HB3030 EnrolledLRB103 05013 BMS 56587 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.3a as follows:
 
6    (215 ILCS 5/356z.3a)
7    Sec. 356z.3a. Billing; emergency services;
8nonparticipating providers.
9    (a) As used in this Section:
10    "Ancillary services" means:
11        (1) items and services related to emergency medicine,
12    anesthesiology, pathology, radiology, and neonatology that
13    are provided by any health care provider;
14        (2) items and services provided by assistant surgeons,
15    hospitalists, and intensivists;
16        (3) diagnostic services, including radiology and
17    laboratory services, except for advanced diagnostic
18    laboratory tests identified on the most current list
19    published by the United States Secretary of Health and
20    Human Services under 42 U.S.C. 300gg-132(b)(3);
21        (4) items and services provided by other specialty
22    practitioners as the United States Secretary of Health and
23    Human Services specifies through rulemaking under 42

 

 

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1    U.S.C. 300gg-132(b)(3);
2        (5) items and services provided by a nonparticipating
3    provider if there is no participating provider who can
4    furnish the item or service at the facility; and
5        (6) items and services provided by a nonparticipating
6    provider if there is no participating provider who will
7    furnish the item or service because a participating
8    provider has asserted the participating provider's rights
9    under the Health Care Right of Conscience Act.
10    "Cost sharing" means the amount an insured, beneficiary,
11or enrollee is responsible for paying for a covered item or
12service under the terms of the policy or certificate. "Cost
13sharing" includes copayments, coinsurance, and amounts paid
14toward deductibles, but does not include amounts paid towards
15premiums, balance billing by out-of-network providers, or the
16cost of items or services that are not covered under the policy
17or certificate.
18    "Emergency department of a hospital" means any hospital
19department that provides emergency services, including a
20hospital outpatient department.
21    "Emergency medical condition" has the meaning ascribed to
22that term in Section 10 of the Managed Care Reform and Patient
23Rights Act.
24    "Emergency medical screening examination" has the meaning
25ascribed to that term in Section 10 of the Managed Care Reform
26and Patient Rights Act.

 

 

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1    "Emergency services" means, with respect to an emergency
2medical condition:
3        (1) in general, an emergency medical screening
4    examination, including ancillary services routinely
5    available to the emergency department to evaluate such
6    emergency medical condition, and such further medical
7    examination and treatment as would be required to
8    stabilize the patient regardless of the department of the
9    hospital or other facility in which such further
10    examination or treatment is furnished; or
11        (2) additional items and services for which benefits
12    are provided or covered under the coverage and that are
13    furnished by a nonparticipating provider or
14    nonparticipating emergency facility regardless of the
15    department of the hospital or other facility in which such
16    items are furnished after the insured, beneficiary, or
17    enrollee is stabilized and as part of outpatient
18    observation or an inpatient or outpatient stay with
19    respect to the visit in which the services described in
20    paragraph (1) are furnished. Services after stabilization
21    cease to be emergency services only when all the
22    conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
23    regulations thereunder are met.
24    "Freestanding Emergency Center" means a facility licensed
25under Section 32.5 of the Emergency Medical Services (EMS)
26Systems Act.

 

 

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1    "Health care facility" means, in the context of
2non-emergency services, any of the following:
3        (1) a hospital as defined in 42 U.S.C. 1395x(e);
4        (2) a hospital outpatient department;
5        (3) a critical access hospital certified under 42
6    U.S.C. 1395i-4(e);
7        (4) an ambulatory surgical treatment center as defined
8    in the Ambulatory Surgical Treatment Center Act; or
9        (5) any recipient of a license under the Hospital
10    Licensing Act that is not otherwise described in this
11    definition.
12    "Health care provider" means a provider as defined in
13subsection (d) of Section 370g. "Health care provider" does
14not include a provider of air ambulance or ground ambulance
15services.
16    "Health care services" has the meaning ascribed to that
17term in subsection (a) of Section 370g.
18    "Health insurance issuer" has the meaning ascribed to that
19term in Section 5 of the Illinois Health Insurance Portability
20and Accountability Act.
21    "Nonparticipating emergency facility" means, with respect
22to the furnishing of an item or service under a policy of group
23or individual health insurance coverage, any of the following
24facilities that does not have a contractual relationship
25directly or indirectly with a health insurance issuer in
26relation to the coverage:

 

 

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1        (1) an emergency department of a hospital;
2        (2) a Freestanding Emergency Center;
3        (3) an ambulatory surgical treatment center as defined
4    in the Ambulatory Surgical Treatment Center Act; or
5        (4) with respect to emergency services described in
6    paragraph (2) of the definition of "emergency services", a
7    hospital.
8    "Nonparticipating provider" means, with respect to the
9furnishing of an item or service under a policy of group or
10individual health insurance coverage, any health care provider
11who does not have a contractual relationship directly or
12indirectly with a health insurance issuer in relation to the
13coverage.
14    "Participating emergency facility" means any of the
15following facilities that has a contractual relationship
16directly or indirectly with a health insurance issuer offering
17group or individual health insurance coverage setting forth
18the terms and conditions on which a relevant health care
19service is provided to an insured, beneficiary, or enrollee
20under the coverage:
21        (1) an emergency department of a hospital;
22        (2) a Freestanding Emergency Center;
23        (3) an ambulatory surgical treatment center as defined
24    in the Ambulatory Surgical Treatment Center Act; or
25        (4) with respect to emergency services described in
26    paragraph (2) of the definition of "emergency services", a

 

 

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1    hospital.
2    For purposes of this definition, a single case agreement
3between an emergency facility and an issuer that is used to
4address unique situations in which an insured, beneficiary, or
5enrollee requires services that typically occur out-of-network
6constitutes a contractual relationship and is limited to the
7parties to the agreement.
8    "Participating health care facility" means any health care
9facility that has a contractual relationship directly or
10indirectly with a health insurance issuer offering group or
11individual health insurance coverage setting forth the terms
12and conditions on which a relevant health care service is
13provided to an insured, beneficiary, or enrollee under the
14coverage. A single case agreement between an emergency
15facility and an issuer that is used to address unique
16situations in which an insured, beneficiary, or enrollee
17requires services that typically occur out-of-network
18constitutes a contractual relationship for purposes of this
19definition and is limited to the parties to the agreement.
20    "Participating provider" means any health care provider
21that has a contractual relationship directly or indirectly
22with a health insurance issuer offering group or individual
23health insurance coverage setting forth the terms and
24conditions on which a relevant health care service is provided
25to an insured, beneficiary, or enrollee under the coverage.
26    "Qualifying payment amount" has the meaning given to that

 

 

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1term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
2promulgated thereunder.
3    "Recognized amount" means the lesser of the amount
4initially billed by the provider or the qualifying payment
5amount.
6    "Stabilize" means "stabilization" as defined in Section 10
7of the Managed Care Reform and Patient Rights Act.
8    "Treating provider" means a health care provider who has
9evaluated the individual.
10    "Visit" means, with respect to health care services
11furnished to an individual at a health care facility, health
12care services furnished by a provider at the facility, as well
13as equipment, devices, telehealth services, imaging services,
14laboratory services, and preoperative and postoperative
15services regardless of whether the provider furnishing such
16services is at the facility.
17    (b) Emergency services. When a beneficiary, insured, or
18enrollee receives emergency services from a nonparticipating
19provider or a nonparticipating emergency facility, the health
20insurance issuer shall ensure that the beneficiary, insured,
21or enrollee shall incur no greater out-of-pocket costs than
22the beneficiary, insured, or enrollee would have incurred with
23a participating provider or a participating emergency
24facility. Any cost-sharing requirements shall be applied as
25though the emergency services had been received from a
26participating provider or a participating facility. Cost

 

 

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1sharing shall be calculated based on the recognized amount for
2the emergency services. If the cost sharing for the same item
3or service furnished by a participating provider would have
4been a flat-dollar copayment, that amount shall be the
5cost-sharing amount unless the provider has billed a lesser
6total amount. In no event shall the beneficiary, insured,
7enrollee, or any group policyholder or plan sponsor be liable
8to or billed by the health insurance issuer, the
9nonparticipating provider, or the nonparticipating emergency
10facility for any amount beyond the cost sharing calculated in
11accordance with this subsection with respect to the emergency
12services delivered. Administrative requirements or limitations
13shall be no greater than those applicable to emergency
14services received from a participating provider or a
15participating emergency facility.
16    (b-5) Non-emergency services at participating health care
17facilities.
18        (1) When a beneficiary, insured, or enrollee utilizes
19    a participating health care facility and, due to any
20    reason, covered ancillary services are provided by a
21    nonparticipating provider during or resulting from the
22    visit, the health insurance issuer shall ensure that the
23    beneficiary, insured, or enrollee shall incur no greater
24    out-of-pocket costs than the beneficiary, insured, or
25    enrollee would have incurred with a participating provider
26    for the ancillary services. Any cost-sharing requirements

 

 

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1    shall be applied as though the ancillary services had been
2    received from a participating provider. Cost sharing shall
3    be calculated based on the recognized amount for the
4    ancillary services. If the cost sharing for the same item
5    or service furnished by a participating provider would
6    have been a flat-dollar copayment, that amount shall be
7    the cost-sharing amount unless the provider has billed a
8    lesser total amount. In no event shall the beneficiary,
9    insured, enrollee, or any group policyholder or plan
10    sponsor be liable to or billed by the health insurance
11    issuer, the nonparticipating provider, or the
12    participating health care facility for any amount beyond
13    the cost sharing calculated in accordance with this
14    subsection with respect to the ancillary services
15    delivered. In addition to ancillary services, the
16    requirements of this paragraph shall also apply with
17    respect to covered items or services furnished as a result
18    of unforeseen, urgent medical needs that arise at the time
19    an item or service is furnished, regardless of whether the
20    nonparticipating provider satisfied the notice and consent
21    criteria under paragraph (2) of this subsection.
22        (2) When a beneficiary, insured, or enrollee utilizes
23    a participating health care facility and receives
24    non-emergency covered health care services other than
25    those described in paragraph (1) of this subsection from a
26    nonparticipating provider during or resulting from the

 

 

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1    visit, the health insurance issuer shall ensure that the
2    beneficiary, insured, or enrollee incurs no greater
3    out-of-pocket costs than the beneficiary, insured, or
4    enrollee would have incurred with a participating provider
5    unless the nonparticipating provider or the participating
6    health care facility on behalf of the nonparticipating
7    provider satisfies the notice and consent criteria
8    provided in 42 U.S.C. 300gg-132 and regulations
9    promulgated thereunder. If the notice and consent criteria
10    are not satisfied, then:
11            (A) any cost-sharing requirements shall be applied
12        as though the health care services had been received
13        from a participating provider;
14            (B) cost sharing shall be calculated based on the
15        recognized amount for the health care services; and
16            (C) in no event shall the beneficiary, insured,
17        enrollee, or any group policyholder or plan sponsor be
18        liable to or billed by the health insurance issuer,
19        the nonparticipating provider, or the participating
20        health care facility for any amount beyond the cost
21        sharing calculated in accordance with this subsection
22        with respect to the health care services delivered.
23    (c) Notwithstanding any other provision of this Code,
24except when the notice and consent criteria are satisfied for
25the situation in paragraph (2) of subsection (b-5), any
26benefits a beneficiary, insured, or enrollee receives for

 

 

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1services under the situations in subsection (b) or (b-5) are
2assigned to the nonparticipating providers or the facility
3acting on their behalf. Upon receipt of the provider's bill or
4facility's bill, the health insurance issuer shall provide the
5nonparticipating provider or the facility with a written
6explanation of benefits that specifies the proposed
7reimbursement and the applicable deductible, copayment, or
8coinsurance amounts owed by the insured, beneficiary, or
9enrollee. The health insurance issuer shall pay any
10reimbursement subject to this Section directly to the
11nonparticipating provider or the facility.
12    (d) For bills assigned under subsection (c), the
13nonparticipating provider or the facility may bill the health
14insurance issuer for the services rendered, and the health
15insurance issuer may pay the billed amount or attempt to
16negotiate reimbursement with the nonparticipating provider or
17the facility. Within 30 calendar days after the provider or
18facility transmits the bill to the health insurance issuer,
19the issuer shall send an initial payment or notice of denial of
20payment with the written explanation of benefits to the
21provider or facility. If attempts to negotiate reimbursement
22for services provided by a nonparticipating provider do not
23result in a resolution of the payment dispute within 30 days
24after receipt of written explanation of benefits by the health
25insurance issuer, then the health insurance issuer or
26nonparticipating provider or the facility may initiate binding

 

 

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1arbitration to determine payment for services provided on a
2per-bill or batched-bill basis, in accordance with Section
3300gg-111 of the Public Health Service Act and the regulations
4promulgated thereunder. The party requesting arbitration shall
5notify the other party arbitration has been initiated and
6state its final offer before arbitration. In response to this
7notice, the nonrequesting party shall inform the requesting
8party of its final offer before the arbitration occurs.
9Arbitration shall be initiated by filing a request with the
10Department of Insurance.
11    (e) The Department of Insurance shall publish a list of
12approved arbitrators or entities that shall provide binding
13arbitration. These arbitrators shall be American Arbitration
14Association or American Health Lawyers Association trained
15arbitrators. Both parties must agree on an arbitrator from the
16Department of Insurance's or its approved entity's list of
17arbitrators. If no agreement can be reached, then a list of 5
18arbitrators shall be provided by the Department of Insurance
19or the approved entity. From the list of 5 arbitrators, the
20health insurance issuer can veto 2 arbitrators and the
21provider or facility can veto 2 arbitrators. The remaining
22arbitrator shall be the chosen arbitrator. This arbitration
23shall consist of a review of the written submissions by both
24parties. The arbitrator shall not establish a rebuttable
25presumption that the qualifying payment amount should be the
26total amount owed to the provider or facility by the

 

 

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1combination of the issuer and the insured, beneficiary, or
2enrollee. Binding arbitration shall provide for a written
3decision within 45 days after the request is filed with the
4Department of Insurance. Both parties shall be bound by the
5arbitrator's decision. The arbitrator's expenses and fees,
6together with other expenses, not including attorney's fees,
7incurred in the conduct of the arbitration, shall be paid as
8provided in the decision.
9    (f) (Blank).
10    (g) Section 368a of this Act shall not apply during the
11pendency of a decision under subsection (d). Upon the issuance
12of the arbitrator's decision, Section 368a applies with
13respect to the amount, if any, by which the arbitrator's
14determination exceeds the issuer's initial payment under
15subsection (c), or the entire amount of the arbitrator's
16determination if initial payment was denied. Any interest
17required to be paid to a provider under Section 368a shall not
18accrue until after 30 days of an arbitrator's decision as
19provided in subsection (d), but in no circumstances longer
20than 150 days from the date the nonparticipating
21facility-based provider billed for services rendered.
22    (h) Nothing in this Section shall be interpreted to change
23the prudent layperson provisions with respect to emergency
24services under the Managed Care Reform and Patient Rights Act.
25    (i) Nothing in this Section shall preclude a health care
26provider from billing a beneficiary, insured, or enrollee for

 

 

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1reasonable administrative fees, such as service fees for
2checks returned for nonsufficient funds and missed
3appointments.
4    (j) Nothing in this Section shall preclude a beneficiary,
5insured, or enrollee from assigning benefits to a
6nonparticipating provider when the notice and consent criteria
7are satisfied under paragraph (2) of subsection (b-5) or in
8any other situation not described in subsection (b) or (b-5).
9    (k) Except when the notice and consent criteria are
10satisfied under paragraph (2) of subsection (b-5), if an
11individual receives health care services under the situations
12described in subsection (b) or (b-5), no referral requirement
13or any other provision contained in the policy or certificate
14of coverage shall deny coverage, reduce benefits, or otherwise
15defeat the requirements of this Section for services that
16would have been covered with a participating provider.
17However, this subsection shall not be construed to preclude a
18provider contract with a health insurance issuer, or with an
19administrator or similar entity acting on the issuer's behalf,
20from imposing requirements on the participating provider,
21participating emergency facility, or participating health care
22facility relating to the referral of covered individuals to
23nonparticipating providers.
24    (l) Except if the notice and consent criteria are
25satisfied under paragraph (2) of subsection (b-5),
26cost-sharing amounts calculated in conformity with this

 

 

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1Section shall count toward any deductible or out-of-pocket
2maximum applicable to in-network coverage.
3    (m) The Department has the authority to enforce the
4requirements of this Section in the situations described in
5subsections (b) and (b-5), and in any other situation for
6which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
7regulations promulgated thereunder would prohibit an
8individual from being billed or liable for emergency services
9furnished by a nonparticipating provider or nonparticipating
10emergency facility or for non-emergency health care services
11furnished by a nonparticipating provider at a participating
12health care facility.
13    (n) This Section does not apply with respect to air
14ambulance or ground ambulance services. This Section does not
15apply to any policy of excepted benefits or to short-term,
16limited-duration health insurance coverage.
17(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)