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Public Act 103-0440
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HB3030 Enrolled | LRB103 05013 BMS 56587 b |
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by |
changing Section 356z.3a as follows:
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(215 ILCS 5/356z.3a) |
Sec. 356z.3a. Billing; emergency services; |
nonparticipating providers. |
(a) As used in this Section: |
"Ancillary services" means: |
(1) items and services related to emergency medicine, |
anesthesiology, pathology, radiology, and neonatology that |
are provided by any health care provider; |
(2) items and services provided by assistant surgeons, |
hospitalists, and intensivists; |
(3) diagnostic services, including radiology and |
laboratory services, except for advanced diagnostic |
laboratory tests identified on the most current list |
published by the United States Secretary of Health and |
Human Services under 42 U.S.C. 300gg-132(b)(3); |
(4) items and services provided by other specialty |
practitioners as the United States Secretary of Health and |
Human Services specifies through rulemaking under 42 |
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U.S.C. 300gg-132(b)(3); |
(5) items and services provided by a nonparticipating |
provider if there is no participating provider who can |
furnish the item or service at the facility; and |
(6) items and services provided by a nonparticipating |
provider if there is no participating provider who will |
furnish the item or service because a participating |
provider has asserted the participating provider's rights |
under the Health Care Right of Conscience Act. |
"Cost sharing" means the amount an insured, beneficiary, |
or enrollee is responsible for paying for a covered item or |
service under the terms of the policy or certificate. "Cost |
sharing" includes copayments, coinsurance, and amounts paid |
toward deductibles, but does not include amounts paid towards |
premiums, balance billing by out-of-network providers, or the |
cost of items or services that are not covered under the policy |
or certificate. |
"Emergency department of a hospital" means any hospital |
department that provides emergency services, including a |
hospital outpatient department. |
"Emergency medical condition" has the meaning ascribed to |
that term in Section 10 of the Managed Care Reform and Patient |
Rights Act. |
"Emergency medical screening examination" has the meaning |
ascribed to that term in Section 10 of the Managed Care Reform |
and Patient Rights Act. |
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"Emergency services" means, with respect to an emergency |
medical condition: |
(1) in general, an emergency medical screening |
examination, including ancillary
services routinely |
available to the emergency department to evaluate such |
emergency medical condition, and such further medical |
examination and treatment as would be required to |
stabilize the patient regardless of the department of the |
hospital or other facility in which such further |
examination or treatment is furnished; or |
(2) additional items and services for which benefits |
are provided or covered under the coverage and that are |
furnished by a nonparticipating provider or |
nonparticipating emergency facility regardless of the |
department of the hospital or other facility in which such |
items are furnished after the insured, beneficiary, or |
enrollee is stabilized and as part of outpatient |
observation or an inpatient or outpatient stay with |
respect to the visit in which the services described in |
paragraph (1) are furnished. Services after stabilization |
cease to be emergency services only when all the |
conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and |
regulations thereunder are met. |
"Freestanding Emergency Center" means a facility licensed |
under Section 32.5 of the Emergency Medical Services (EMS) |
Systems Act. |
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"Health care facility" means, in the context of |
non-emergency services, any of the following: |
(1) a hospital as defined in 42 U.S.C. 1395x(e); |
(2) a hospital outpatient department; |
(3) a critical access hospital certified under 42 |
U.S.C. 1395i-4(e); |
(4) an ambulatory surgical treatment center as defined |
in the Ambulatory Surgical Treatment Center Act; or |
(5) any recipient of a license under the Hospital |
Licensing Act that is not otherwise described in this |
definition. |
"Health care provider" means a provider as defined in |
subsection (d) of Section 370g. "Health care provider" does |
not include a provider of air ambulance or ground ambulance |
services. |
"Health care services" has the meaning ascribed to that |
term in subsection (a) of Section 370g. |
"Health insurance issuer" has the meaning ascribed to that |
term in Section 5 of the Illinois Health Insurance Portability |
and Accountability Act. |
"Nonparticipating emergency facility" means, with respect |
to the furnishing of an item or service under a policy of group |
or individual health insurance coverage, any of the following |
facilities that does not have a contractual relationship |
directly or indirectly with a health insurance issuer in |
relation to the coverage: |
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(1) an emergency department of a hospital; |
(2) a Freestanding Emergency Center; |
(3) an ambulatory surgical treatment center as defined |
in the Ambulatory Surgical Treatment Center Act; or |
(4) with respect to emergency services described in |
paragraph (2) of the definition of "emergency services", a |
hospital. |
"Nonparticipating provider" means, with respect to the |
furnishing of an item or service under a policy of group or |
individual health insurance coverage, any health care provider |
who does not have a contractual relationship directly or |
indirectly with a health insurance issuer in relation to the |
coverage. |
"Participating emergency facility" means any of the |
following facilities that has a contractual relationship |
directly or indirectly with a health insurance issuer offering |
group or individual health insurance coverage setting forth |
the terms and conditions on which a relevant health care |
service is provided to an insured, beneficiary, or enrollee |
under the coverage: |
(1) an emergency department of a hospital; |
(2) a Freestanding Emergency Center; |
(3) an ambulatory surgical treatment center as defined |
in the Ambulatory Surgical Treatment Center Act; or |
(4) with respect to emergency services described in |
paragraph (2) of the definition of "emergency services", a |
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hospital. |
For purposes of this definition, a single case agreement |
between an emergency facility and an issuer that is used to |
address unique situations in which an insured, beneficiary, or |
enrollee requires services that typically occur out-of-network |
constitutes a contractual relationship and is limited to the |
parties to the agreement. |
"Participating health care facility" means any health care |
facility that has a contractual
relationship directly or |
indirectly with a health insurance issuer offering group or |
individual health insurance coverage setting forth the terms |
and conditions on which a relevant health care service is |
provided to an insured, beneficiary, or enrollee under the |
coverage. A single case agreement between an emergency |
facility and an issuer that is used to address unique |
situations in which an insured, beneficiary, or enrollee |
requires services that typically occur out-of-network |
constitutes a contractual relationship for purposes of this |
definition and is limited to the parties to the agreement. |
"Participating provider" means any health care provider |
that has a
contractual relationship directly or indirectly |
with a health insurance issuer offering group or individual |
health insurance coverage setting forth the terms and |
conditions on which a relevant health care service is provided |
to an insured, beneficiary, or enrollee under the coverage. |
"Qualifying payment amount" has the meaning given to that |
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term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations |
promulgated thereunder. |
"Recognized amount" means the lesser of the amount |
initially billed by the provider or the qualifying payment |
amount. |
"Stabilize" means "stabilization" as defined in Section 10 |
of the Managed Care Reform and Patient Rights Act. |
"Treating provider" means a health care provider who has |
evaluated the individual. |
"Visit" means, with respect to health care services |
furnished to an individual at a health care facility, health |
care services furnished by a provider at the facility, as well |
as equipment, devices, telehealth services, imaging services, |
laboratory services, and preoperative and postoperative |
services regardless of whether the provider furnishing such |
services is at the facility. |
(b) Emergency services. When a beneficiary, insured, or |
enrollee receives emergency services from a nonparticipating |
provider or a nonparticipating emergency facility, 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 provider or a participating emergency |
facility. Any cost-sharing requirements shall be applied as |
though the emergency services had been received from a |
participating provider or a participating facility. Cost |
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sharing shall be calculated based on the recognized amount for |
the emergency services. If the cost sharing for the same item |
or service furnished by a participating provider would have |
been a flat-dollar copayment, that amount shall be the |
cost-sharing amount unless the provider has billed a lesser |
total amount. In no event shall the beneficiary, insured, |
enrollee, or any group policyholder or plan sponsor be liable |
to or billed by the health insurance issuer, the |
nonparticipating provider, or the nonparticipating emergency |
facility for any amount beyond the cost sharing calculated in |
accordance with this subsection with respect to the emergency |
services delivered. Administrative requirements or limitations |
shall be no greater than those applicable to emergency |
services received from a participating provider or a |
participating emergency facility. |
(b-5) Non-emergency services at participating health care |
facilities. |
(1) When a beneficiary, insured, or enrollee utilizes |
a participating health care facility and, due to any |
reason, covered ancillary services are provided by a |
nonparticipating provider during or resulting from the |
visit, 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 provider |
for the ancillary services. Any cost-sharing requirements |
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shall be applied as though the ancillary services had been |
received from a participating provider. Cost sharing shall |
be calculated based on the recognized amount for the |
ancillary services. If the cost sharing for the same item |
or service furnished by a participating provider would |
have been a flat-dollar copayment, that amount shall be |
the cost-sharing amount unless the provider has billed a |
lesser total amount. In no event shall the beneficiary, |
insured, enrollee, or any group policyholder or plan |
sponsor be liable to or billed by the health insurance |
issuer, the nonparticipating provider, or the |
participating health care facility for any amount beyond |
the cost sharing calculated in accordance with this |
subsection with respect to the ancillary services |
delivered. In addition to ancillary services, the |
requirements of this paragraph shall also apply with |
respect to covered items or services furnished as a result |
of unforeseen, urgent medical needs that arise at the time |
an item or service is furnished, regardless of whether the |
nonparticipating provider satisfied the notice and consent |
criteria under paragraph (2) of this subsection. |
(2) When a beneficiary, insured, or enrollee utilizes |
a participating health care facility and receives |
non-emergency covered health care services other than |
those described in paragraph (1) of this subsection from a |
nonparticipating provider during or resulting from the |
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visit, the health insurance issuer shall ensure that the |
beneficiary, insured, or enrollee incurs no greater |
out-of-pocket costs than the beneficiary, insured, or |
enrollee would have incurred with a participating provider |
unless the nonparticipating provider or the participating |
health care facility on behalf of the nonparticipating |
provider satisfies the notice and consent criteria |
provided in 42 U.S.C. 300gg-132 and regulations |
promulgated thereunder. If the notice and consent criteria |
are not satisfied, then: |
(A) any cost-sharing requirements shall be applied |
as though the health care services had been received |
from a participating provider; |
(B) cost sharing shall be calculated based on the |
recognized amount for the health care services; and |
(C) in no event shall the beneficiary, insured, |
enrollee, or any group policyholder or plan sponsor be |
liable to or billed by the health insurance issuer, |
the nonparticipating provider, or the participating |
health care facility for any amount beyond the cost |
sharing calculated in accordance with this subsection |
with respect to the health care services delivered. |
(c) Notwithstanding any other provision of this Code, |
except when the notice and consent criteria are satisfied for |
the situation in paragraph (2) of subsection (b-5), any |
benefits a beneficiary, insured, or enrollee receives for |
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services under the situations in subsection (b) or (b-5) are |
assigned to the nonparticipating providers or the facility |
acting on their behalf. Upon receipt of the provider's bill or |
facility's bill, the health insurance issuer shall provide the |
nonparticipating provider or the facility with a written |
explanation of benefits that specifies the proposed |
reimbursement and the applicable deductible, copayment, or |
coinsurance amounts owed by the insured, beneficiary, or |
enrollee. The health insurance issuer shall pay any |
reimbursement subject to this Section directly to the |
nonparticipating provider or the facility. |
(d) For bills assigned under subsection (c), the |
nonparticipating provider or the facility may bill the health |
insurance issuer for the services rendered, and the health |
insurance issuer may pay the billed amount or attempt to |
negotiate reimbursement with the nonparticipating provider or |
the facility. Within 30 calendar days after the provider or |
facility transmits the bill to the health insurance issuer, |
the issuer shall send an initial payment or notice of denial of |
payment with the written explanation of benefits to the |
provider or facility. If attempts to negotiate reimbursement |
for services provided by a nonparticipating provider do not |
result in a resolution of the payment dispute within 30 days |
after receipt of written explanation of benefits by the health |
insurance issuer, then the health insurance issuer or |
nonparticipating provider or the facility may initiate binding |
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arbitration to determine payment for services provided on a |
per-bill or batched-bill basis , in accordance with Section |
300gg-111 of the Public Health Service Act and the regulations |
promulgated thereunder . The party requesting arbitration shall |
notify the other party arbitration has been initiated and |
state its final offer before arbitration. In response to this |
notice, the nonrequesting party shall inform the requesting |
party of its final offer before the arbitration occurs. |
Arbitration shall be initiated by filing a request with the |
Department of Insurance. |
(e) The Department of Insurance shall publish a list of |
approved arbitrators or entities that shall provide binding |
arbitration. These arbitrators shall be American Arbitration |
Association or American Health Lawyers Association trained |
arbitrators. Both parties must agree on an arbitrator from the |
Department of Insurance's or its approved entity's list of |
arbitrators. If no agreement can be reached, then a list of 5 |
arbitrators shall be provided by the Department of Insurance |
or the approved entity. From the list of 5 arbitrators, the |
health insurance issuer can veto 2 arbitrators and the |
provider or facility can veto 2 arbitrators. The remaining |
arbitrator shall be the chosen arbitrator. This arbitration |
shall consist of a review of the written submissions by both |
parties. The arbitrator shall not establish a rebuttable |
presumption that the qualifying payment amount should be the |
total amount owed to the provider or facility by the |
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combination of the issuer and the insured, beneficiary, or |
enrollee. Binding arbitration shall provide for a written |
decision within 45 days after the request is filed with the |
Department of Insurance. Both parties shall be bound by the |
arbitrator's decision. The arbitrator's expenses and fees, |
together with other expenses, not including attorney's fees, |
incurred in the conduct of the arbitration, shall be paid as |
provided in the decision. |
(f) (Blank). |
(g) Section 368a of this Act shall not apply during the |
pendency of a decision under subsection (d). Upon the issuance |
of the arbitrator's decision, Section 368a applies with |
respect to the amount, if any, by which the arbitrator's |
determination exceeds the issuer's initial payment under |
subsection (c), or the entire amount of the arbitrator's |
determination if initial payment was denied. Any interest |
required to be paid to a provider under Section 368a shall not |
accrue until after 30 days of an arbitrator's decision as |
provided in subsection (d), but in no circumstances longer |
than 150 days from the date the nonparticipating |
facility-based provider billed for services rendered.
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(h) Nothing in this Section shall be interpreted to change |
the prudent layperson provisions with respect to emergency |
services under the Managed Care Reform and Patient Rights Act. |
(i) Nothing in this Section shall preclude a health care |
provider from billing a beneficiary, insured, or enrollee for |
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reasonable administrative fees, such as service fees for |
checks returned for nonsufficient funds and missed |
appointments. |
(j) Nothing in this Section shall preclude a beneficiary, |
insured, or enrollee from assigning benefits to a |
nonparticipating provider when the notice and consent criteria |
are satisfied under paragraph (2) of subsection (b-5) or in |
any other situation not described in subsection (b) or (b-5). |
(k) Except when the notice and consent criteria are |
satisfied under paragraph (2) of subsection (b-5), if an |
individual receives health care services under the situations |
described in subsection (b) or (b-5), no referral requirement |
or any other provision contained in the policy or certificate |
of coverage shall deny coverage, reduce benefits, or otherwise |
defeat the requirements of this Section for services that |
would have been covered with a participating provider. |
However, this subsection shall not be construed to preclude a |
provider contract with a health insurance issuer, or with an |
administrator or similar entity acting on the issuer's behalf, |
from imposing requirements on the participating provider, |
participating emergency facility, or participating health care |
facility relating to the referral of covered individuals to |
nonparticipating providers. |
(l) Except if the notice and consent criteria are |
satisfied under paragraph (2) of subsection (b-5), |
cost-sharing amounts calculated in conformity with this |
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Section shall count toward any deductible or out-of-pocket |
maximum applicable to in-network coverage. |
(m) The Department has the authority to enforce the |
requirements of this Section in the situations described in |
subsections (b) and (b-5), and in any other situation for |
which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and |
regulations promulgated thereunder would prohibit an |
individual from being billed or liable for emergency services |
furnished by a nonparticipating provider or nonparticipating |
emergency facility or for non-emergency health care services |
furnished by a nonparticipating provider at a participating |
health care facility. |
(n) This Section does not apply with respect to air |
ambulance or ground ambulance services. This Section does not |
apply to any policy of excepted benefits or to short-term, |
limited-duration health insurance coverage. |
(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
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