103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB3778

 

Introduced 2/9/2024, by Sen. Lakesia Collins

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.3a

    Amends the Illinois Insurance Code. In a provision concerning services provided by nonparticipating providers, provides that "health care facility" in the context of non-emergency services, includes a facility or office in which a patient receives reproductive health care, as defined in the Reproductive Health Act.


LRB103 38205 RPS 68339 b

 

 

A BILL FOR

 

SB3778LRB103 38205 RPS 68339 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

 

 

SB3778- 2 -LRB103 38205 RPS 68339 b

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.

 

 

SB3778- 3 -LRB103 38205 RPS 68339 b

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.

 

 

SB3778- 4 -LRB103 38205 RPS 68339 b

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; or .
12        (6) a facility or office in which a patient receives
13    reproductive health care, as defined in Section 1-10 of
14    the Reproductive Health Act.
15    "Health care provider" means a provider as defined in
16subsection (d) of Section 370g. "Health care provider" does
17not include a provider of air ambulance or ground ambulance
18services.
19    "Health care services" has the meaning ascribed to that
20term in subsection (a) of Section 370g.
21    "Health insurance issuer" has the meaning ascribed to that
22term in Section 5 of the Illinois Health Insurance Portability
23and Accountability Act.
24    "Nonparticipating emergency facility" means, with respect
25to the furnishing of an item or service under a policy of group
26or individual health insurance coverage, any of the following

 

 

SB3778- 5 -LRB103 38205 RPS 68339 b

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

 

 

SB3778- 6 -LRB103 38205 RPS 68339 b

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

 

 

SB3778- 7 -LRB103 38205 RPS 68339 b

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

 

 

SB3778- 8 -LRB103 38205 RPS 68339 b

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

 

 

SB3778- 9 -LRB103 38205 RPS 68339 b

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

 

 

SB3778- 10 -LRB103 38205 RPS 68339 b

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

 

 

SB3778- 11 -LRB103 38205 RPS 68339 b

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

 

 

SB3778- 12 -LRB103 38205 RPS 68339 b

1after receipt of written explanation of benefits by the health
2insurance issuer, then the health insurance issuer or
3nonparticipating provider or the facility may initiate binding
4arbitration to determine payment for services provided on a
5per-bill or batched-bill basis, in accordance with Section
6300gg-111 of the Public Health Service Act and the regulations
7promulgated thereunder. The party requesting arbitration shall
8notify the other party arbitration has been initiated and
9state its final offer before arbitration. In response to this
10notice, the nonrequesting party shall inform the requesting
11party of its final offer before the arbitration occurs.
12Arbitration shall be initiated by filing a request with the
13Department of Insurance.
14    (e) The Department of Insurance shall publish a list of
15approved arbitrators or entities that shall provide binding
16arbitration. These arbitrators shall be American Arbitration
17Association or American Health Lawyers Association trained
18arbitrators. Both parties must agree on an arbitrator from the
19Department of Insurance's or its approved entity's list of
20arbitrators. If no agreement can be reached, then a list of 5
21arbitrators shall be provided by the Department of Insurance
22or the approved entity. From the list of 5 arbitrators, the
23health insurance issuer can veto 2 arbitrators and the
24provider or facility can veto 2 arbitrators. The remaining
25arbitrator shall be the chosen arbitrator. This arbitration
26shall consist of a review of the written submissions by both

 

 

SB3778- 13 -LRB103 38205 RPS 68339 b

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

 

 

SB3778- 14 -LRB103 38205 RPS 68339 b

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

 

 

SB3778- 15 -LRB103 38205 RPS 68339 b

1    (l) Except if the notice and consent criteria are
2satisfied under paragraph (2) of subsection (b-5),
3cost-sharing amounts calculated in conformity with this
4Section shall count toward any deductible or out-of-pocket
5maximum applicable to in-network coverage.
6    (m) The Department has the authority to enforce the
7requirements of this Section in the situations described in
8subsections (b) and (b-5), and in any other situation for
9which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
10regulations promulgated thereunder would prohibit an
11individual from being billed or liable for emergency services
12furnished by a nonparticipating provider or nonparticipating
13emergency facility or for non-emergency health care services
14furnished by a nonparticipating provider at a participating
15health care facility.
16    (n) This Section does not apply with respect to air
17ambulance or ground ambulance services. This Section does not
18apply to any policy of excepted benefits or to short-term,
19limited-duration health insurance coverage.
20(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23;
21103-440, eff. 1-1-24.)