7 applies to the unit of local government as though it were the
585	585	8 ambulance provider. This Section also applies when a unit of
586	586	9 local government directly operates the ambulance provider that
587	587	10 furnished emergency services to a beneficiary, insured, or
588	588	11 enrollee.
589	589	12 (p) A home rule unit may not regulate ambulance providers
590	590	13 in a manner inconsistent with this Section. This Section is a
591	591	14 limitation under subsection (i) of Section 6 of Article VII of
592	592	15 the Illinois Constitution on the concurrent exercise by home
593	593	16 rule units of powers and functions exercised by the State.
594	594	17 (Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23;
595	595	18 103-440, eff. 1-1-24.)
596	596	19 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
597	597	20 Sec. 370g. Definitions. As used in this Article, the
598	598	21 following definitions apply:
599	599	22 (a) "Health care services" means health care services or
600	600	23 products rendered or sold by a provider within the scope of the
601	601	24 provider's license or legal authorization. The term includes,
602	602	25 but is not limited to, hospital, medical, surgical, dental,
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613	613	1 vision, ground ambulance, and pharmaceutical services or
614	614	2 products.
615	615	3 (b) "Insurer" means an insurance company or a health
616	616	4 service corporation authorized in this State to issue policies
617	617	5 or subscriber contracts which reimburse for expenses of health
618	618	6 care services.
619	619	7 (c) "Insured" means an individual entitled to
620	620	8 reimbursement for expenses of health care services under a
621	621	9 policy or subscriber contract issued or administered by an
622	622	10 insurer.
623	623	11 (d) "Provider" means an individual or entity duly licensed
624	624	12 or legally authorized to provide health care services.
625	625	13 (e) "Noninstitutional provider" means any person licensed
626	626	14 under the Medical Practice Act of 1987, as now or hereafter
627	627	15 amended.
628	628	16 (f) "Beneficiary" means an individual entitled to
629	629	17 reimbursement for expenses of or the discount of provider fees
630	630	18 for health care services under a program where the beneficiary
631	631	19 has an incentive to utilize the services of a provider which
632	632	20 has entered into an agreement or arrangement with an
633	633	21 administrator.
634	634	22 (g) "Administrator" means any person, partnership or
635	635	23 corporation, other than an insurer or health maintenance
636	636	24 organization holding a certificate of authority under the
637	637	25 "Health Maintenance Organization Act", as now or hereafter
638	638	26 amended, that arranges, contracts with, or administers
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649	649	1 contracts with a provider whereby beneficiaries are provided
650	650	2 an incentive to use the services of such provider.
651	651	3 (h) "Emergency medical condition" has the meaning given to
652	652	4 that term in Section 10 of the Managed Care Reform and Patient
653	653	5 Rights Act.
654	654	6 (Source: P.A. 102-409, eff. 1-1-22.)
655	655	7 Section 10. The Health Maintenance Organization Act is
656	656	8 amended by changing Section 4-15 as follows:
657	657	9 (215 ILCS 125/4-15) (from Ch. 111 1/2, par. 1409.8)
658	658	10 Sec. 4-15. (a) No contract or evidence of coverage for
659	659	11 basic health care services delivered, issued for delivery,
660	660	12 renewed or amended by a Health Maintenance Organization shall
661	661	13 exclude coverage for emergency transportation by ambulance.
662	662	14 For the purposes of this Section, the term "emergency" means a
663	663	15 need for immediate medical attention resulting from a life
664	664	16 threatening condition or situation or a need for immediate
665	665	17 medical attention as otherwise reasonably determined by a
666	666	18 physician, public safety official or other emergency medical
667	667	19 personnel.
668	668	20 (b) (Blank). Upon reasonable demand by a provider of
669	669	21 emergency transportation by ambulance, a Health Maintenance
670	670	22 Organization shall promptly pay to the provider, subject to
671	671	23 coverage limitations stated in the contract or evidence of
672	672	24 coverage, the charges for emergency transportation by
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