Bill Text: IL HB4931 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code. In a provision concerning billing for services provided by nonparticipating providers or facilities, provides that when calculating an enrollee's contribution to the annual limitation on cost sharing set forth under specified federal law, a health insurance issuer or its subcontractors shall include expenditures for any item or health care service covered under the policy issued to the enrollee by the health insurance issuer or its subcontractors if that item or health care service is included within a category of essential health benefits and regardless of whether the health insurance issuer or its subcontractors classify that item or service as an essential health benefit. Effective immediately.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2024-02-07 - Referred to Rules Committee [HB4931 Detail]

Download: Illinois-2023-HB4931-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4931 Introduced , by Rep. Margaret Croke SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.3a
Amends the Illinois Insurance Code. In a provision concerning billing for services provided by nonparticipating providers or facilities, provides that when calculating an enrollee's contribution to the annual limitation on cost sharing set forth under specified federal law, a health insurance issuer or its subcontractors shall include expenditures for any item or health care service covered under the policy issued to the enrollee by the health insurance issuer or its subcontractors if that item or health care service is included within a category of essential health benefits and regardless of whether the health insurance issuer or its subcontractors classify that item or service as an essential health benefit. Effective immediately.
LRB103 35342 RPS 65406 b
A BILL FOR
HB4931 LRB103 35342 RPS 65406 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
changing Section 356z.3a as follows:
(215 ILCS 5/356z.3a)
(Text of Section before amendment by P.A. 103-440)
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

HB4931 - 2 - LRB103 35342 RPS 65406 b
Human Services specifies through rulemaking under 42
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

HB4931 - 3 - LRB103 35342 RPS 65406 b
and Patient Rights Act.
"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)

HB4931 - 4 - LRB103 35342 RPS 65406 b
Systems Act.
"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

HB4931 - 5 - LRB103 35342 RPS 65406 b
relation to 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
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

HB4931 - 6 - LRB103 35342 RPS 65406 b
paragraph (2) of the definition of "emergency services", a
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.

HB4931 - 7 - LRB103 35342 RPS 65406 b
"Qualifying payment amount" has the meaning given to that
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

HB4931 - 8 - LRB103 35342 RPS 65406 b
participating provider or a participating facility. Cost
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

HB4931 - 9 - LRB103 35342 RPS 65406 b
for the ancillary services. Any cost-sharing requirements
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. When
calculating an enrollee's contribution to the annual
limitation on cost sharing set forth in 42 U.S.C. 18022(c)
and 42 U.S.C. 300gg-6(b), a health insurance issuer or its
subcontractors shall include expenditures for any item or

HB4931 - 10 - LRB103 35342 RPS 65406 b
health care service covered under the policy issued to the
enrollee by the health insurance issuer or its
subcontractors if that item or health care service is
included within a category of essential health benefits,
as described in 42 U.S.C. 18022(b)(1), and regardless of
whether the health insurance issuer or its subcontractors
classify that item or service as an essential health
benefit.
(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
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;

HB4931 - 11 - LRB103 35342 RPS 65406 b
(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;
and .
(D) when calculating an enrollee's contribution to
the annual limitation on cost sharing set forth in 42
U.S.C. 18022(c) and 42 U.S.C. 300gg-6(b), a health
insurance issuer or its subcontractors shall include
expenditures for any item or health care service
covered under the policy issued to the enrollee by the
health insurance issuer or its subcontractors if that
item or health care service is included within a
category of essential health benefits, as described in
42 U.S.C. 18022(b)(1), and regardless of whether the
health insurance issuer or its subcontractors classify
that item or service as an essential health benefit.
(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

HB4931 - 12 - LRB103 35342 RPS 65406 b
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

HB4931 - 13 - LRB103 35342 RPS 65406 b
arbitration to determine payment for services provided on a
per-bill basis. 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
combination of the issuer and the insured, beneficiary, or
enrollee. Binding arbitration shall provide for a written

HB4931 - 14 - LRB103 35342 RPS 65406 b
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.
(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
reasonable administrative fees, such as service fees for
checks returned for nonsufficient funds and missed

HB4931 - 15 - LRB103 35342 RPS 65406 b
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
Section shall count toward any deductible or out-of-pocket
maximum applicable to in-network coverage.

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(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.)
(Text of Section after amendment by P.A. 103-440)
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;

HB4931 - 17 - LRB103 35342 RPS 65406 b
(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
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

HB4931 - 18 - LRB103 35342 RPS 65406 b
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.
"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

HB4931 - 19 - LRB103 35342 RPS 65406 b
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.
"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

HB4931 - 20 - LRB103 35342 RPS 65406 b
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:
(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

HB4931 - 21 - LRB103 35342 RPS 65406 b
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
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

HB4931 - 22 - LRB103 35342 RPS 65406 b
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
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

HB4931 - 23 - LRB103 35342 RPS 65406 b
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
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

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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
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

HB4931 - 25 - LRB103 35342 RPS 65406 b
an item or service is furnished, regardless of whether the
nonparticipating provider satisfied the notice and consent
criteria under paragraph (2) of this subsection. When
calculating an enrollee's contribution to the annual
limitation on cost sharing set forth in 42 U.S.C. 18022(c)
and 42 U.S.C. 300gg-6(b), a health insurance issuer or its
subcontractors shall include expenditures for any item or
health care service covered under the policy issued to the
enrollee by the health insurance issuer or its
subcontractors if that item or health care service is
included within a category of essential health benefits,
as described in 42 U.S.C. 18022(b)(1), and regardless of
whether the health insurance issuer or its subcontractors
classify that item or service as an essential health
benefit.
(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
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

HB4931 - 26 - LRB103 35342 RPS 65406 b
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;
and .
(D) when calculating an enrollee's contribution to
the annual limitation on cost sharing set forth in 42
U.S.C. 18022(c) and 42 U.S.C. 300gg-6(b), a health
insurance issuer or its subcontractors shall include
expenditures for any item or health care service
covered under the policy issued to the enrollee by the
health insurance issuer or its subcontractors if that
item or health care service is included within a
category of essential health benefits, as described in

HB4931 - 27 - LRB103 35342 RPS 65406 b
42 U.S.C. 18022(b)(1), and regardless of whether the
health insurance issuer or its subcontractors classify
that item or service as an essential health benefit.
(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
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

HB4931 - 28 - LRB103 35342 RPS 65406 b
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
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

HB4931 - 29 - LRB103 35342 RPS 65406 b
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
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

HB4931 - 30 - LRB103 35342 RPS 65406 b
than 150 days from the date the nonparticipating
facility-based provider billed for services rendered.
(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
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,

HB4931 - 31 - LRB103 35342 RPS 65406 b
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
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;
103-440, eff. 1-1-24.)

HB4931 - 32 - LRB103 35342 RPS 65406 b
Section 95. No acceleration or delay. Where this Act makes
changes in a statute that is represented in this Act by text
that is not yet or no longer in effect (for example, a Section
represented by multiple versions), the use of that text does
not accelerate or delay the taking effect of (i) the changes
made by this Act or (ii) provisions derived from any other
Public Act.