Bill Text: IL SB2405 | 2025-2026 | 104th General Assembly | Introduced

---

Bill Title: 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.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2025-02-07 - Referred to Assignments [SB2405 Detail]

Download: Illinois-2025-SB2405-Introduced.html

---

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.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
A BILL FOR
SB2405 LRB104 10637 BAB 20714 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. This Act may be cited as the Consumer
Protection from Surprise Health Care Billing Act.
Section 2. The General Assembly finds that:
(1) Consumers, health insurance issuers, health care
providers, and government bodies will benefit from clearly
articulated consumer protections against surprise health
care billing.
(2) Surprise health care bills contribute
substantially to high levels of medical debt for consumers
in Illinois.
(3) Ground ambulance services are a necessity for
patients and patients' positive health outcomes and should
not be the cause for surprise health care bills.
(4) Consumers should be protected from being in the
middle of billing disputes between health insurance
issuers and health care providers.
Section 3. The purpose of this Act is to protect patients
from surprise medical bills when receiving certain emergency
services and non-emergency services from out-of-network

SB2405 - 2 - LRB104 10637 BAB 20714 b
providers.
Section 5. The Illinois Insurance Code is amended by
changing Sections 356z.3a and 370g as follows:
(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
U.S.C. 300gg-132(b)(3);
(5) items and services provided by a nonparticipating
provider if there is no participating provider who can

SB2405 - 3 - LRB104 10637 BAB 20714 b
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.
"Emergency services" means, with respect to an emergency
medical condition:
(1) in general, an emergency medical screening

SB2405 - 4 - LRB104 10637 BAB 20714 b
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.
"Ground ambulance service" means both medical
transportation services that are described as ground ambulance
services by the Centers for Medicare and Medicaid Services and

SB2405 - 5 - LRB104 10637 BAB 20714 b
medical non-transportation services such as evaluation without
transport, treatment without transport, or paramedic intercept
that are either provided in a vehicle that is licensed as an
ambulance under the Emergency Medical Services (EMS) Systems
Act or provided by EMS Personnel assigned to a vehicle that is
licensed as an ambulance under the Emergency Medical Services
(EMS) Systems Act.
"Ground ambulance service provider" means a vehicle
service provider under the Emergency Medical Services (EMS)
Systems Act that operates licensed ground ambulances for the
purpose of providing emergency ambulance services,
non-emergency ambulance services, or both. "Ground ambulance
service provider" includes both ambulance providers and
ambulance suppliers as described by the Centers for Medicare
and Medicaid Services.
"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.

SB2405 - 6 - LRB104 10637 BAB 20714 b
"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:
(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

SB2405 - 7 - LRB104 10637 BAB 20714 b
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
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

SB2405 - 8 - LRB104 10637 BAB 20714 b
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
term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
promulgated thereunder.
"Recognized amount" means the lesser of the following
amounts: (1) the amount initially billed by the provider; (2)
or the qualifying payment amount; or, (3) if applicable, the
allowable amount established by this Section.
"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

SB2405 - 9 - LRB104 10637 BAB 20714 b
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
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

SB2405 - 10 - LRB104 10637 BAB 20714 b
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
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

SB2405 - 11 - LRB104 10637 BAB 20714 b
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
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:

SB2405 - 12 - LRB104 10637 BAB 20714 b
(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
services under the situations in subsections subsection (b),
or (b-5), (f), (f-5), or (f-10) 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

SB2405 - 13 - LRB104 10637 BAB 20714 b
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
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

SB2405 - 14 - LRB104 10637 BAB 20714 b
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
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) (f) Payments to nonparticipating ground ambulance

SB2405 - 15 - LRB104 10637 BAB 20714 b
service providers. (Blank).
(1) On or after July 1, 2025, notwithstanding any
other provision of this Section, 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. 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. The health insurance issuer shall approve
charges for nonparticipating ground ambulance service
providers at a recognized amount that shall be calculated
as the lessor of: (i) the nonparticipating ground
ambulance service provider's billed charge; (ii) the
negotiated rate between the nonparticipating ground
ambulance service provider and the health insurance
insurer; or (iii) the maximum allowable amount specified
in subsection (f-5) or the amount specified in subsection
(f-10).
(2) Payment for ground ambulance services shall be
made on a per occurrence basis. For purposes of this
subsection, occurrence means in individual ground

SB2405 - 16 - LRB104 10637 BAB 20714 b
ambulance response and, if applicable, the corresponding
transport and shall consist of a base charge and, if
applicable, a loaded mileage charge.
(4) The cost sharing amount for any occurrence in
which a ground ambulance service is provided to a
beneficiary, insured, or enrollee, shall not exceed the
lessor of the plan's emergency room visit copay or 10% of
the recognized amount for the occurrence.
(5) With respect appeals for payments made by health
insurance issuers under this subsection, beneficiaries,
insureds, enrollees, and ground ambulance service
providers are not required to follow a health insurance
issuer's internal appeals process and may seek relief in
any appropriate court for the purpose of resolving a
payment dispute. In such a dispute litigated in court, a
prevailing beneficiary, insured, enrollee, or ground
ambulance service provider shall be entitled to payment
for reasonable attorney's fees and may seek payment for
other damages, including punitive damages, arising from a
health insurance issuer's failure to provide payment in
compliance with this Act.
(6) Definition of emergency. In addition to any other
criteria for the definition of emergency described in this
Act or in the definition of emergency described in the
Healthcare Common Procedure Coding System (HCPCS) as it
pertains to ground ambulance services, ground ambulance

SB2405 - 17 - LRB104 10637 BAB 20714 b
services provided by ground ambulance service providers
shall be considered emergency services if the services
were provided pursuant to a request to 9-1-1 or an
equivalent telephone number, texting system, or other
method of summonsing emergency services or if the services
provided were provided when a patient's condition, at the
time of service, was considered to be an emergency medical
condition as defined by this Act or as determined by a
physician licensed pursuant to the Medical Practice Act of
1997.
(7) As used in subsections (f-5) and (f-10):
(i) "Evaluation" means the provision of a
medical screening examination to determine whether
an emergency medical condition exists.
(ii) "Treatment" means the provision of an
assessment and a therapy or therapeutic agent used
to treat a medical condition, or a procedure used
to treat a medical condition.
(iii) "Paramedic intercept" means a situation
when a paramedic (advanced life support) staffed
ambulance rendezvous with a non-paramedic (basic
life support or intermediate life support) staffed
ambulance to provide advanced life support care.
Advanced life support is warranted when a
patient's condition and need for treatment exceeds
the basic life support or intermediate life

SB2405 - 18 - LRB104 10637 BAB 20714 b
support level of care.
(iv) "Unit of government" means a county, as
described in the Counties Code; a township, as
described in the Township Code; a municipality, as
described in the Municipal Code; a fire protection
district, as described in the Fire Protection
District Act; a rescue squad district, as
described in the Rescue Squad District Act; or an
Emergency Services District, as described in the
Emergency Services District Act.
(f-5) The maximum allowable payment amounts by individual
service types for nonparticipating ground ambulance service
providers owned, operated, or controlled by a private
organization, to include both private for profit organizations
and private not-for-profit organizations and nonparticipating
ground ambulance service providers owned, operated, or
controlled by a unit of government that does not participate
in the Ground Emergency Medical Transportation (GEMT) program
administered by the Department of Healthcare and Family
Services, shall be as follows: (i) basic life support,
non-emergency base $2,030; (ii) basic life support, emergency
base $2,660; (iii) advanced life support, non-emergency, level
1 base $2,800; (iv) advanced life support, emergency, level 1
base $2,905; (v) advanced life support, level 2 base $3,080;
(vi) specialty care transport base $7,140; (vii) evaluation
without transport, 25% of the basic life support, emergency

SB2405 - 19 - LRB104 10637 BAB 20714 b
base; (vii) treatment without transport, 50% of the advanced
life support, emergency, level 1 base; (viii) paramedic
intercept, 75% of the advanced life support, emergency, level
1 base; and (ix) ground mileage, per loaded mile $56. The
amounts in this subsection shall be adjusted at a rate of 5%
annually, effective on January 1 of each year, beginning on
January 1, 2026.
(f-10) Payments to nonparticipating ground ambulance
service providers owned, operated, or controlled by a unit of
government that participates in the Ground Emergency Medical
Transportation (GEMT) program administered by the Department
of Healthcare and Family Services, shall be the cost-based
amount, as reflected in the ground ambulance service
provider's GEMT cost report for the applicable date of
service. Individual services types shall be as follows: (i)
basic life support, emergency base; (ii) advanced life
support, emergency, level 1 base; (iii) advanced life support,
level 2 base; (iv) evaluation without transport, 100% of the
basic life support, emergency base, no mileage; (v) treatment
without transport, 100% of the advanced life support,
emergency, level 1 base, no mileage; (vi) paramedic intercept,
100% of the advanced life support, emergency, level 1 base, no
mileage; and (vii) ground mileage, per loaded mile. In
situations where a ground ambulance service provider that
qualifies for payments under this subsection charges for a
services type, including a basic life support, non-emergency

SB2405 - 20 - LRB104 10637 BAB 20714 b
base, or an advanced life support, non-emergency base payments
by the health insurance issuers shall be as described in
subsection (f-5).
(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
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

SB2405 - 21 - LRB104 10637 BAB 20714 b
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.
(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

SB2405 - 22 - LRB104 10637 BAB 20714 b
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.
(m-5) A failure by a health insurance issuer to comply
with the requirements in this Section constitutes an unlawful
practice under the Consumer Fraud and Deceptive Business
Practices Act. All remedies, penalties, and authority granted
to the Attorney General by that Act shall be available to the
Attorney General for the enforcement of this Section.
(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.)
(215 ILCS 5/370g) (from Ch. 73, par. 982g)
Sec. 370g. Definitions. As used in this Article, the
following definitions apply:
(a) "Health care services" means health care services or
products rendered or sold by a provider within the scope of the
provider's license or legal authorization. The term includes,
but is not limited to, hospital, medical, surgical, dental,

SB2405 - 23 - LRB104 10637 BAB 20714 b
vision, ground ambulance services, and pharmaceutical services
or products.
(b) "Insurer" means an insurance company or a health
service corporation authorized in this State to issue policies
or subscriber contracts which reimburse for expenses of health
care services.
(c) "Insured" means an individual entitled to
reimbursement for expenses of health care services under a
policy or subscriber contract issued or administered by an
insurer.
(d) "Provider" means an individual or entity duly licensed
or legally authorized to provide health care services.
(e) "Noninstitutional provider" means any person licensed
under the Medical Practice Act of 1987, as now or hereafter
amended.
(f) "Beneficiary" means an individual entitled to
reimbursement for expenses of or the discount of provider fees
for health care services under a program where the beneficiary
has an incentive to utilize the services of a provider which
has entered into an agreement or arrangement with an
administrator.
(g) "Administrator" means any person, partnership or
corporation, other than an insurer or health maintenance
organization holding a certificate of authority under the
"Health Maintenance Organization Act", as now or hereafter
amended, that arranges, contracts with, or administers

SB2405 - 24 - LRB104 10637 BAB 20714 b
contracts with a provider whereby beneficiaries are provided
an incentive to use the services of such provider.
(h) "Emergency medical condition" has the meaning given to
that term in Section 10 of the Managed Care Reform and Patient
Rights Act.
(Source: P.A. 102-409, eff. 1-1-22.)
Section 10. The Health Maintenance Organization Act is
amended by changing Section 4-15 as follows:
(215 ILCS 125/4-15) (from Ch. 111 1/2, par. 1409.8)
Sec. 4-15. (a) No contract or evidence of coverage for
basic health care services delivered, issued for delivery,
renewed or amended by a Health Maintenance Organization shall
exclude coverage for emergency transportation by ambulance.
For the purposes of this Section, the term "emergency" means a
need for immediate medical attention resulting from a life
threatening condition or situation or a need for immediate
medical attention as otherwise reasonably determined by a
physician, public safety official or other emergency medical
personnel.
(b) Payments to nonparticipating ground ambulance service
providers shall be as described in subsections (f), (f-5), and
(f-10) of Section 356z.3a of the Illinois Insurance Code. Upon
reasonable demand by a provider of emergency transportation by
ambulance, a Health Maintenance Organization shall promptly

SB2405 - 25 - LRB104 10637 BAB 20714 b
pay to the provider, subject to coverage limitations stated in
the contract or evidence of coverage, the charges for
emergency transportation by ambulance provided to an enrollee
in a health care plan arranged for by the Health Maintenance
Organization. By accepting any such payment from the Health
Maintenance Organization, the provider of emergency
transportation by ambulance agrees not to seek any payment
from the enrollee for services provided to the enrollee.
(Source: P.A. 86-833; 86-1028.)
Section 15. The Consumer Fraud and Deceptive Business
Practices Act is amended by adding Section 2HHHH as follows:
(815 ILCS 505/2HHHH new)
Sec. 2HHHH. Violations of the Consumer Protection from
Surprise Health Care Billing Act. A health insurer commits an
unlawful practice within the meaning of this Act when it
refuses to comply with the requirements of subsection (m-5) of
Section 356z.3a of the Illinois Insurance Code.
Section 99. Effective date. This Act takes effect July 1,
2025.