103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB1925

 

Introduced 2/9/2023, by Sen. Linda Holmes

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.3a
215 ILCS 5/370g  from Ch. 73, par. 982g
215 ILCS 125/4-15  from Ch. 111 1/2, par. 1409.8

    Amends the Illinois Insurance Code. Provides that nothing in the provisions shall require an ambulance provider to bill a beneficiary, insured, enrollee, or health insurance issuer when prohibited by any other law, rule, ordinance, contract, or agreement. Limits home rule powers. Changes the definition of "emergency services" and "health care provider". Amends the Health Maintenance Organization Act. Removes language providing that upon reasonable demand by a provider of emergency transportation by ambulance, a health maintenance organization shall promptly pay to the provider, subject to coverage limitations stated in the contract or evidence of coverage, the charges for emergency transportation by ambulance provided to an enrollee in a health care plan arranged for by the health maintenance organization.


LRB103 27680 BMS 54057 b

 

 

A BILL FOR

 

SB1925LRB103 27680 BMS 54057 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 Sections 356z.3a and 370g as follows:
 
6    (215 ILCS 5/356z.3a)
7    Sec. 356z.3a. Billing; emergency services;
8nonparticipating providers.
9    (a) As used in this Section:
10    "Ancillary services" means:
11        (1) items and services related to emergency medicine,
12    anesthesiology, pathology, radiology, and neonatology that
13    are provided by any health care provider;
14        (2) items and services provided by assistant surgeons,
15    hospitalists, and intensivists;
16        (3) diagnostic services, including radiology and
17    laboratory services, except for advanced diagnostic
18    laboratory tests identified on the most current list
19    published by the United States Secretary of Health and
20    Human Services under 42 U.S.C. 300gg-132(b)(3);
21        (4) items and services provided by other specialty
22    practitioners as the United States Secretary of Health and
23    Human Services specifies through rulemaking under 42

 

 

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

 

 

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1    "Emergency services" means, with respect to an emergency
2medical condition:
3        (1) in general, any health care service provided to a
4    person to evaluate or treat a condition that requires
5    immediate unscheduled medical care, an emergency medical
6    screening examination, including ancillary services
7    routinely available to the emergency department to
8    evaluate such emergency medical condition, and such
9    further medical examination and treatment as would be
10    required to stabilize the patient regardless of the
11    department of the hospital, ground ambulance, or other
12    facility in which such further examination or treatment is
13    furnished, including any covered service for
14    transportation of a patient by a health care provider to a
15    participating or nonparticipating emergency facility for
16    an emergency medical condition; or
17        (2) additional items and services for which benefits
18    are provided or covered under the coverage and that are
19    furnished by a nonparticipating provider or
20    nonparticipating emergency facility regardless of the
21    department of the hospital or other facility in which such
22    items are furnished after the insured, beneficiary, or
23    enrollee is stabilized and as part of outpatient
24    observation or an inpatient or outpatient stay with
25    respect to the visit in which the services described in
26    paragraph (1) are furnished. Services after stabilization

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1provider or facility. If attempts to negotiate reimbursement
2for services provided by a nonparticipating provider do not
3result in a resolution of the payment dispute within 30 days
4after receipt of written explanation of benefits by the health
5insurance issuer, then the health insurance issuer or
6nonparticipating provider or the facility may initiate binding
7arbitration to determine payment for services provided on a
8per-bill basis. The party requesting arbitration shall notify
9the other party arbitration has been initiated and state its
10final offer before arbitration. In response to this notice,
11the nonrequesting party shall inform the requesting party of
12its final offer before the arbitration occurs. Arbitration
13shall be initiated by filing a request with the Department of
14Insurance.
15    (e) The Department of Insurance shall publish a list of
16approved arbitrators or entities that shall provide binding
17arbitration. These arbitrators shall be American Arbitration
18Association or American Health Lawyers Association trained
19arbitrators. Both parties must agree on an arbitrator from the
20Department of Insurance's or its approved entity's list of
21arbitrators. If no agreement can be reached, then a list of 5
22arbitrators shall be provided by the Department of Insurance
23or the approved entity. From the list of 5 arbitrators, the
24health insurance issuer can veto 2 arbitrators and the
25provider or facility can veto 2 arbitrators. The remaining
26arbitrator shall be the chosen arbitrator. This arbitration

 

 

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

 

 

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

 

 

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1nonparticipating providers.
2    (l) Except if the notice and consent criteria are
3satisfied under paragraph (2) of subsection (b-5),
4cost-sharing amounts calculated in conformity with this
5Section shall count toward any deductible or out-of-pocket
6maximum applicable to in-network coverage.
7    (m) The Department has the authority to enforce the
8requirements of this Section in the situations described in
9subsections (b) and (b-5), and in any other situation for
10which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and
11regulations promulgated thereunder would prohibit an
12individual from being billed or liable for emergency services
13furnished by a nonparticipating provider or nonparticipating
14emergency facility or for non-emergency health care services
15furnished by a nonparticipating provider at a participating
16health care facility.
17    (n) This Section does not apply with respect to air
18ambulance or ground ambulance services. This Section does not
19apply to any policy of excepted benefits or to short-term,
20limited-duration health insurance coverage.
21    (o) Nothing in this Section shall require an ambulance
22provider to bill a beneficiary, insured, enrollee, or health
23insurance issuer when prohibited by any other law, rule,
24ordinance, contract, or agreement. If an ambulance provider
25other than an air ambulance provider is a nonparticipating
26provider when it furnishes emergency services under a contract

 

 

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1with a unit of local government of this State, and if the unit
2of local government is permitted or required to bill a
3beneficiary, insured, enrollee, or health insurance issuer for
4the services furnished by the ambulance provider, this Section
5applies to the unit of local government as though it were the
6ambulance provider. This Section also applies when a unit of
7local government directly operates the ambulance provider that
8furnished emergency services to a beneficiary, insured, or
9enrollee.
10    (p) A home rule unit may not regulate ambulance providers
11in a manner inconsistent with this Section. This Section is a
12limitation under subsection (i) of Section 6 of Article VII of
13the Illinois Constitution on the concurrent exercise by home
14rule units of powers and functions exercised by the State.
15(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23.)
 
16    (215 ILCS 5/370g)  (from Ch. 73, par. 982g)
17    Sec. 370g. Definitions. As used in this Article, the
18following definitions apply:
19    (a) "Health care services" means health care services or
20products rendered or sold by a provider within the scope of the
21provider's license or legal authorization. The term includes,
22but is not limited to, hospital, medical, surgical, dental,
23vision, ground ambulance, and pharmaceutical services or
24products.
25    (b) "Insurer" means an insurance company or a health

 

 

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1service corporation authorized in this State to issue policies
2or subscriber contracts which reimburse for expenses of health
3care services.
4    (c) "Insured" means an individual entitled to
5reimbursement for expenses of health care services under a
6policy or subscriber contract issued or administered by an
7insurer.
8    (d) "Provider" means an individual or entity duly licensed
9or legally authorized to provide health care services.
10    (e) "Noninstitutional provider" means any person licensed
11under the Medical Practice Act of 1987, as now or hereafter
12amended.
13    (f) "Beneficiary" means an individual entitled to
14reimbursement for expenses of or the discount of provider fees
15for health care services under a program where the beneficiary
16has an incentive to utilize the services of a provider which
17has entered into an agreement or arrangement with an
18administrator.
19    (g) "Administrator" means any person, partnership or
20corporation, other than an insurer or health maintenance
21organization holding a certificate of authority under the
22"Health Maintenance Organization Act", as now or hereafter
23amended, that arranges, contracts with, or administers
24contracts with a provider whereby beneficiaries are provided
25an incentive to use the services of such provider.
26    (h) "Emergency medical condition" has the meaning given to

 

 

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1that term in Section 10 of the Managed Care Reform and Patient
2Rights Act.
3(Source: P.A. 102-409, eff. 1-1-22.)
 
4    Section 10. The Health Maintenance Organization Act is
5amended by changing Section 4-15 as follows:
 
6    (215 ILCS 125/4-15)  (from Ch. 111 1/2, par. 1409.8)
7    Sec. 4-15. (a) No contract or evidence of coverage for
8basic health care services delivered, issued for delivery,
9renewed or amended by a Health Maintenance Organization shall
10exclude coverage for emergency transportation by ambulance.
11For the purposes of this Section, the term "emergency" means a
12need for immediate medical attention resulting from a life
13threatening condition or situation or a need for immediate
14medical attention as otherwise reasonably determined by a
15physician, public safety official or other emergency medical
16personnel.
17    (b) (Blank) Upon reasonable demand by a provider of
18emergency transportation by ambulance, a Health Maintenance
19Organization shall promptly pay to the provider, subject to
20coverage limitations stated in the contract or evidence of
21coverage, the charges for emergency transportation by
22ambulance provided to an enrollee in a health care plan
23arranged for by the Health Maintenance Organization. By
24accepting any such payment from the Health Maintenance

 

 

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1Organization, the provider of emergency transportation by
2ambulance agrees not to seek any payment from the enrollee for
3services provided to the enrollee.
4(Source: P.A. 86-833; 86-1028.)