103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB3307

 

Introduced 2/7/2024, by Sen. Linda Holmes

 

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 35341 RPS 65405 b

 

 

A BILL FOR

 

SB3307LRB103 35341 RPS 65405 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    (Text of Section before amendment by P.A. 103-440)
8    Sec. 356z.3a. Billing; emergency services;
9nonparticipating providers.
10    (a) As used in this Section:
11    "Ancillary services" means:
12        (1) items and services related to emergency medicine,
13    anesthesiology, pathology, radiology, and neonatology that
14    are provided by any health care provider;
15        (2) items and services provided by assistant surgeons,
16    hospitalists, and intensivists;
17        (3) diagnostic services, including radiology and
18    laboratory services, except for advanced diagnostic
19    laboratory tests identified on the most current list
20    published by the United States Secretary of Health and
21    Human Services under 42 U.S.C. 300gg-132(b)(3);
22        (4) items and services provided by other specialty
23    practitioners as the United States Secretary of Health and

 

 

SB3307- 2 -LRB103 35341 RPS 65405 b

1    Human Services specifies through rulemaking under 42
2    U.S.C. 300gg-132(b)(3);
3        (5) items and services provided by a nonparticipating
4    provider if there is no participating provider who can
5    furnish the item or service at the facility; and
6        (6) items and services provided by a nonparticipating
7    provider if there is no participating provider who will
8    furnish the item or service because a participating
9    provider has asserted the participating provider's rights
10    under the Health Care Right of Conscience Act.
11    "Cost sharing" means the amount an insured, beneficiary,
12or enrollee is responsible for paying for a covered item or
13service under the terms of the policy or certificate. "Cost
14sharing" includes copayments, coinsurance, and amounts paid
15toward deductibles, but does not include amounts paid towards
16premiums, balance billing by out-of-network providers, or the
17cost of items or services that are not covered under the policy
18or certificate.
19    "Emergency department of a hospital" means any hospital
20department that provides emergency services, including a
21hospital outpatient department.
22    "Emergency medical condition" has the meaning ascribed to
23that term in Section 10 of the Managed Care Reform and Patient
24Rights Act.
25    "Emergency medical screening examination" has the meaning
26ascribed to that term in Section 10 of the Managed Care Reform

 

 

SB3307- 3 -LRB103 35341 RPS 65405 b

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

 

 

SB3307- 4 -LRB103 35341 RPS 65405 b

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

 

 

SB3307- 5 -LRB103 35341 RPS 65405 b

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

 

 

SB3307- 6 -LRB103 35341 RPS 65405 b

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

 

 

SB3307- 7 -LRB103 35341 RPS 65405 b

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

 

 

SB3307- 8 -LRB103 35341 RPS 65405 b

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

 

 

SB3307- 9 -LRB103 35341 RPS 65405 b

1    for the ancillary services. Any cost-sharing requirements
2    shall be applied as though the ancillary services had been
3    received from a participating provider. Cost sharing shall
4    be calculated based on the recognized amount for the
5    ancillary services. If the cost sharing for the same item
6    or service furnished by a participating provider would
7    have been a flat-dollar copayment, that amount shall be
8    the cost-sharing amount unless the provider has billed a
9    lesser total amount. In no event shall the beneficiary,
10    insured, enrollee, or any group policyholder or plan
11    sponsor be liable to or billed by the health insurance
12    issuer, the nonparticipating provider, or the
13    participating health care facility for any amount beyond
14    the cost sharing calculated in accordance with this
15    subsection with respect to the ancillary services
16    delivered. In addition to ancillary services, the
17    requirements of this paragraph shall also apply with
18    respect to covered items or services furnished as a result
19    of unforeseen, urgent medical needs that arise at the time
20    an item or service is furnished, regardless of whether the
21    nonparticipating provider satisfied the notice and consent
22    criteria under paragraph (2) of this subsection. When
23    calculating an enrollee's contribution to the annual
24    limitation on cost sharing set forth in 42 U.S.C. 18022(c)
25    and 42 U.S.C. 300gg-6(b), a health insurance issuer or its
26    subcontractors shall include expenditures for any item or

 

 

SB3307- 10 -LRB103 35341 RPS 65405 b

1    health care service covered under the policy issued to the
2    enrollee by the health insurance issuer or its
3    subcontractors if that item or health care service is
4    included within a category of essential health benefits,
5    as described in 42 U.S.C. 18022(b)(1), and regardless of
6    whether the health insurance issuer or its subcontractors
7    classify that item or service as an essential health
8    benefit.
9        (2) When a beneficiary, insured, or enrollee utilizes
10    a participating health care facility and receives
11    non-emergency covered health care services other than
12    those described in paragraph (1) of this subsection from a
13    nonparticipating provider during or resulting from the
14    visit, the health insurance issuer shall ensure that the
15    beneficiary, insured, or enrollee incurs no greater
16    out-of-pocket costs than the beneficiary, insured, or
17    enrollee would have incurred with a participating provider
18    unless the nonparticipating provider or the participating
19    health care facility on behalf of the nonparticipating
20    provider satisfies the notice and consent criteria
21    provided in 42 U.S.C. 300gg-132 and regulations
22    promulgated thereunder. If the notice and consent criteria
23    are not satisfied, then:
24            (A) any cost-sharing requirements shall be applied
25        as though the health care services had been received
26        from a participating provider;

 

 

SB3307- 11 -LRB103 35341 RPS 65405 b

1            (B) cost sharing shall be calculated based on the
2        recognized amount for the health care services; and
3            (C) in no event shall the beneficiary, insured,
4        enrollee, or any group policyholder or plan sponsor be
5        liable to or billed by the health insurance issuer,
6        the nonparticipating provider, or the participating
7        health care facility for any amount beyond the cost
8        sharing calculated in accordance with this subsection
9        with respect to the health care services delivered;
10        and .
11            (D) when calculating an enrollee's contribution to
12        the annual limitation on cost sharing set forth in 42
13        U.S.C. 18022(c) and 42 U.S.C. 300gg-6(b), a health
14        insurance issuer or its subcontractors shall include
15        expenditures for any item or health care service
16        covered under the policy issued to the enrollee by the
17        health insurance issuer or its subcontractors if that
18        item or health care service is included within a
19        category of essential health benefits, as described in
20        42 U.S.C. 18022(b)(1), and regardless of whether the
21        health insurance issuer or its subcontractors classify
22        that item or service as an essential health benefit.
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

 

 

SB3307- 12 -LRB103 35341 RPS 65405 b

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

 

 

SB3307- 13 -LRB103 35341 RPS 65405 b

1arbitration to determine payment for services provided on a
2per-bill basis. The party requesting arbitration shall notify
3the other party arbitration has been initiated and state its
4final offer before arbitration. In response to this notice,
5the nonrequesting party shall inform the requesting party of
6its final offer before the arbitration occurs. Arbitration
7shall be initiated by filing a request with the Department of
8Insurance.
9    (e) The Department of Insurance shall publish a list of
10approved arbitrators or entities that shall provide binding
11arbitration. These arbitrators shall be American Arbitration
12Association or American Health Lawyers Association trained
13arbitrators. Both parties must agree on an arbitrator from the
14Department of Insurance's or its approved entity's list of
15arbitrators. If no agreement can be reached, then a list of 5
16arbitrators shall be provided by the Department of Insurance
17or the approved entity. From the list of 5 arbitrators, the
18health insurance issuer can veto 2 arbitrators and the
19provider or facility can veto 2 arbitrators. The remaining
20arbitrator shall be the chosen arbitrator. This arbitration
21shall consist of a review of the written submissions by both
22parties. The arbitrator shall not establish a rebuttable
23presumption that the qualifying payment amount should be the
24total amount owed to the provider or facility by the
25combination of the issuer and the insured, beneficiary, or
26enrollee. Binding arbitration shall provide for a written

 

 

SB3307- 14 -LRB103 35341 RPS 65405 b

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

 

 

SB3307- 15 -LRB103 35341 RPS 65405 b

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

 

 

SB3307- 16 -LRB103 35341 RPS 65405 b

1    (m) The Department has the authority to enforce the
2requirements of this Section in the situations described in
3subsections (b) and (b-5), and in any other situation for
4which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
5regulations promulgated thereunder would prohibit an
6individual from being billed or liable for emergency services
7furnished by a nonparticipating provider or nonparticipating
8emergency facility or for non-emergency health care services
9furnished by a nonparticipating provider at a participating
10health care facility.
11    (n) This Section does not apply with respect to air
12ambulance or ground ambulance services. This Section does not
13apply to any policy of excepted benefits or to short-term,
14limited-duration health insurance coverage.
15(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
 
16    (Text of Section after amendment by P.A. 103-440)
17    Sec. 356z.3a. Billing; emergency services;
18nonparticipating providers.
19    (a) As used in this Section:
20    "Ancillary services" means:
21        (1) items and services related to emergency medicine,
22    anesthesiology, pathology, radiology, and neonatology that
23    are provided by any health care provider;
24        (2) items and services provided by assistant surgeons,
25    hospitalists, and intensivists;

 

 

SB3307- 17 -LRB103 35341 RPS 65405 b

1        (3) diagnostic services, including radiology and
2    laboratory services, except for advanced diagnostic
3    laboratory tests identified on the most current list
4    published by the United States Secretary of Health and
5    Human Services under 42 U.S.C. 300gg-132(b)(3);
6        (4) items and services provided by other specialty
7    practitioners as the United States Secretary of Health and
8    Human Services specifies through rulemaking under 42
9    U.S.C. 300gg-132(b)(3);
10        (5) items and services provided by a nonparticipating
11    provider if there is no participating provider who can
12    furnish the item or service at the facility; and
13        (6) items and services provided by a nonparticipating
14    provider if there is no participating provider who will
15    furnish the item or service because a participating
16    provider has asserted the participating provider's rights
17    under the Health Care Right of Conscience Act.
18    "Cost sharing" means the amount an insured, beneficiary,
19or enrollee is responsible for paying for a covered item or
20service under the terms of the policy or certificate. "Cost
21sharing" includes copayments, coinsurance, and amounts paid
22toward deductibles, but does not include amounts paid towards
23premiums, balance billing by out-of-network providers, or the
24cost of items or services that are not covered under the policy
25or certificate.
26    "Emergency department of a hospital" means any hospital

 

 

SB3307- 18 -LRB103 35341 RPS 65405 b

1department that provides emergency services, including a
2hospital outpatient department.
3    "Emergency medical condition" has the meaning ascribed to
4that term in Section 10 of the Managed Care Reform and Patient
5Rights Act.
6    "Emergency medical screening examination" has the meaning
7ascribed to that term in Section 10 of the Managed Care Reform
8and Patient Rights Act.
9    "Emergency services" means, with respect to an emergency
10medical condition:
11        (1) in general, an emergency medical screening
12    examination, including ancillary services routinely
13    available to the emergency department to evaluate such
14    emergency medical condition, and such further medical
15    examination and treatment as would be required to
16    stabilize the patient regardless of the department of the
17    hospital or other facility in which such further
18    examination or treatment is furnished; or
19        (2) additional items and services for which benefits
20    are provided or covered under the coverage and that are
21    furnished by a nonparticipating provider or
22    nonparticipating emergency facility regardless of the
23    department of the hospital or other facility in which such
24    items are furnished after the insured, beneficiary, or
25    enrollee is stabilized and as part of outpatient
26    observation or an inpatient or outpatient stay with

 

 

SB3307- 19 -LRB103 35341 RPS 65405 b

1    respect to the visit in which the services described in
2    paragraph (1) are furnished. Services after stabilization
3    cease to be emergency services only when all the
4    conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and
5    regulations thereunder are met.
6    "Freestanding Emergency Center" means a facility licensed
7under Section 32.5 of the Emergency Medical Services (EMS)
8Systems Act.
9    "Health care facility" means, in the context of
10non-emergency services, any of the following:
11        (1) a hospital as defined in 42 U.S.C. 1395x(e);
12        (2) a hospital outpatient department;
13        (3) a critical access hospital certified under 42
14    U.S.C. 1395i-4(e);
15        (4) an ambulatory surgical treatment center as defined
16    in the Ambulatory Surgical Treatment Center Act; or
17        (5) any recipient of a license under the Hospital
18    Licensing Act that is not otherwise described in this
19    definition.
20    "Health care provider" means a provider as defined in
21subsection (d) of Section 370g. "Health care provider" does
22not include a provider of air ambulance or ground ambulance
23services.
24    "Health care services" has the meaning ascribed to that
25term in subsection (a) of Section 370g.
26    "Health insurance issuer" has the meaning ascribed to that

 

 

SB3307- 20 -LRB103 35341 RPS 65405 b

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

 

 

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1service is provided to an insured, beneficiary, or enrollee
2under the coverage:
3        (1) an emergency department of a hospital;
4        (2) a Freestanding Emergency Center;
5        (3) an ambulatory surgical treatment center as defined
6    in the Ambulatory Surgical Treatment Center Act; or
7        (4) with respect to emergency services described in
8    paragraph (2) of the definition of "emergency services", a
9    hospital.
10    For purposes of this definition, a single case agreement
11between an emergency facility and an issuer that is used to
12address unique situations in which an insured, beneficiary, or
13enrollee requires services that typically occur out-of-network
14constitutes a contractual relationship and is limited to the
15parties to the agreement.
16    "Participating health care facility" means any health care
17facility that has a contractual relationship directly or
18indirectly with a health insurance issuer offering group or
19individual health insurance coverage setting forth the terms
20and conditions on which a relevant health care service is
21provided to an insured, beneficiary, or enrollee under the
22coverage. A single case agreement between an emergency
23facility and an issuer that is used to address unique
24situations in which an insured, beneficiary, or enrollee
25requires services that typically occur out-of-network
26constitutes a contractual relationship for purposes of this

 

 

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1definition and is limited to the parties to the agreement.
2    "Participating provider" means any health care provider
3that has a contractual relationship directly or indirectly
4with a health insurance issuer offering group or individual
5health insurance coverage setting forth the terms and
6conditions on which a relevant health care service is provided
7to an insured, beneficiary, or enrollee under the coverage.
8    "Qualifying payment amount" has the meaning given to that
9term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations
10promulgated thereunder.
11    "Recognized amount" means the lesser of the amount
12initially billed by the provider or the qualifying payment
13amount.
14    "Stabilize" means "stabilization" as defined in Section 10
15of the Managed Care Reform and Patient Rights Act.
16    "Treating provider" means a health care provider who has
17evaluated the individual.
18    "Visit" means, with respect to health care services
19furnished to an individual at a health care facility, health
20care services furnished by a provider at the facility, as well
21as equipment, devices, telehealth services, imaging services,
22laboratory services, and preoperative and postoperative
23services regardless of whether the provider furnishing such
24services is at the facility.
25    (b) Emergency services. When a beneficiary, insured, or
26enrollee receives emergency services from a nonparticipating

 

 

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

 

 

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1    a participating health care facility and, due to any
2    reason, covered ancillary services are provided by a
3    nonparticipating provider during or resulting from the
4    visit, the health insurance issuer shall ensure that the
5    beneficiary, insured, or enrollee shall incur no greater
6    out-of-pocket costs than the beneficiary, insured, or
7    enrollee would have incurred with a participating provider
8    for the ancillary services. Any cost-sharing requirements
9    shall be applied as though the ancillary services had been
10    received from a participating provider. Cost sharing shall
11    be calculated based on the recognized amount for the
12    ancillary services. If the cost sharing for the same item
13    or service furnished by a participating provider would
14    have been a flat-dollar copayment, that amount shall be
15    the cost-sharing amount unless the provider has billed a
16    lesser total amount. In no event shall the beneficiary,
17    insured, enrollee, or any group policyholder or plan
18    sponsor be liable to or billed by the health insurance
19    issuer, the nonparticipating provider, or the
20    participating health care facility for any amount beyond
21    the cost sharing calculated in accordance with this
22    subsection with respect to the ancillary services
23    delivered. In addition to ancillary services, the
24    requirements of this paragraph shall also apply with
25    respect to covered items or services furnished as a result
26    of unforeseen, urgent medical needs that arise at the time

 

 

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1    an item or service is furnished, regardless of whether the
2    nonparticipating provider satisfied the notice and consent
3    criteria under paragraph (2) of this subsection. When
4    calculating an enrollee's contribution to the annual
5    limitation on cost sharing set forth in 42 U.S.C. 18022(c)
6    and 42 U.S.C. 300gg-6(b), a health insurance issuer or its
7    subcontractors shall include expenditures for any item or
8    health care service covered under the policy issued to the
9    enrollee by the health insurance issuer or its
10    subcontractors if that item or health care service is
11    included within a category of essential health benefits,
12    as described in 42 U.S.C. 18022(b)(1), and regardless of
13    whether the health insurance issuer or its subcontractors
14    classify that item or service as an essential health
15    benefit.
16        (2) When a beneficiary, insured, or enrollee utilizes
17    a participating health care facility and receives
18    non-emergency covered health care services other than
19    those described in paragraph (1) of this subsection from a
20    nonparticipating provider during or resulting from the
21    visit, the health insurance issuer shall ensure that the
22    beneficiary, insured, or enrollee incurs no greater
23    out-of-pocket costs than the beneficiary, insured, or
24    enrollee would have incurred with a participating provider
25    unless the nonparticipating provider or the participating
26    health care facility on behalf of the nonparticipating

 

 

SB3307- 26 -LRB103 35341 RPS 65405 b

1    provider satisfies the notice and consent criteria
2    provided in 42 U.S.C. 300gg-132 and regulations
3    promulgated thereunder. If the notice and consent criteria
4    are not satisfied, then:
5            (A) any cost-sharing requirements shall be applied
6        as though the health care services had been received
7        from a participating provider;
8            (B) cost sharing shall be calculated based on the
9        recognized amount for the health care services; and
10            (C) in no event shall the beneficiary, insured,
11        enrollee, or any group policyholder or plan sponsor be
12        liable to or billed by the health insurance issuer,
13        the nonparticipating provider, or the participating
14        health care facility for any amount beyond the cost
15        sharing calculated in accordance with this subsection
16        with respect to the health care services delivered;
17        and .
18            (D) when calculating an enrollee's contribution to
19        the annual limitation on cost sharing set forth in 42
20        U.S.C. 18022(c) and 42 U.S.C. 300gg-6(b), a health
21        insurance issuer or its subcontractors shall include
22        expenditures for any item or health care service
23        covered under the policy issued to the enrollee by the
24        health insurance issuer or its subcontractors if that
25        item or health care service is included within a
26        category of essential health benefits, as described in

 

 

SB3307- 27 -LRB103 35341 RPS 65405 b

1        42 U.S.C. 18022(b)(1), and regardless of whether the
2        health insurance issuer or its subcontractors classify
3        that item or service as an essential health benefit.
4    (c) Notwithstanding any other provision of this Code,
5except when the notice and consent criteria are satisfied for
6the situation in paragraph (2) of subsection (b-5), any
7benefits a beneficiary, insured, or enrollee receives for
8services under the situations in subsection (b) or (b-5) are
9assigned to the nonparticipating providers or the facility
10acting on their behalf. Upon receipt of the provider's bill or
11facility's bill, the health insurance issuer shall provide the
12nonparticipating provider or the facility with a written
13explanation of benefits that specifies the proposed
14reimbursement and the applicable deductible, copayment, or
15coinsurance amounts owed by the insured, beneficiary, or
16enrollee. The health insurance issuer shall pay any
17reimbursement subject to this Section directly to the
18nonparticipating provider or the facility.
19    (d) For bills assigned under subsection (c), the
20nonparticipating provider or the facility may bill the health
21insurance issuer for the services rendered, and the health
22insurance issuer may pay the billed amount or attempt to
23negotiate reimbursement with the nonparticipating provider or
24the facility. Within 30 calendar days after the provider or
25facility transmits the bill to the health insurance issuer,
26the issuer shall send an initial payment or notice of denial of

 

 

SB3307- 28 -LRB103 35341 RPS 65405 b

1payment with the written explanation of benefits to the
2provider or facility. If attempts to negotiate reimbursement
3for services provided by a nonparticipating provider do not
4result in a resolution of the payment dispute within 30 days
5after receipt of written explanation of benefits by the health
6insurance issuer, then the health insurance issuer or
7nonparticipating provider or the facility may initiate binding
8arbitration to determine payment for services provided on a
9per-bill or batched-bill basis, in accordance with Section
10300gg-111 of the Public Health Service Act and the regulations
11promulgated thereunder. The party requesting arbitration shall
12notify the other party arbitration has been initiated and
13state its final offer before arbitration. In response to this
14notice, the nonrequesting party shall inform the requesting
15party of its final offer before the arbitration occurs.
16Arbitration shall be initiated by filing a request with the
17Department of Insurance.
18    (e) The Department of Insurance shall publish a list of
19approved arbitrators or entities that shall provide binding
20arbitration. These arbitrators shall be American Arbitration
21Association or American Health Lawyers Association trained
22arbitrators. Both parties must agree on an arbitrator from the
23Department of Insurance's or its approved entity's list of
24arbitrators. If no agreement can be reached, then a list of 5
25arbitrators shall be provided by the Department of Insurance
26or the approved entity. From the list of 5 arbitrators, the

 

 

SB3307- 29 -LRB103 35341 RPS 65405 b

1health insurance issuer can veto 2 arbitrators and the
2provider or facility can veto 2 arbitrators. The remaining
3arbitrator shall be the chosen arbitrator. This arbitration
4shall consist of a review of the written submissions by both
5parties. The arbitrator shall not establish a rebuttable
6presumption that the qualifying payment amount should be the
7total amount owed to the provider or facility by the
8combination of the issuer and the insured, beneficiary, or
9enrollee. Binding arbitration shall provide for a written
10decision within 45 days after the request is filed with the
11Department of Insurance. Both parties shall be bound by the
12arbitrator's decision. The arbitrator's expenses and fees,
13together with other expenses, not including attorney's fees,
14incurred in the conduct of the arbitration, shall be paid as
15provided in the decision.
16    (f) (Blank).
17    (g) Section 368a of this Act shall not apply during the
18pendency of a decision under subsection (d). Upon the issuance
19of the arbitrator's decision, Section 368a applies with
20respect to the amount, if any, by which the arbitrator's
21determination exceeds the issuer's initial payment under
22subsection (c), or the entire amount of the arbitrator's
23determination if initial payment was denied. Any interest
24required to be paid to a provider under Section 368a shall not
25accrue until after 30 days of an arbitrator's decision as
26provided in subsection (d), but in no circumstances longer

 

 

SB3307- 30 -LRB103 35341 RPS 65405 b

1than 150 days from the date the nonparticipating
2facility-based provider billed for services rendered.
3    (h) Nothing in this Section shall be interpreted to change
4the prudent layperson provisions with respect to emergency
5services under the Managed Care Reform and Patient Rights Act.
6    (i) Nothing in this Section shall preclude a health care
7provider from billing a beneficiary, insured, or enrollee for
8reasonable administrative fees, such as service fees for
9checks returned for nonsufficient funds and missed
10appointments.
11    (j) Nothing in this Section shall preclude a beneficiary,
12insured, or enrollee from assigning benefits to a
13nonparticipating provider when the notice and consent criteria
14are satisfied under paragraph (2) of subsection (b-5) or in
15any other situation not described in subsection (b) or (b-5).
16    (k) Except when the notice and consent criteria are
17satisfied under paragraph (2) of subsection (b-5), if an
18individual receives health care services under the situations
19described in subsection (b) or (b-5), no referral requirement
20or any other provision contained in the policy or certificate
21of coverage shall deny coverage, reduce benefits, or otherwise
22defeat the requirements of this Section for services that
23would have been covered with a participating provider.
24However, this subsection shall not be construed to preclude a
25provider contract with a health insurance issuer, or with an
26administrator or similar entity acting on the issuer's behalf,

 

 

SB3307- 31 -LRB103 35341 RPS 65405 b

1from imposing requirements on the participating provider,
2participating emergency facility, or participating health care
3facility relating to the referral of covered individuals to
4nonparticipating providers.
5    (l) Except if the notice and consent criteria are
6satisfied under paragraph (2) of subsection (b-5),
7cost-sharing amounts calculated in conformity with this
8Section shall count toward any deductible or out-of-pocket
9maximum applicable to in-network coverage.
10    (m) The Department has the authority to enforce the
11requirements of this Section in the situations described in
12subsections (b) and (b-5), and in any other situation for
13which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
14regulations promulgated thereunder would prohibit an
15individual from being billed or liable for emergency services
16furnished by a nonparticipating provider or nonparticipating
17emergency facility or for non-emergency health care services
18furnished by a nonparticipating provider at a participating
19health care facility.
20    (n) This Section does not apply with respect to air
21ambulance or ground ambulance services. This Section does not
22apply to any policy of excepted benefits or to short-term,
23limited-duration health insurance coverage.
24(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23;
25103-440, eff. 1-1-24.)
 

 

 

SB3307- 32 -LRB103 35341 RPS 65405 b

1    Section 95. No acceleration or delay. Where this Act makes
2changes in a statute that is represented in this Act by text
3that is not yet or no longer in effect (for example, a Section
4represented by multiple versions), the use of that text does
5not accelerate or delay the taking effect of (i) the changes
6made by this Act or (ii) provisions derived from any other
7Public Act.
 
8    Section 99. Effective date. This Act takes effect upon
9becoming law.