Full Text of HB3030 103rd General Assembly
HB3030enr 103RD GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 356z.3a as follows: | 6 | | (215 ILCS 5/356z.3a) | 7 | | Sec. 356z.3a. Billing; emergency services; | 8 | | nonparticipating 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, | 11 | | or enrollee is responsible for paying for a covered item or | 12 | | service under the terms of the policy or certificate. "Cost | 13 | | sharing" includes copayments, coinsurance, and amounts paid | 14 | | toward deductibles, but does not include amounts paid towards | 15 | | premiums, balance billing by out-of-network providers, or the | 16 | | cost of items or services that are not covered under the policy | 17 | | or certificate. | 18 | | "Emergency department of a hospital" means any hospital | 19 | | department that provides emergency services, including a | 20 | | hospital outpatient department. | 21 | | "Emergency medical condition" has the meaning ascribed to | 22 | | that term in Section 10 of the Managed Care Reform and Patient | 23 | | Rights Act. | 24 | | "Emergency medical screening examination" has the meaning | 25 | | ascribed to that term in Section 10 of the Managed Care Reform | 26 | | and Patient Rights Act. |
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| 1 | | "Emergency services" means, with respect to an emergency | 2 | | medical 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 | 25 | | under Section 32.5 of the Emergency Medical Services (EMS) | 26 | | Systems Act. |
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| 1 | | "Health care facility" means, in the context of | 2 | | non-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 | 13 | | subsection (d) of Section 370g. "Health care provider" does | 14 | | not include a provider of air ambulance or ground ambulance | 15 | | services. | 16 | | "Health care services" has the meaning ascribed to that | 17 | | term in subsection (a) of Section 370g. | 18 | | "Health insurance issuer" has the meaning ascribed to that | 19 | | term in Section 5 of the Illinois Health Insurance Portability | 20 | | and Accountability Act. | 21 | | "Nonparticipating emergency facility" means, with respect | 22 | | to the furnishing of an item or service under a policy of group | 23 | | or individual health insurance coverage, any of the following | 24 | | facilities that does not have a contractual relationship | 25 | | directly or indirectly with a health insurance issuer in | 26 | | relation 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 | 9 | | furnishing of an item or service under a policy of group or | 10 | | individual health insurance coverage, any health care provider | 11 | | who does not have a contractual relationship directly or | 12 | | indirectly with a health insurance issuer in relation to the | 13 | | coverage. | 14 | | "Participating emergency facility" means any of the | 15 | | following facilities that has a contractual relationship | 16 | | directly or indirectly with a health insurance issuer offering | 17 | | group or individual health insurance coverage setting forth | 18 | | the terms and conditions on which a relevant health care | 19 | | service is provided to an insured, beneficiary, or enrollee | 20 | | under 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 | 3 | | between an emergency facility and an issuer that is used to | 4 | | address unique situations in which an insured, beneficiary, or | 5 | | enrollee requires services that typically occur out-of-network | 6 | | constitutes a contractual relationship and is limited to the | 7 | | parties to the agreement. | 8 | | "Participating health care facility" means any health care | 9 | | facility that has a contractual
relationship directly or | 10 | | indirectly with a health insurance issuer offering group or | 11 | | individual health insurance coverage setting forth the terms | 12 | | and conditions on which a relevant health care service is | 13 | | provided to an insured, beneficiary, or enrollee under the | 14 | | coverage. A single case agreement between an emergency | 15 | | facility and an issuer that is used to address unique | 16 | | situations in which an insured, beneficiary, or enrollee | 17 | | requires services that typically occur out-of-network | 18 | | constitutes a contractual relationship for purposes of this | 19 | | definition and is limited to the parties to the agreement. | 20 | | "Participating provider" means any health care provider | 21 | | that has a
contractual relationship directly or indirectly | 22 | | with a health insurance issuer offering group or individual | 23 | | health insurance coverage setting forth the terms and | 24 | | conditions on which a relevant health care service is provided | 25 | | to an insured, beneficiary, or enrollee under the coverage. | 26 | | "Qualifying payment amount" has the meaning given to that |
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| 1 | | term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations | 2 | | promulgated thereunder. | 3 | | "Recognized amount" means the lesser of the amount | 4 | | initially billed by the provider or the qualifying payment | 5 | | amount. | 6 | | "Stabilize" means "stabilization" as defined in Section 10 | 7 | | of the Managed Care Reform and Patient Rights Act. | 8 | | "Treating provider" means a health care provider who has | 9 | | evaluated the individual. | 10 | | "Visit" means, with respect to health care services | 11 | | furnished to an individual at a health care facility, health | 12 | | care services furnished by a provider at the facility, as well | 13 | | as equipment, devices, telehealth services, imaging services, | 14 | | laboratory services, and preoperative and postoperative | 15 | | services regardless of whether the provider furnishing such | 16 | | services is at the facility. | 17 | | (b) Emergency services. When a beneficiary, insured, or | 18 | | enrollee receives emergency services from a nonparticipating | 19 | | provider or a nonparticipating emergency facility, the health | 20 | | insurance issuer shall ensure that the beneficiary, insured, | 21 | | or enrollee shall incur no greater out-of-pocket costs than | 22 | | the beneficiary, insured, or enrollee would have incurred with | 23 | | a participating provider or a participating emergency | 24 | | facility. Any cost-sharing requirements shall be applied as | 25 | | though the emergency services had been received from a | 26 | | participating provider or a participating facility. Cost |
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| 1 | | sharing shall be calculated based on the recognized amount for | 2 | | the emergency services. If the cost sharing for the same item | 3 | | or service furnished by a participating provider would have | 4 | | been a flat-dollar copayment, that amount shall be the | 5 | | cost-sharing amount unless the provider has billed a lesser | 6 | | total amount. In no event shall the beneficiary, insured, | 7 | | enrollee, or any group policyholder or plan sponsor be liable | 8 | | to or billed by the health insurance issuer, the | 9 | | nonparticipating provider, or the nonparticipating emergency | 10 | | facility for any amount beyond the cost sharing calculated in | 11 | | accordance with this subsection with respect to the emergency | 12 | | services delivered. Administrative requirements or limitations | 13 | | shall be no greater than those applicable to emergency | 14 | | services received from a participating provider or a | 15 | | participating emergency facility. | 16 | | (b-5) Non-emergency services at participating health care | 17 | | facilities. | 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, | 24 | | except when the notice and consent criteria are satisfied for | 25 | | the situation in paragraph (2) of subsection (b-5), any | 26 | | benefits a beneficiary, insured, or enrollee receives for |
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| 1 | | services under the situations in subsection (b) or (b-5) are | 2 | | assigned to the nonparticipating providers or the facility | 3 | | acting on their behalf. Upon receipt of the provider's bill or | 4 | | facility's bill, the health insurance issuer shall provide the | 5 | | nonparticipating provider or the facility with a written | 6 | | explanation of benefits that specifies the proposed | 7 | | reimbursement and the applicable deductible, copayment, or | 8 | | coinsurance amounts owed by the insured, beneficiary, or | 9 | | enrollee. The health insurance issuer shall pay any | 10 | | reimbursement subject to this Section directly to the | 11 | | nonparticipating provider or the facility. | 12 | | (d) For bills assigned under subsection (c), the | 13 | | nonparticipating provider or the facility may bill the health | 14 | | insurance issuer for the services rendered, and the health | 15 | | insurance issuer may pay the billed amount or attempt to | 16 | | negotiate reimbursement with the nonparticipating provider or | 17 | | the facility. Within 30 calendar days after the provider or | 18 | | facility transmits the bill to the health insurance issuer, | 19 | | the issuer shall send an initial payment or notice of denial of | 20 | | payment with the written explanation of benefits to the | 21 | | provider or facility. If attempts to negotiate reimbursement | 22 | | for services provided by a nonparticipating provider do not | 23 | | result in a resolution of the payment dispute within 30 days | 24 | | after receipt of written explanation of benefits by the health | 25 | | insurance issuer, then the health insurance issuer or | 26 | | nonparticipating provider or the facility may initiate binding |
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| 1 | | arbitration to determine payment for services provided on a | 2 | | per-bill or batched-bill basis , in accordance with Section | 3 | | 300gg-111 of the Public Health Service Act and the regulations | 4 | | promulgated thereunder . The party requesting arbitration shall | 5 | | notify the other party arbitration has been initiated and | 6 | | state its final offer before arbitration. In response to this | 7 | | notice, the nonrequesting party shall inform the requesting | 8 | | party of its final offer before the arbitration occurs. | 9 | | Arbitration shall be initiated by filing a request with the | 10 | | Department of Insurance. | 11 | | (e) The Department of Insurance shall publish a list of | 12 | | approved arbitrators or entities that shall provide binding | 13 | | arbitration. These arbitrators shall be American Arbitration | 14 | | Association or American Health Lawyers Association trained | 15 | | arbitrators. Both parties must agree on an arbitrator from the | 16 | | Department of Insurance's or its approved entity's list of | 17 | | arbitrators. If no agreement can be reached, then a list of 5 | 18 | | arbitrators shall be provided by the Department of Insurance | 19 | | or the approved entity. From the list of 5 arbitrators, the | 20 | | health insurance issuer can veto 2 arbitrators and the | 21 | | provider or facility can veto 2 arbitrators. The remaining | 22 | | arbitrator shall be the chosen arbitrator. This arbitration | 23 | | shall consist of a review of the written submissions by both | 24 | | parties. The arbitrator shall not establish a rebuttable | 25 | | presumption that the qualifying payment amount should be the | 26 | | total amount owed to the provider or facility by the |
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| 1 | | combination of the issuer and the insured, beneficiary, or | 2 | | enrollee. Binding arbitration shall provide for a written | 3 | | decision within 45 days after the request is filed with the | 4 | | Department of Insurance. Both parties shall be bound by the | 5 | | arbitrator's decision. The arbitrator's expenses and fees, | 6 | | together with other expenses, not including attorney's fees, | 7 | | incurred in the conduct of the arbitration, shall be paid as | 8 | | provided in the decision. | 9 | | (f) (Blank). | 10 | | (g) Section 368a of this Act shall not apply during the | 11 | | pendency of a decision under subsection (d). Upon the issuance | 12 | | of the arbitrator's decision, Section 368a applies with | 13 | | respect to the amount, if any, by which the arbitrator's | 14 | | determination exceeds the issuer's initial payment under | 15 | | subsection (c), or the entire amount of the arbitrator's | 16 | | determination if initial payment was denied. Any interest | 17 | | required to be paid to a provider under Section 368a shall not | 18 | | accrue until after 30 days of an arbitrator's decision as | 19 | | provided in subsection (d), but in no circumstances longer | 20 | | than 150 days from the date the nonparticipating | 21 | | facility-based provider billed for services rendered.
| 22 | | (h) Nothing in this Section shall be interpreted to change | 23 | | the prudent layperson provisions with respect to emergency | 24 | | services under the Managed Care Reform and Patient Rights Act. | 25 | | (i) Nothing in this Section shall preclude a health care | 26 | | provider from billing a beneficiary, insured, or enrollee for |
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| 1 | | reasonable administrative fees, such as service fees for | 2 | | checks returned for nonsufficient funds and missed | 3 | | appointments. | 4 | | (j) Nothing in this Section shall preclude a beneficiary, | 5 | | insured, or enrollee from assigning benefits to a | 6 | | nonparticipating provider when the notice and consent criteria | 7 | | are satisfied under paragraph (2) of subsection (b-5) or in | 8 | | any other situation not described in subsection (b) or (b-5). | 9 | | (k) Except when the notice and consent criteria are | 10 | | satisfied under paragraph (2) of subsection (b-5), if an | 11 | | individual receives health care services under the situations | 12 | | described in subsection (b) or (b-5), no referral requirement | 13 | | or any other provision contained in the policy or certificate | 14 | | of coverage shall deny coverage, reduce benefits, or otherwise | 15 | | defeat the requirements of this Section for services that | 16 | | would have been covered with a participating provider. | 17 | | However, this subsection shall not be construed to preclude a | 18 | | provider contract with a health insurance issuer, or with an | 19 | | administrator or similar entity acting on the issuer's behalf, | 20 | | from imposing requirements on the participating provider, | 21 | | participating emergency facility, or participating health care | 22 | | facility relating to the referral of covered individuals to | 23 | | nonparticipating providers. | 24 | | (l) Except if the notice and consent criteria are | 25 | | satisfied under paragraph (2) of subsection (b-5), | 26 | | cost-sharing amounts calculated in conformity with this |
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| 1 | | Section shall count toward any deductible or out-of-pocket | 2 | | maximum applicable to in-network coverage. | 3 | | (m) The Department has the authority to enforce the | 4 | | requirements of this Section in the situations described in | 5 | | subsections (b) and (b-5), and in any other situation for | 6 | | which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and | 7 | | regulations promulgated thereunder would prohibit an | 8 | | individual from being billed or liable for emergency services | 9 | | furnished by a nonparticipating provider or nonparticipating | 10 | | emergency facility or for non-emergency health care services | 11 | | furnished by a nonparticipating provider at a participating | 12 | | health care facility. | 13 | | (n) This Section does not apply with respect to air | 14 | | ambulance or ground ambulance services. This Section does not | 15 | | apply to any policy of excepted benefits or to short-term, | 16 | | limited-duration health insurance coverage. | 17 | | (Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
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