104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2405 Introduced 2/7/2025, by Sen. Ram Villivalam 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. 1409.8815 ILCS 505/2HHHH new Amends the Illinois Insurance Code to create the Consumer Protection from Surprise Health Care Billing Act. Provides that, on or after July 1, 2025, notwithstanding any other applicable provision, when a beneficiary, insured, or enrollee receives services from a nonparticipating ground ambulance service provider, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating ground ambulance service provider. Provides that any cost-sharing requirements shall be applied as though the services provided by the nonparticipating ground ambulance service provider had been provided by a participating ground ambulance service provider. Sets forth provisions concerning payment for ground ambulance services; calculating the recognized amount; limitations for the cost sharing amount for any occurrence in which a ground ambulance service is provided to a beneficiary; appeals for payments made by health insurance issuers; the maximum allowable payment amounts, by individual service types, for nonparticipating ground ambulance service providers owned, operated, or controlled by a private organization; and payments to nonparticipating ground ambulance service providers owned, operated, or controlled, by a unit of government which participates in the Ground Emergency Medical Transportation program administered by the Department of Healthcare and Family Services. Makes conforming changes. Provides that the failure by a health insurance issuer to comply with the specified requirements constitutes an unlawful practice under the Consumer Fraud and Deceptive Business Practices Act and enforcement authority is granted to the Attorney General. Amends the Health Maintenance Organization Act and the Consumer Fraud and Deceptive Business Practices Act to make corresponding changes. Effective July 1, 2025. LRB104 10637 BAB 20714 b A BILL FOR 104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2405 Introduced 2/7/2025, by Sen. Ram Villivalam 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. 1409.8815 ILCS 505/2HHHH new 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. 1409.8 815 ILCS 505/2HHHH new Amends the Illinois Insurance Code to create the Consumer Protection from Surprise Health Care Billing Act. Provides that, on or after July 1, 2025, notwithstanding any other applicable provision, when a beneficiary, insured, or enrollee receives services from a nonparticipating ground ambulance service provider, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating ground ambulance service provider. Provides that any cost-sharing requirements shall be applied as though the services provided by the nonparticipating ground ambulance service provider had been provided by a participating ground ambulance service provider. Sets forth provisions concerning payment for ground ambulance services; calculating the recognized amount; limitations for the cost sharing amount for any occurrence in which a ground ambulance service is provided to a beneficiary; appeals for payments made by health insurance issuers; the maximum allowable payment amounts, by individual service types, for nonparticipating ground ambulance service providers owned, operated, or controlled by a private organization; and payments to nonparticipating ground ambulance service providers owned, operated, or controlled, by a unit of government which participates in the Ground Emergency Medical Transportation program administered by the Department of Healthcare and Family Services. Makes conforming changes. Provides that the failure by a health insurance issuer to comply with the specified requirements constitutes an unlawful practice under the Consumer Fraud and Deceptive Business Practices Act and enforcement authority is granted to the Attorney General. Amends the Health Maintenance Organization Act and the Consumer Fraud and Deceptive Business Practices Act to make corresponding changes. Effective July 1, 2025. LRB104 10637 BAB 20714 b LRB104 10637 BAB 20714 b A BILL FOR
104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2405 Introduced 2/7/2025, by Sen. Ram Villivalam 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. 1409.8815 ILCS 505/2HHHH new 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. 1409.8 815 ILCS 505/2HHHH new
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
815 ILCS 505/2HHHH new
Amends the Illinois Insurance Code to create the Consumer Protection from Surprise Health Care Billing Act. Provides that, on or after July 1, 2025, notwithstanding any other applicable provision, when a beneficiary, insured, or enrollee receives services from a nonparticipating ground ambulance service provider, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating ground ambulance service provider. Provides that any cost-sharing requirements shall be applied as though the services provided by the nonparticipating ground ambulance service provider had been provided by a participating ground ambulance service provider. Sets forth provisions concerning payment for ground ambulance services; calculating the recognized amount; limitations for the cost sharing amount for any occurrence in which a ground ambulance service is provided to a beneficiary; appeals for payments made by health insurance issuers; the maximum allowable payment amounts, by individual service types, for nonparticipating ground ambulance service providers owned, operated, or controlled by a private organization; and payments to nonparticipating ground ambulance service providers owned, operated, or controlled, by a unit of government which participates in the Ground Emergency Medical Transportation program administered by the Department of Healthcare and Family Services. Makes conforming changes. Provides that the failure by a health insurance issuer to comply with the specified requirements constitutes an unlawful practice under the Consumer Fraud and Deceptive Business Practices Act and enforcement authority is granted to the Attorney General. Amends the Health Maintenance Organization Act and the Consumer Fraud and Deceptive Business Practices Act to make corresponding changes. Effective July 1, 2025.
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A BILL FOR
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SB2405 LRB104 10637 BAB 20714 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. This Act may be cited as the Consumer
5 Protection from Surprise Health Care Billing Act.
6 Section 2. The General Assembly finds that:
7 (1) Consumers, health insurance issuers, health care
8 providers, and government bodies will benefit from clearly
9 articulated consumer protections against surprise health
10 care billing.
11 (2) Surprise health care bills contribute
12 substantially to high levels of medical debt for consumers
13 in Illinois.
14 (3) Ground ambulance services are a necessity for
15 patients and patients' positive health outcomes and should
16 not be the cause for surprise health care bills.
17 (4) Consumers should be protected from being in the
18 middle of billing disputes between health insurance
19 issuers and health care providers.
20 Section 3. The purpose of this Act is to protect patients
21 from surprise medical bills when receiving certain emergency
22 services and non-emergency services from out-of-network
104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2405 Introduced 2/7/2025, by Sen. Ram Villivalam 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. 1409.8815 ILCS 505/2HHHH new 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. 1409.8 815 ILCS 505/2HHHH new
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
815 ILCS 505/2HHHH new
Amends the Illinois Insurance Code to create the Consumer Protection from Surprise Health Care Billing Act. Provides that, on or after July 1, 2025, notwithstanding any other applicable provision, when a beneficiary, insured, or enrollee receives services from a nonparticipating ground ambulance service provider, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating ground ambulance service provider. Provides that any cost-sharing requirements shall be applied as though the services provided by the nonparticipating ground ambulance service provider had been provided by a participating ground ambulance service provider. Sets forth provisions concerning payment for ground ambulance services; calculating the recognized amount; limitations for the cost sharing amount for any occurrence in which a ground ambulance service is provided to a beneficiary; appeals for payments made by health insurance issuers; the maximum allowable payment amounts, by individual service types, for nonparticipating ground ambulance service providers owned, operated, or controlled by a private organization; and payments to nonparticipating ground ambulance service providers owned, operated, or controlled, by a unit of government which participates in the Ground Emergency Medical Transportation program administered by the Department of Healthcare and Family Services. Makes conforming changes. Provides that the failure by a health insurance issuer to comply with the specified requirements constitutes an unlawful practice under the Consumer Fraud and Deceptive Business Practices Act and enforcement authority is granted to the Attorney General. Amends the Health Maintenance Organization Act and the Consumer Fraud and Deceptive Business Practices Act to make corresponding changes. Effective July 1, 2025.
LRB104 10637 BAB 20714 b LRB104 10637 BAB 20714 b
LRB104 10637 BAB 20714 b
A BILL FOR
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
815 ILCS 505/2HHHH new
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1 providers.
2 Section 5. The Illinois Insurance Code is amended by
3 changing Sections 356z.3a and 370g as follows:
4 (215 ILCS 5/356z.3a)
5 Sec. 356z.3a. Billing; emergency services;
6 nonparticipating providers.
7 (a) As used in this Section:
8 "Ancillary services" means:
9 (1) items and services related to emergency medicine,
10 anesthesiology, pathology, radiology, and neonatology that
11 are provided by any health care provider;
12 (2) items and services provided by assistant surgeons,
13 hospitalists, and intensivists;
14 (3) diagnostic services, including radiology and
15 laboratory services, except for advanced diagnostic
16 laboratory tests identified on the most current list
17 published by the United States Secretary of Health and
18 Human Services under 42 U.S.C. 300gg-132(b)(3);
19 (4) items and services provided by other specialty
20 practitioners as the United States Secretary of Health and
21 Human Services specifies through rulemaking under 42
22 U.S.C. 300gg-132(b)(3);
23 (5) items and services provided by a nonparticipating
24 provider if there is no participating provider who can
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1 furnish the item or service at the facility; and
2 (6) items and services provided by a nonparticipating
3 provider if there is no participating provider who will
4 furnish the item or service because a participating
5 provider has asserted the participating provider's rights
6 under the Health Care Right of Conscience Act.
7 "Cost sharing" means the amount an insured, beneficiary,
8 or enrollee is responsible for paying for a covered item or
9 service under the terms of the policy or certificate. "Cost
10 sharing" includes copayments, coinsurance, and amounts paid
11 toward deductibles, but does not include amounts paid towards
12 premiums, balance billing by out-of-network providers, or the
13 cost of items or services that are not covered under the policy
14 or certificate.
15 "Emergency department of a hospital" means any hospital
16 department that provides emergency services, including a
17 hospital outpatient department.
18 "Emergency medical condition" has the meaning ascribed to
19 that term in Section 10 of the Managed Care Reform and Patient
20 Rights Act.
21 "Emergency medical screening examination" has the meaning
22 ascribed to that term in Section 10 of the Managed Care Reform
23 and Patient Rights Act.
24 "Emergency services" means, with respect to an emergency
25 medical condition:
26 (1) in general, an emergency medical screening
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1 examination, including ancillary services routinely
2 available to the emergency department to evaluate such
3 emergency medical condition, and such further medical
4 examination and treatment as would be required to
5 stabilize the patient regardless of the department of the
6 hospital or other facility in which such further
7 examination or treatment is furnished; or
8 (2) additional items and services for which benefits
9 are provided or covered under the coverage and that are
10 furnished by a nonparticipating provider or
11 nonparticipating emergency facility regardless of the
12 department of the hospital or other facility in which such
13 items are furnished after the insured, beneficiary, or
14 enrollee is stabilized and as part of outpatient
15 observation or an inpatient or outpatient stay with
16 respect to the visit in which the services described in
17 paragraph (1) are furnished. Services after stabilization
18 cease to be emergency services only when all the
19 conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
20 regulations thereunder are met.
21 "Freestanding Emergency Center" means a facility licensed
22 under Section 32.5 of the Emergency Medical Services (EMS)
23 Systems Act.
24 "Ground ambulance service" means both medical
25 transportation services that are described as ground ambulance
26 services by the Centers for Medicare and Medicaid Services and
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1 medical non-transportation services such as evaluation without
2 transport, treatment without transport, or paramedic intercept
3 that are either provided in a vehicle that is licensed as an
4 ambulance under the Emergency Medical Services (EMS) Systems
5 Act or provided by EMS Personnel assigned to a vehicle that is
6 licensed as an ambulance under the Emergency Medical Services
7 (EMS) Systems Act.
8 "Ground ambulance service provider" means a vehicle
9 service provider under the Emergency Medical Services (EMS)
10 Systems Act that operates licensed ground ambulances for the
11 purpose of providing emergency ambulance services,
12 non-emergency ambulance services, or both. "Ground ambulance
13 service provider" includes both ambulance providers and
14 ambulance suppliers as described by the Centers for Medicare
15 and Medicaid Services.
16 "Health care facility" means, in the context of
17 non-emergency services, any of the following:
18 (1) a hospital as defined in 42 U.S.C. 1395x(e);
19 (2) a hospital outpatient department;
20 (3) a critical access hospital certified under 42
21 U.S.C. 1395i-4(e);
22 (4) an ambulatory surgical treatment center as defined
23 in the Ambulatory Surgical Treatment Center Act; or
24 (5) any recipient of a license under the Hospital
25 Licensing Act that is not otherwise described in this
26 definition.
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1 "Health care provider" means a provider as defined in
2 subsection (d) of Section 370g. "Health care provider" does
3 not include a provider of air ambulance or ground ambulance
4 services.
5 "Health care services" has the meaning ascribed to that
6 term in subsection (a) of Section 370g.
7 "Health insurance issuer" has the meaning ascribed to that
8 term in Section 5 of the Illinois Health Insurance Portability
9 and Accountability Act.
10 "Nonparticipating emergency facility" means, with respect
11 to the furnishing of an item or service under a policy of group
12 or individual health insurance coverage, any of the following
13 facilities that does not have a contractual relationship
14 directly or indirectly with a health insurance issuer in
15 relation to the coverage:
16 (1) an emergency department of a hospital;
17 (2) a Freestanding Emergency Center;
18 (3) an ambulatory surgical treatment center as defined
19 in the Ambulatory Surgical Treatment Center Act; or
20 (4) with respect to emergency services described in
21 paragraph (2) of the definition of "emergency services", a
22 hospital.
23 "Nonparticipating provider" means, with respect to the
24 furnishing of an item or service under a policy of group or
25 individual health insurance coverage, any health care provider
26 who does not have a contractual relationship directly or
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1 indirectly with a health insurance issuer in relation to the
2 coverage.
3 "Participating emergency facility" means any of the
4 following facilities that has a contractual relationship
5 directly or indirectly with a health insurance issuer offering
6 group or individual health insurance coverage setting forth
7 the terms and conditions on which a relevant health care
8 service is provided to an insured, beneficiary, or enrollee
9 under the coverage:
10 (1) an emergency department of a hospital;
11 (2) a Freestanding Emergency Center;
12 (3) an ambulatory surgical treatment center as defined
13 in the Ambulatory Surgical Treatment Center Act; or
14 (4) with respect to emergency services described in
15 paragraph (2) of the definition of "emergency services", a
16 hospital.
17 For purposes of this definition, a single case agreement
18 between an emergency facility and an issuer that is used to
19 address unique situations in which an insured, beneficiary, or
20 enrollee requires services that typically occur out-of-network
21 constitutes a contractual relationship and is limited to the
22 parties to the agreement.
23 "Participating health care facility" means any health care
24 facility that has a contractual relationship directly or
25 indirectly with a health insurance issuer offering group or
26 individual health insurance coverage setting forth the terms
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1 and conditions on which a relevant health care service is
2 provided to an insured, beneficiary, or enrollee under the
3 coverage. A single case agreement between an emergency
4 facility and an issuer that is used to address unique
5 situations in which an insured, beneficiary, or enrollee
6 requires services that typically occur out-of-network
7 constitutes a contractual relationship for purposes of this
8 definition and is limited to the parties to the agreement.
9 "Participating provider" means any health care provider
10 that has a contractual relationship directly or indirectly
11 with a health insurance issuer offering group or individual
12 health insurance coverage setting forth the terms and
13 conditions on which a relevant health care service is provided
14 to an insured, beneficiary, or enrollee under the coverage.
15 "Qualifying payment amount" has the meaning given to that
16 term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
17 promulgated thereunder.
18 "Recognized amount" means the lesser of the following
19 amounts: (1) the amount initially billed by the provider; (2)
20 or the qualifying payment amount; or, (3) if applicable, the
21 allowable amount established by this Section.
22 "Stabilize" means "stabilization" as defined in Section 10
23 of the Managed Care Reform and Patient Rights Act.
24 "Treating provider" means a health care provider who has
25 evaluated the individual.
26 "Visit" means, with respect to health care services
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1 furnished to an individual at a health care facility, health
2 care services furnished by a provider at the facility, as well
3 as equipment, devices, telehealth services, imaging services,
4 laboratory services, and preoperative and postoperative
5 services regardless of whether the provider furnishing such
6 services is at the facility.
7 (b) Emergency services. When a beneficiary, insured, or
8 enrollee receives emergency services from a nonparticipating
9 provider or a nonparticipating emergency facility, the health
10 insurance issuer shall ensure that the beneficiary, insured,
11 or enrollee shall incur no greater out-of-pocket costs than
12 the beneficiary, insured, or enrollee would have incurred with
13 a participating provider or a participating emergency
14 facility. Any cost-sharing requirements shall be applied as
15 though the emergency services had been received from a
16 participating provider or a participating facility. Cost
17 sharing shall be calculated based on the recognized amount for
18 the emergency services. If the cost sharing for the same item
19 or service furnished by a participating provider would have
20 been a flat-dollar copayment, that amount shall be the
21 cost-sharing amount unless the provider has billed a lesser
22 total amount. In no event shall the beneficiary, insured,
23 enrollee, or any group policyholder or plan sponsor be liable
24 to or billed by the health insurance issuer, the
25 nonparticipating provider, or the nonparticipating emergency
26 facility for any amount beyond the cost sharing calculated in
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1 accordance with this subsection with respect to the emergency
2 services delivered. Administrative requirements or limitations
3 shall be no greater than those applicable to emergency
4 services received from a participating provider or a
5 participating emergency facility.
6 (b-5) Non-emergency services at participating health care
7 facilities.
8 (1) When a beneficiary, insured, or enrollee utilizes
9 a participating health care facility and, due to any
10 reason, covered ancillary services are provided by a
11 nonparticipating provider during or resulting from the
12 visit, the health insurance issuer shall ensure that the
13 beneficiary, insured, or enrollee shall incur no greater
14 out-of-pocket costs than the beneficiary, insured, or
15 enrollee would have incurred with a participating provider
16 for the ancillary services. Any cost-sharing requirements
17 shall be applied as though the ancillary services had been
18 received from a participating provider. Cost sharing shall
19 be calculated based on the recognized amount for the
20 ancillary services. If the cost sharing for the same item
21 or service furnished by a participating provider would
22 have been a flat-dollar copayment, that amount shall be
23 the cost-sharing amount unless the provider has billed a
24 lesser total amount. In no event shall the beneficiary,
25 insured, enrollee, or any group policyholder or plan
26 sponsor be liable to or billed by the health insurance
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1 issuer, the nonparticipating provider, or the
2 participating health care facility for any amount beyond
3 the cost sharing calculated in accordance with this
4 subsection with respect to the ancillary services
5 delivered. In addition to ancillary services, the
6 requirements of this paragraph shall also apply with
7 respect to covered items or services furnished as a result
8 of unforeseen, urgent medical needs that arise at the time
9 an item or service is furnished, regardless of whether the
10 nonparticipating provider satisfied the notice and consent
11 criteria under paragraph (2) of this subsection.
12 (2) When a beneficiary, insured, or enrollee utilizes
13 a participating health care facility and receives
14 non-emergency covered health care services other than
15 those described in paragraph (1) of this subsection from a
16 nonparticipating provider during or resulting from the
17 visit, the health insurance issuer shall ensure that the
18 beneficiary, insured, or enrollee incurs no greater
19 out-of-pocket costs than the beneficiary, insured, or
20 enrollee would have incurred with a participating provider
21 unless the nonparticipating provider or the participating
22 health care facility on behalf of the nonparticipating
23 provider satisfies the notice and consent criteria
24 provided in 42 U.S.C. 300gg-132 and regulations
25 promulgated thereunder. If the notice and consent criteria
26 are not satisfied, then:
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1 (A) any cost-sharing requirements shall be applied
2 as though the health care services had been received
3 from a participating provider;
4 (B) cost sharing shall be calculated based on the
5 recognized amount for the health care services; and
6 (C) in no event shall the beneficiary, insured,
7 enrollee, or any group policyholder or plan sponsor be
8 liable to or billed by the health insurance issuer,
9 the nonparticipating provider, or the participating
10 health care facility for any amount beyond the cost
11 sharing calculated in accordance with this subsection
12 with respect to the health care services delivered.
13 (c) Notwithstanding any other provision of this Code,
14 except when the notice and consent criteria are satisfied for
15 the situation in paragraph (2) of subsection (b-5), any
16 benefits a beneficiary, insured, or enrollee receives for
17 services under the situations in subsections subsection (b),
18 or (b-5), (f), (f-5), or (f-10) are assigned to the
19 nonparticipating providers or the facility acting on their
20 behalf. Upon receipt of the provider's bill or facility's
21 bill, the health insurance issuer shall provide the
22 nonparticipating provider or the facility with a written
23 explanation of benefits that specifies the proposed
24 reimbursement and the applicable deductible, copayment, or
25 coinsurance amounts owed by the insured, beneficiary, or
26 enrollee. The health insurance issuer shall pay any
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1 reimbursement subject to this Section directly to the
2 nonparticipating provider or the facility.
3 (d) For bills assigned under subsection (c), the
4 nonparticipating provider or the facility may bill the health
5 insurance issuer for the services rendered, and the health
6 insurance issuer may pay the billed amount or attempt to
7 negotiate reimbursement with the nonparticipating provider or
8 the facility. Within 30 calendar days after the provider or
9 facility transmits the bill to the health insurance issuer,
10 the issuer shall send an initial payment or notice of denial of
11 payment with the written explanation of benefits to the
12 provider or facility. If attempts to negotiate reimbursement
13 for services provided by a nonparticipating provider do not
14 result in a resolution of the payment dispute within 30 days
15 after receipt of written explanation of benefits by the health
16 insurance issuer, then the health insurance issuer or
17 nonparticipating provider or the facility may initiate binding
18 arbitration to determine payment for services provided on a
19 per-bill or batched-bill basis, in accordance with Section
20 300gg-111 of the Public Health Service Act and the regulations
21 promulgated thereunder. The party requesting arbitration shall
22 notify the other party arbitration has been initiated and
23 state its final offer before arbitration. In response to this
24 notice, the nonrequesting party shall inform the requesting
25 party of its final offer before the arbitration occurs.
26 Arbitration shall be initiated by filing a request with the
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1 Department of Insurance.
2 (e) The Department of Insurance shall publish a list of
3 approved arbitrators or entities that shall provide binding
4 arbitration. These arbitrators shall be American Arbitration
5 Association or American Health Lawyers Association trained
6 arbitrators. Both parties must agree on an arbitrator from the
7 Department of Insurance's or its approved entity's list of
8 arbitrators. If no agreement can be reached, then a list of 5
9 arbitrators shall be provided by the Department of Insurance
10 or the approved entity. From the list of 5 arbitrators, the
11 health insurance issuer can veto 2 arbitrators and the
12 provider or facility can veto 2 arbitrators. The remaining
13 arbitrator shall be the chosen arbitrator. This arbitration
14 shall consist of a review of the written submissions by both
15 parties. The arbitrator shall not establish a rebuttable
16 presumption that the qualifying payment amount should be the
17 total amount owed to the provider or facility by the
18 combination of the issuer and the insured, beneficiary, or
19 enrollee. Binding arbitration shall provide for a written
20 decision within 45 days after the request is filed with the
21 Department of Insurance. Both parties shall be bound by the
22 arbitrator's decision. The arbitrator's expenses and fees,
23 together with other expenses, not including attorney's fees,
24 incurred in the conduct of the arbitration, shall be paid as
25 provided in the decision.
26 (f) (f) Payments to nonparticipating ground ambulance
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1 service providers. (Blank).
2 (1) On or after July 1, 2025, notwithstanding any
3 other provision of this Section, when a beneficiary,
4 insured, or enrollee receives services from a
5 nonparticipating ground ambulance service provider, the
6 health insurance issuer shall ensure that the beneficiary,
7 insured, or enrollee shall incur no greater out-of-pocket
8 costs than the beneficiary, insured, or enrollee would
9 have incurred with a participating ground ambulance
10 service provider. Any cost-sharing requirements shall be
11 applied as though the services provided by the
12 nonparticipating ground ambulance service provider had
13 been provided by a participating ground ambulance service
14 provider. The health insurance issuer shall approve
15 charges for nonparticipating ground ambulance service
16 providers at a recognized amount that shall be calculated
17 as the lessor of: (i) the nonparticipating ground
18 ambulance service provider's billed charge; (ii) the
19 negotiated rate between the nonparticipating ground
20 ambulance service provider and the health insurance
21 insurer; or (iii) the maximum allowable amount specified
22 in subsection (f-5) or the amount specified in subsection
23 (f-10).
24 (2) Payment for ground ambulance services shall be
25 made on a per occurrence basis. For purposes of this
26 subsection, occurrence means in individual ground
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1 ambulance response and, if applicable, the corresponding
2 transport and shall consist of a base charge and, if
3 applicable, a loaded mileage charge.
4 (4) The cost sharing amount for any occurrence in
5 which a ground ambulance service is provided to a
6 beneficiary, insured, or enrollee, shall not exceed the
7 lessor of the plan's emergency room visit copay or 10% of
8 the recognized amount for the occurrence.
9 (5) With respect appeals for payments made by health
10 insurance issuers under this subsection, beneficiaries,
11 insureds, enrollees, and ground ambulance service
12 providers are not required to follow a health insurance
13 issuer's internal appeals process and may seek relief in
14 any appropriate court for the purpose of resolving a
15 payment dispute. In such a dispute litigated in court, a
16 prevailing beneficiary, insured, enrollee, or ground
17 ambulance service provider shall be entitled to payment
18 for reasonable attorney's fees and may seek payment for
19 other damages, including punitive damages, arising from a
20 health insurance issuer's failure to provide payment in
21 compliance with this Act.
22 (6) Definition of emergency. In addition to any other
23 criteria for the definition of emergency described in this
24 Act or in the definition of emergency described in the
25 Healthcare Common Procedure Coding System (HCPCS) as it
26 pertains to ground ambulance services, ground ambulance
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1 services provided by ground ambulance service providers
2 shall be considered emergency services if the services
3 were provided pursuant to a request to 9-1-1 or an
4 equivalent telephone number, texting system, or other
5 method of summonsing emergency services or if the services
6 provided were provided when a patient's condition, at the
7 time of service, was considered to be an emergency medical
8 condition as defined by this Act or as determined by a
9 physician licensed pursuant to the Medical Practice Act of
10 1997.
11 (7) As used in subsections (f-5) and (f-10):
12 (i) "Evaluation" means the provision of a
13 medical screening examination to determine whether
14 an emergency medical condition exists.
15 (ii) "Treatment" means the provision of an
16 assessment and a therapy or therapeutic agent used
17 to treat a medical condition, or a procedure used
18 to treat a medical condition.
19 (iii) "Paramedic intercept" means a situation
20 when a paramedic (advanced life support) staffed
21 ambulance rendezvous with a non-paramedic (basic
22 life support or intermediate life support) staffed
23 ambulance to provide advanced life support care.
24 Advanced life support is warranted when a
25 patient's condition and need for treatment exceeds
26 the basic life support or intermediate life
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1 support level of care.
2 (iv) "Unit of government" means a county, as
3 described in the Counties Code; a township, as
4 described in the Township Code; a municipality, as
5 described in the Municipal Code; a fire protection
6 district, as described in the Fire Protection
7 District Act; a rescue squad district, as
8 described in the Rescue Squad District Act; or an
9 Emergency Services District, as described in the
10 Emergency Services District Act.
11 (f-5) The maximum allowable payment amounts by individual
12 service types for nonparticipating ground ambulance service
13 providers owned, operated, or controlled by a private
14 organization, to include both private for profit organizations
15 and private not-for-profit organizations and nonparticipating
16 ground ambulance service providers owned, operated, or
17 controlled by a unit of government that does not participate
18 in the Ground Emergency Medical Transportation (GEMT) program
19 administered by the Department of Healthcare and Family
20 Services, shall be as follows: (i) basic life support,
21 non-emergency base $2,030; (ii) basic life support, emergency
22 base $2,660; (iii) advanced life support, non-emergency, level
23 1 base $2,800; (iv) advanced life support, emergency, level 1
24 base $2,905; (v) advanced life support, level 2 base $3,080;
25 (vi) specialty care transport base $7,140; (vii) evaluation
26 without transport, 25% of the basic life support, emergency
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1 base; (vii) treatment without transport, 50% of the advanced
2 life support, emergency, level 1 base; (viii) paramedic
3 intercept, 75% of the advanced life support, emergency, level
4 1 base; and (ix) ground mileage, per loaded mile $56. The
5 amounts in this subsection shall be adjusted at a rate of 5%
6 annually, effective on January 1 of each year, beginning on
7 January 1, 2026.
8 (f-10) Payments to nonparticipating ground ambulance
9 service providers owned, operated, or controlled by a unit of
10 government that participates in the Ground Emergency Medical
11 Transportation (GEMT) program administered by the Department
12 of Healthcare and Family Services, shall be the cost-based
13 amount, as reflected in the ground ambulance service
14 provider's GEMT cost report for the applicable date of
15 service. Individual services types shall be as follows: (i)
16 basic life support, emergency base; (ii) advanced life
17 support, emergency, level 1 base; (iii) advanced life support,
18 level 2 base; (iv) evaluation without transport, 100% of the
19 basic life support, emergency base, no mileage; (v) treatment
20 without transport, 100% of the advanced life support,
21 emergency, level 1 base, no mileage; (vi) paramedic intercept,
22 100% of the advanced life support, emergency, level 1 base, no
23 mileage; and (vii) ground mileage, per loaded mile. In
24 situations where a ground ambulance service provider that
25 qualifies for payments under this subsection charges for a
26 services type, including a basic life support, non-emergency
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1 base, or an advanced life support, non-emergency base payments
2 by the health insurance issuers shall be as described in
3 subsection (f-5).
4 (g) Section 368a of this Act shall not apply during the
5 pendency of a decision under subsection (d). Upon the issuance
6 of the arbitrator's decision, Section 368a applies with
7 respect to the amount, if any, by which the arbitrator's
8 determination exceeds the issuer's initial payment under
9 subsection (c), or the entire amount of the arbitrator's
10 determination if initial payment was denied. Any interest
11 required to be paid to a provider under Section 368a shall not
12 accrue until after 30 days of an arbitrator's decision as
13 provided in subsection (d), but in no circumstances longer
14 than 150 days from the date the nonparticipating
15 facility-based provider billed for services rendered.
16 (h) Nothing in this Section shall be interpreted to change
17 the prudent layperson provisions with respect to emergency
18 services under the Managed Care Reform and Patient Rights Act.
19 (i) Nothing in this Section shall preclude a health care
20 provider from billing a beneficiary, insured, or enrollee for
21 reasonable administrative fees, such as service fees for
22 checks returned for nonsufficient funds and missed
23 appointments.
24 (j) Nothing in this Section shall preclude a beneficiary,
25 insured, or enrollee from assigning benefits to a
26 nonparticipating provider when the notice and consent criteria
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1 are satisfied under paragraph (2) of subsection (b-5) or in
2 any other situation not described in subsection (b) or (b-5).
3 (k) Except when the notice and consent criteria are
4 satisfied under paragraph (2) of subsection (b-5), if an
5 individual receives health care services under the situations
6 described in subsection (b) or (b-5), no referral requirement
7 or any other provision contained in the policy or certificate
8 of coverage shall deny coverage, reduce benefits, or otherwise
9 defeat the requirements of this Section for services that
10 would have been covered with a participating provider.
11 However, this subsection shall not be construed to preclude a
12 provider contract with a health insurance issuer, or with an
13 administrator or similar entity acting on the issuer's behalf,
14 from imposing requirements on the participating provider,
15 participating emergency facility, or participating health care
16 facility relating to the referral of covered individuals to
17 nonparticipating providers.
18 (l) Except if the notice and consent criteria are
19 satisfied under paragraph (2) of subsection (b-5),
20 cost-sharing amounts calculated in conformity with this
21 Section shall count toward any deductible or out-of-pocket
22 maximum applicable to in-network coverage.
23 (m) The Department has the authority to enforce the
24 requirements of this Section in the situations described in
25 subsections (b) and (b-5), and in any other situation for
26 which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
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1 regulations promulgated thereunder would prohibit an
2 individual from being billed or liable for emergency services
3 furnished by a nonparticipating provider or nonparticipating
4 emergency facility or for non-emergency health care services
5 furnished by a nonparticipating provider at a participating
6 health care facility.
7 (m-5) A failure by a health insurance issuer to comply
8 with the requirements in this Section constitutes an unlawful
9 practice under the Consumer Fraud and Deceptive Business
10 Practices Act. All remedies, penalties, and authority granted
11 to the Attorney General by that Act shall be available to the
12 Attorney General for the enforcement of this Section.
13 (n) This Section does not apply with respect to air
14 ambulance or ground ambulance services. This Section does not
15 apply to any policy of excepted benefits or to short-term,
16 limited-duration health insurance coverage.
17 (Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23;
18 103-440, eff. 1-1-24.)
19 (215 ILCS 5/370g) (from Ch. 73, par. 982g)
20 Sec. 370g. Definitions. As used in this Article, the
21 following definitions apply:
22 (a) "Health care services" means health care services or
23 products rendered or sold by a provider within the scope of the
24 provider's license or legal authorization. The term includes,
25 but is not limited to, hospital, medical, surgical, dental,
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1 vision, ground ambulance services, and pharmaceutical services
2 or products.
3 (b) "Insurer" means an insurance company or a health
4 service corporation authorized in this State to issue policies
5 or subscriber contracts which reimburse for expenses of health
6 care services.
7 (c) "Insured" means an individual entitled to
8 reimbursement for expenses of health care services under a
9 policy or subscriber contract issued or administered by an
10 insurer.
11 (d) "Provider" means an individual or entity duly licensed
12 or legally authorized to provide health care services.
13 (e) "Noninstitutional provider" means any person licensed
14 under the Medical Practice Act of 1987, as now or hereafter
15 amended.
16 (f) "Beneficiary" means an individual entitled to
17 reimbursement for expenses of or the discount of provider fees
18 for health care services under a program where the beneficiary
19 has an incentive to utilize the services of a provider which
20 has entered into an agreement or arrangement with an
21 administrator.
22 (g) "Administrator" means any person, partnership or
23 corporation, other than an insurer or health maintenance
24 organization holding a certificate of authority under the
25 "Health Maintenance Organization Act", as now or hereafter
26 amended, that arranges, contracts with, or administers
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1 contracts with a provider whereby beneficiaries are provided
2 an incentive to use the services of such provider.
3 (h) "Emergency medical condition" has the meaning given to
4 that term in Section 10 of the Managed Care Reform and Patient
5 Rights Act.
6 (Source: P.A. 102-409, eff. 1-1-22.)
7 Section 10. The Health Maintenance Organization Act is
8 amended by changing Section 4-15 as follows:
9 (215 ILCS 125/4-15) (from Ch. 111 1/2, par. 1409.8)
10 Sec. 4-15. (a) No contract or evidence of coverage for
11 basic health care services delivered, issued for delivery,
12 renewed or amended by a Health Maintenance Organization shall
13 exclude coverage for emergency transportation by ambulance.
14 For the purposes of this Section, the term "emergency" means a
15 need for immediate medical attention resulting from a life
16 threatening condition or situation or a need for immediate
17 medical attention as otherwise reasonably determined by a
18 physician, public safety official or other emergency medical
19 personnel.
20 (b) Payments to nonparticipating ground ambulance service
21 providers shall be as described in subsections (f), (f-5), and
22 (f-10) of Section 356z.3a of the Illinois Insurance Code. Upon
23 reasonable demand by a provider of emergency transportation by
24 ambulance, a Health Maintenance Organization shall promptly
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1 pay to the provider, subject to coverage limitations stated in
2 the contract or evidence of coverage, the charges for
3 emergency transportation by ambulance provided to an enrollee
4 in a health care plan arranged for by the Health Maintenance
5 Organization. By accepting any such payment from the Health
6 Maintenance Organization, the provider of emergency
7 transportation by ambulance agrees not to seek any payment
8 from the enrollee for services provided to the enrollee.
9 (Source: P.A. 86-833; 86-1028.)
10 Section 15. The Consumer Fraud and Deceptive Business
11 Practices Act is amended by adding Section 2HHHH as follows:
12 (815 ILCS 505/2HHHH new)
13 Sec. 2HHHH. Violations of the Consumer Protection from
14 Surprise Health Care Billing Act. A health insurer commits an
15 unlawful practice within the meaning of this Act when it
16 refuses to comply with the requirements of subsection (m-5) of
17 Section 356z.3a of the Illinois Insurance Code.
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