100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4679

 

Introduced , by Rep. Justin Slaughter

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/355.5 new

    Amends the Illinois Insurance Code. Defines "surprise bill" to mean a bill for health care services received by certain out-of-network providers in which the enrollee did not knowingly elect to obtain those services from an out-of-network provider. Provides that a carrier shall require an enrollee to pay only certain expenses of a surprise bill that would be imposed for health care services if the services were rendered by a network provider. Provides for reimbursement to the out-of-network provider or enrollee at the average network rate, unless the carrier and out-of-network provider agree otherwise. Provides that if a carrier has an inadequate network, as determined by the Director of Insurance, the carrier shall ensure that the enrollee obtains covered service at no greater cost to the enrollee than if the service was obtained from a network provider or make other arrangements acceptable to the Director.


LRB100 17738 SMS 32911 b

 

 

A BILL FOR

 

HB4679LRB100 17738 SMS 32911 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 adding
5Section 355.5 as follows:
 
6    (215 ILCS 5/355.5 new)
7    Sec. 355.5. Protection from surprise bills.
8    (a) As used in this Section:
9    "Carrier" means:
10        (1) an insurance company authorized to transact
11    business in accordance with this Code to provide health
12    insurance;
13        (2) a health maintenance organization as defined in the
14    Health Maintenance Organization Act;
15        (3) a preferred provider organization;
16        (4) a fraternal benefit society;
17        (5) a nonprofit hospital or medical service
18    organization or health plan;
19        (6) a multiple-employer welfare arrangement;
20        (7) a self-insured employer subject to State
21    regulation; or
22        (8) notwithstanding any other provision of this Code,
23    an entity offering coverage in this State that is subject

 

 

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1    to the requirements of the federal Patient Protection and
2    Affordable Care Act.
3    "Carrier" does not include an employer exempted from the
4applicability of this Code under the federal Employee
5Retirement Income Security Act of 1974.
6    "Enrollee" means an individual who is enrolled in a health
7plan or a managed care plan.
8    "Health plan" means a plan offered or administered by a
9carrier that provides for the financing or delivery of health
10care services to persons enrolled in the plan, other than a
11plan that provides only accidental injury, specified disease,
12hospital indemnity, Medicare supplement, disability income,
13long-term care, or other limited benefit coverage not subject
14to the requirements of the federal Patient Protection and
15Affordable Care Act. A plan that is subject to the requirements
16of the federal Patient Protection and Affordable Care Act and
17offered in this State by a carrier, including, but not limited
18to, a qualified health plan offered on an American Health
19Benefit Exchange or a SHOP Exchange established pursuant to the
20federal Patient Protection and Affordable Care Act, is a health
21plan for purposes of this Section.
22    "Provider" means a practitioner or facility licensed,
23accredited, or certified to perform specified health care
24services consistent with State law.
25    "Surprise bill" means a bill for health care services,
26other than emergency services, received by an enrollee for

 

 

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1covered services rendered by an out-of-network provider, when
2such services were rendered by that out-of-network provider at
3a network provider, during a service or procedure performed by
4a network provider, or during a service or procedure previously
5approved or authorized by the carrier and the enrollee did not
6knowingly elect to obtain such services from that
7out-of-network provider. "Surprise bill" does not include a
8bill for health care services received by an enrollee when a
9network provider was available to render the services and the
10enrollee knowingly elected to obtain the services from another
11provider who was an out-of-network provider.
12    (b) With respect to a surprise bill:
13        (1) a carrier shall require an enrollee to pay only the
14    applicable coinsurance, copayment, deductible, or other
15    out-of-pocket expense that would be imposed for health care
16    services if the services were rendered by a network
17    provider;
18        (2) a carrier shall reimburse the out-of-network
19    provider or enrollee, as applicable, for health care
20    services rendered at the average network rate under the
21    enrollee's health care plan as payment in full, unless the
22    carrier and out-of-network provider agree otherwise; and
23        (3) notwithstanding paragraph (2), if a carrier has an
24    inadequate network, as determined by the Director, the
25    carrier shall ensure that the enrollee obtains the covered
26    service at no greater cost to the enrollee than if the

 

 

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1    service was obtained from a network provider or shall make
2    other arrangements acceptable to the Director.