5-13-22;

10400SB2405sam002 -3- LRB104 10637 BAB 25960 a 102-816, eff.

1-1-23;

102-860, eff.

1-1-23;

102-1093, eff.

1-1-23;

102-1117, eff.

1-13-23;

103-8, eff.

1-1-24;

103-84, eff.

1-1-24;

103-91, eff.

1-1-24;

103-420, eff.

1-1-24;

103-445, eff.

1-1-24;

103-535, eff.

8-11-23;

103-551, eff.

8-11-23;

103-605, eff.

7-1-24;

103-718, eff.

7-19-24;

103-751, eff.

8-2-24;

103-870, eff.

1-1-25;

103-914, eff.

1-1-25;

103-918, eff.

1-1-25;

103-951, eff.

1-1-25;

103-1024, eff.

1-1-25;

revised 11-26-24.) Section 10.

The Counties Code is amended by changing Section 5-1069.3 as follows:

(55 ILCS 5/5-1069.3) Sec.

5-1069.3.

Required health benefits.

If a county, including a home rule county, is a self-insurer for purposes of providing health insurance coverage for its employees, the coverage shall include coverage for the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71, 10400SB2405sam002 -4- LRB104 10637 BAB 25960 a 356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code.

The coverage shall comply with Sections 155.22a, 355b, 356z.19, and 370c of the Illinois Insurance Code.

The Department of Insurance shall enforce the requirements of this Section.

The requirement that health benefits be covered as provided in this Section is an exclusive power and function of the State and is a denial and limitation under Article VII, Section 6, subsection (h) of the Illinois Constitution.

A home rule county to which this Section applies must comply with every provision of this Section.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules;

any purported rule not so adopted, for whatever reason, is unauthorized.

(Source:

P.A.

102-30, eff.

1-1-22;

102-103, eff.

1-1-22;

102-203, eff.

1-1-22;

102-306, eff.

1-1-22;

102-443, eff.

1-1-22;

102-642, eff.

1-1-22;

102-665, eff.

10-8-21;

102-731, eff.

1-1-23;

102-804, eff.

1-1-23;

102-813, eff.

5-13-22;

102-816, eff.

1-1-23;

102-860, eff.

1-1-23;

102-1093, eff.

1-1-23;

102-1117, eff.

1-13-23;

103-84, eff.

1-1-24;

103-91, eff.

1-1-24;

103-420, eff.

1-1-24;

103-445, eff.

1-1-24;

103-535, eff.

8-11-23;

103-551, eff.

8-11-23;

103-605, eff.

7-1-24;

103-718, eff.

7-19-24;

103-751, eff.

8-2-24;

103-914, eff.

1-1-25;

103-918, eff.

1-1-25;

103-1024, eff.

1-1-25;

10400SB2405sam002 -5- LRB104 10637 BAB 25960 a revised 11-26-24.) Section 15.

The Illinois Municipal Code is amended by changing Section 10-4-2.3 as follows:

(65 ILCS 5/10-4-2.3) Sec.

10-4-2.3.

Required health benefits.

If a municipality, including a home rule municipality, is a self-insurer for purposes of providing health insurance coverage for its employees, the coverage shall include coverage for the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code.

The coverage shall comply with Sections 155.22a, 355b, 356z.19, and 370c of the Illinois Insurance Code.

The Department of Insurance shall enforce the requirements of this Section.

The requirement that health benefits be covered as provided in this is an exclusive power and function of the State and is a denial and limitation 10400SB2405sam002 -6- LRB104 10637 BAB 25960 a under Article VII, Section 6, subsection (h) of the Illinois Constitution.

A home rule municipality to which this Section applies must comply with every provision of this Section.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules;

any purported rule not so adopted, for whatever reason, is unauthorized.

(Source:

P.A.

102-30, eff.

1-1-22;

102-103, eff.

1-1-22;

102-203, eff.

1-1-22;

102-306, eff.

1-1-22;

102-443, eff.

1-1-22;

102-642, eff.

1-1-22;

102-665, eff.

10-8-21;

102-731, eff.

1-1-23;

102-804, eff.

1-1-23;

102-813, eff.

5-13-22;

102-816, eff.

1-1-23;

102-860, eff.

1-1-23;

102-1093, eff.

1-1-23;

102-1117, eff.

1-13-23;

103-84, eff.

1-1-24;

103-91, eff.

1-1-24;

103-420, eff.

1-1-24;

103-445, eff.

1-1-24;

103-535, eff.

8-11-23;

103-551, eff.

8-11-23;

103-605, eff.

7-1-24;

103-718, eff.

7-19-24;

103-751, eff.

8-2-24;

103-914, eff.

1-1-25;

103-918, eff.

1-1-25;

103-1024, eff.

1-1-25;

revised 11-26-24.) Section 20.

The School Code is amended by changing Section 10-22.3f as follows:

(105 ILCS 5/10-22.3f) Sec.

10-22.3f.

Required health benefits.

Insurance 10400SB2405sam002 -7- LRB104 10637 BAB 25960 a protection and benefits for employees shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code.

Insurance policies shall comply with Section 356z.19 of the Illinois Insurance Code.

The coverage shall comply with Sections 155.22a, 355b, and 370c of the Illinois Insurance Code.

The Department of Insurance shall enforce the requirements of this Section.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules;

any purported rule not so adopted, for whatever reason, is unauthorized.

(Source:

P.A.

102-30, eff.

1-1-22;

102-103, eff.

1-1-22;

102-203, eff.

1-1-22;

102-306, eff.

1-1-22;

102-642, eff.

1-1-22;

102-665, eff.

10-8-21;

102-731, eff.

1-1-23;

102-804, eff.

1-1-23;

102-813, eff.

5-13-22;

102-816, eff.

1-1-23;

10400SB2405sam002 -8- LRB104 10637 BAB 25960 a 102-860, eff.

1-1-23;

102-1093, eff.

1-1-23;

102-1117, eff.

1-13-23;

103-84, eff.

1-1-24;

103-91, eff.

1-1-24;

103-420, eff.

1-1-24;

103-445, eff.

1-1-24;

103-535, eff.

8-11-23;

103-551, eff.

8-11-23;

103-605, eff.

7-1-24;

103-718, eff.

7-19-24;

103-751, eff.

8-2-24;

103-914, eff.

1-1-25;

103-918, eff.

1-1-25;

103-1024, eff.

1-1-25;

revised 11-26-24.) Section 25.

The Illinois Insurance Code is amended by changing Section 356z.3a and by adding Section 356z.80 as follows:

10400SB2405sam002 -9- LRB104 10637 BAB 25960 a (4) items and services provided by other specialty practitioners as the United States Secretary of Health and Human Services specifies through rulemaking under 42 U.S.C.

(5) items and services provided by a nonparticipating provider if there is no participating provider who can SB2405 - 3 - LRB104 10637 BAB 20714 b furnish the item or service at the facility;

10400SB2405sam002 -10- LRB104 10637 BAB 25960 a "Emergency medical screening examination" has the meaning ascribed to that term in Section 10 of the Managed Care Reform and Patient Rights Act.

(1) in general, an emergency medical screening SB2405 - 4 - LRB104 10637 BAB 20714 b examination, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and such further medical examination and treatment as would be required to stabilize the patient regardless of the department of the hospital or other facility in which such further examination or treatment is furnished;

10400SB2405sam002 -11- LRB104 10637 BAB 25960 a "Emergency service" includes ground ambulance service provided by ground ambulance service providers if the service was provided pursuant to a request to 9-1-1 or an equivalent telephone number, texting system, or other method of summoning emergency service or if the service provided was provided when a patient's condition, at the time of service, was considered to be an emergency medical condition as defined by this Act or as determined by a physician licensed pursuant to the Medical Practice Act of 1987.

"Evaluation" means, with respect to ground ambulance service, the provision of a medical screening examination to determine whether an emergency medical condition exists.

"Ground ambulance service" means both medical transportation servicesservice that areis described as ground ambulance servicesservice by the Centers for Medicare and Medicaid Services and SB2405 - 5 - LRB104 10637 BAB 20714 b medical non-transportationnontransportation servicesservice, such as evaluation without transport, treatment without transport, or paramedic interceptintercept, and that areis, in either case, provided in a vehicle that is licensed as an ambulance under the Emergency Medical Services (EMS) Systems Act or provided by EMS Personnel assigned to a vehicle that is licensed as an ambulance under the Emergency Medical Services (EMS) Systems Act.

"Ground ambulance serviceservice" provider"may meansinclude aany vehiclecombination serviceof provider under the Emergencyfollowing: Medical Services (EMS) Systems Act that operates licensed ground ambulances for the purpose of providing emergency ambulance services, non-emergency ambulance services, or both.

emergency ground 10400SB2405sam002 -12- LRB104 10637 BAB 25960 a ambulance service in a ground ambulance, urgent ground ambulance service, evaluation without treatment, treatment without transport, and paramedic intercept.

"Ground ambulance service provider" means a vehicle service provider under the Emergency Medical Services (EMS) Systems Act that operates licensed ground ambulances.

SB2405 - 6 - LRB104 10637 BAB 20714 b "Health care provider" means a provider as defined in subsection (d) of Section 370g.

10400SB2405sam002 -13- LRB104 10637 BAB 25960 a "Health insurance issuer" has the meaning ascribed to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act.

"Nonparticipating ground ambulance service provider" means, with respect to the furnishing of an item or serviceservices under a policy of group or individual health insurance coverage, any healthground careambulance service provider whothat does not have a contractual relationship directly or SB2405 - 7 - LRB104 10637 BAB 20714 b indirectly with a health insurance issuer in relation to the coverage.

"Nonparticipating provider" means, with respect to the furnishing of an item or service under a policy of group or individual health insurance coverage, any health care provider who does not have a contractual relationship directly or 10400SB2405sam002 -14- LRB104 10637 BAB 25960 a indirectly with a health insurance issuer in relation to the coverage.

"Paramedic intercept" means a service in which a ground ambulance staffed by licensed paramedics rendezvouses with a ground ambulance staffed with nonparamedics to provide advanced life support care.

In this definition, "advanced life support care" means life support care that is warranted when a patient's condition and need for treatment exceed the basic life support or intermediate life support level of care.

For purposes of this definition, a single case agreement between an emergency facility and an issuer that is used to address unique situations in which an insured, beneficiary, or 10400SB2405sam002 -15- LRB104 10637 BAB 25960 a enrollee requires services that typically occur out-of-network constitutes a contractual relationship and is limited to the parties to the agreement.

"Participating health care facility" means any health care facility that has a contractual relationship directly or indirectly with a health insurance issuer offering group or individual health insurance coverage setting forth the terms SB2405 - 8 - LRB104 10637 BAB 20714 b and conditions on which a relevant health care service is provided to an insured, beneficiary, or enrollee under the coverage.

"Recognized amount" meansmeans, except as otherwise provided in this Section, the lesser of the followingamount amounts:initially billed by the 10400SB2405sam002 -16- LRB104 10637 BAB 25960 a provider or the qualifying payment amount.

(1) the amount initially billed by the provider;

(2) or the qualifying payment amount;

or, (3) if applicable, the allowable amount established by this Section.

"Visit""Treatment" means, with respect to healththe careprovision servicesof SB2405ground -ambulance 9service, -the LRB104provision 10637of BAB(i) 20714an bassessment furnishedand to(ii) aneither individual at a healththerapy careor facility,therapeutic healthagent careused servicesto furnishedtreat by a providermedical atcondition theor facility,a asprocedure wellused asto equipment,treat devices,a telehealthmedical services,condition. imaging services, laboratory services, and preoperative and postoperative services regardless of whether the provider furnishing such services is at the facility.

"Urgent ground ambulance service" means ground ambulance service that is deemed medically necessary by a health care professional and is required within 12 hours after the certification of the need for the service.

"Visit" means, with respect to health care services furnished to an individual at a health care facility, health care services furnished by a provider at the facility, as well as equipment, devices, telehealth services, imaging services, laboratory services, and preoperative and postoperative services regardless of whether the provider furnishing such services is at the facility.

When a beneficiary, insured, or enrollee receives emergency services from a nonparticipating provider or a nonparticipating emergency facility, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with 10400SB2405sam002 -17- LRB104 10637 BAB 25960 a a participating provider or a participating emergency facility.

In no event shall the beneficiary, insured, enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance issuer, the nonparticipating provider, or the nonparticipating emergency facility for any amount beyond the cost sharing calculated in SB2405 - 10 - LRB104 10637 BAB 20714 b accordance with this subsection with respect to the emergency services delivered.

(1) When a beneficiary, insured, or enrollee utilizes a participating health care facility and, due to any reason, covered ancillary services are provided by a nonparticipating provider during or resulting from the visit, the health insurance issuer shall ensure that the 10400SB2405sam002 -18- LRB104 10637 BAB 25960 a beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating provider for the ancillary services.

In no event shall the beneficiary, insured, enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance SB2405 - 11 - LRB104 10637 BAB 20714 b issuer, the nonparticipating provider, or the participating health care facility for any amount beyond the cost sharing calculated in accordance with this subsection with respect to the ancillary services delivered.

(2) When a beneficiary, insured, or enrollee utilizes 10400SB2405sam002 -19- LRB104 10637 BAB 25960 a a participating health care facility and receives non-emergency covered health care services other than those described in paragraph (1) of this subsection from a nonparticipating provider during or resulting from the visit, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee incurs no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating provider unless the nonparticipating provider or the participating health care facility on behalf of the nonparticipating provider satisfies the notice and consent criteria provided in 42 U.S.C.

SB2405 - 12 - LRB104 10637 BAB 20714 b (A) any cost-sharing requirements shall be applied as though the health care services had been received from a participating provider;

(c)10400SB2405sam002 Notwithstanding-20- anyLRB104 other10637 provisionBAB of25960 thisa Code,(b-10) exceptPayments whento thenonparticipating noticeground andambulance consentservice criteriaproviders are satisfied for thedates situation in paragraph (2) of subsectionservice (b-5),on any benefits a beneficiary, insured, or enrolleeafter receivesJanuary for1, services2026. under the situations in subsections subsection (b), or (b-5), (f), (f-5), or (f-10) are assigned to the nonparticipating providers or the facility acting on their behalf.

Upon(1) receiptAs ofused thein provider'sthis billsubsection, or"occurrence" facility'smeans bill,a thebase healthcharge insuranceand, issuerif shallapplicable, provide the nonparticipating provider or the facility with a writtenloaded explanationmileage ofcharge. benefits that specifies the proposed reimbursement and the applicable deductible, copayment, or coinsurance amounts owed by the insured, beneficiary, or enrollee.

The(2) Notwithstanding any other provision of this Section, when a beneficiary, insured, or enrollee receives ground ambulance services from a nonparticipating ground ambulance service provider, the health insurance issuer shall payensure anythat SB2405the -beneficiary, 13insured, -or LRB104enrollee 10637shall BABincur 20714no bgreater reimbursementout-of-pocket subjectcosts tothan thisthe Sectionbeneficiary, directlyinsured, toor theenrollee nonparticipatingwould providerhave orincurred thewith facility.a participating ground ambulance service provider.

Any cost-sharing requirements shall be applied as though the services provided by the nonparticipating ground ambulance service provider had been provided by a participating ground ambulance service provider.

(3) Health insurance issuers shall approve charges for nonparticipating ground ambulance service providers at a recognized amount that shall be calculated as the lesser of:

(i) the nonparticipating ground ambulance service provider's billed charge;

(ii) the negotiated rate between the nonparticipating ground ambulance service provider and the health insurance insurer;

or (iii) the rate the ground ambulance service provider has filed for the date of service in question with the Department of Insurance as 10400SB2405sam002 -21- LRB104 10637 BAB 25960 a specified in (b-15).

(4) Payment for ground ambulance services shall be made on a per occurrence basis and shall be paid directly to the nonparticipating ground ambulance service provider.

(5) Except as otherwise provided by State or federal law, the cost-sharing amount for any occurrence of a ground ambulance service provided to a beneficiary, insured, or enrollee shall not exceed the lesser of the plan's emergency room visit copay or 10% of the recognized amount for the occurrence.

(6) If a health insurance issuer has calculated the allowable amount for services provided by a ground ambulance service provider in compliance with this subsection, by accepting payment from the health insurance issuer, the nonparticipating ground ambulance service provider shall not seek any payment from the beneficiary, insured, or enrollee for any amount which exceeds the deductible, coinsurance, or copay for services provided to the beneficiary, insured, or enrollee.

(b-15) Rates for services provided by nonparticipating ground ambulance service providers.

By no later than October 1, 2025, each ground ambulance service provider in Illinois shall file with the Department of Insurance, in the form and manner prescribed by the Department of Insurance, its rates for the provision of ground ambulance services provided on January 1, 2025 and its rates for ground ambulance services to 10400SB2405sam002 -22- LRB104 10637 BAB 25960 a be provided during the calendar year beginning January 1, 2026.

For calendar year 2026, the proposed rates may not exceed the rates in place on January 1, 2025 by more than the annual unadjusted percentage increase in the consumer price index-u for the 12 months ending with the immediately preceding June plus 10%.

As used in this subsection (b-15), "consumer price index-u" means the index published by the Bureau of Labor Statistics of the United States Department of Labor that measures the average change in prices of goods and services purchased by all urban consumers, United States city average, all items, 1982-84 = 100.

The filing required under this subsection (b-15) shall include rates for each of the following ground ambulance services, as applicable:

(1) basic life support, emergency base;

(2) basic life support, non-emergency base;

(3) advanced life support, non-emergency, level 1 base;

(4) advanced life support, emergency, level 1 base;

(5) advanced life support, level 2 base;

(6) specialty care transport base;

(7) evaluation without transport;

(8) treatment without transport;

(9) paramedic intercept;

and (10) ground mileage, per loaded mile.

If a ground ambulance service provider does not have a rate in place for the provision of ground ambulance service 10400SB2405sam002 -23- LRB104 10637 BAB 25960 a provided on January 1, 2025, for evaluation without transport, treatment without transport, or paramedic intercept, the ground ambulance service provider may stipulate a rate as follows:

(i) for evaluation without transport, 25% of the ground ambulance service provider's basic life support, emergency base;

(ii) for treatment without transport, 50% of the ground ambulance service provider's advanced life support, emergency, level 1 base;

(iii) for paramedic intercept, 75% of the ground ambulance service provider's advanced life support, level 1 base.

If a ground ambulance service provider does not have a rate in place for any other base rate or for ground mileage, per loaded mile, the ground ambulance service provider may request that the Department of Insurance calculate such a rate.

Upon receiving a request from a ground ambulance service provider to calculate a rate, the Department of Insurance shall calculate a rate using the unweighted average of the applicable rates provided by all of the ground ambulance service providers within the Medicare locality of the ground ambulance service provider's registered office.

If a ground ambulance service provider begins providing ground ambulance services after January 1, 2025, the Department of Insurance shall calculate applicable rates for the ground ambulance service provider, when requested by a ground ambulance service provider, using the same methodology as for calculating any other rate for a ground ambulance service provider described in this subsection.

Where a ground 10400SB2405sam002 -24- LRB104 10637 BAB 25960 a ambulance service provider participates in the Ground Emergency Transportation (GEMT) program administered by the Department of Healthcare and Family Services, it may substitute its basic life support, emergency base and advanced life support, level 1 base, as calculated by the Department of Healthcare and Family Services, for the calendar year in which the rates were calculated, for its respective reported rate, for January 1, 2026 or any subsequent year without regard to any provision of this subsection that restricts the percentage by which rates may increase on a year-over-year basis.

By October 1, 2026, and by October 1 of each year thereafter, each ground ambulance service provider in Illinois shall file with the Department of Insurance, in the form and manner prescribed by the Department of Insurance, its rates for the provision of ground ambulance services for the following calendar year.

For calendar year 2027 and each year thereafter, the proposed rates may not exceed the rates in place on January 1 of the immediately preceding year by more than the annual unadjusted percentage increase in the consumer price index-u for the 12 months ending with the immediately preceding June plus 10%.

As used in this subsection (b-15), "consumer price index-u" means the index published by the Bureau of Labor Statistics of the United States Department of Labor that measures the average change in prices of goods and services purchased by all urban consumers, United States city average, all items, 1982-84 = 100.

10400SB2405sam002 -25- LRB104 10637 BAB 25960 a (c) Notwithstanding any other provision of this Code, except when the notice and consent criteria are satisfied for the situation in paragraph (2) of subsection (b-5), any benefits a beneficiary, insured, or enrollee receives for services under the situations in subsection (b), or (b-5), (b-10), or (b-15) are assigned to the nonparticipating providers, nonparticipating ground ambulance service provider, or the facility acting on their behalf.

Upon receipt of the provider's bill or facility's bill, the health insurance issuer shall provide the nonparticipating provider, nonparticipating ground ambulance service provider, or the facility with a written explanation of benefits that specifies the proposed reimbursement and the applicable deductible, copayment, or coinsurance amounts owed by the insured, beneficiary, or enrollee.

The health insurance issuer shall pay any reimbursement subject to this Section directly to the nonparticipating provider, nonparticipating ground ambulance service provider, or the facility.

Within 30 calendar days after the provider or facility transmits the bill to the health insurance issuer, the issuer shall send an initial payment or notice of denial of 10400SB2405sam002 -26- LRB104 10637 BAB 25960 a payment with the written explanation of benefits to the provider or facility.

Arbitration shall be initiated by filing a request with the SB2405 - 14 - LRB104 10637 BAB 20714 b Department of Insurance.

From the list of 5 arbitrators, the 10400SB2405sam002 -27- LRB104 10637 BAB 25960 a health insurance issuer can veto 2 arbitrators and the provider or facility can veto 2 arbitrators.

(f) (f)(Blank). Payments to nonparticipating ground ambulance SB2405 - 15 - LRB104 10637 BAB 20714 b service providers.

(Blank).

(1) On or after July 1, 2025, notwithstanding any other provision of this Section, when a beneficiary, insured, or enrollee receives services from a nonparticipating ground ambulance service provider, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating ground ambulance service provider.

Any cost-sharing requirements shall be applied as though the services provided by the nonparticipating ground ambulance service provider had been provided by a participating ground ambulance service provider.

The health insurance issuer shall approve charges for nonparticipating ground ambulance service providers at a recognized amount that shall be calculated as the lessor of:

(i) the nonparticipating ground ambulance service provider's billed charge;

(ii) the negotiated rate between the nonparticipating ground ambulance service provider and the health insurance insurer;

or (iii) the maximum allowable amount specified in subsection (f-5) or the amount specified in subsection (f-10).

(2) Payment for ground ambulance services shall be made on a per occurrence basis.

For purposes of this subsection, occurrence means in individual ground SB2405 - 16 - LRB104 10637 BAB 20714 b ambulance response and, if applicable, the corresponding transport and shall consist of a base charge and, if applicable, a loaded mileage charge.

(4) The cost sharing amount for any occurrence in which a ground ambulance service is provided to a beneficiary, insured, or enrollee, shall not exceed the lessor of the plan's emergency room visit copay or 10% of the recognized amount for the occurrence.

(5) With respect appeals for payments made by health insurance issuers under this subsection, beneficiaries, insureds, enrollees, and ground ambulance service providers are not required to follow a health insurance issuer's internal appeals process and may seek relief in any appropriate court for the purpose of resolving a payment dispute.

In such a dispute litigated in court, a prevailing beneficiary, insured, enrollee, or ground ambulance service provider shall be entitled to payment for reasonable attorney's fees and may seek payment for other damages, including punitive damages, arising from a health insurance issuer's failure to provide payment in compliance with this Act.

(6) Definition of emergency.

In addition to any other criteria for the definition of emergency described in this Act or in the definition of emergency described in the Healthcare Common Procedure Coding System (HCPCS) as it pertains to ground ambulance services, ground ambulance SB2405 - 17 - LRB104 10637 BAB 20714 b services provided by ground ambulance service providers shall be considered emergency services if the services were provided pursuant to a request to 9-1-1 or an equivalent telephone number, texting system, or other method of summonsing emergency services or if the services provided were provided when a patient's condition, at the time of service, was considered to be an emergency medical condition as defined by this Act or as determined by a physician licensed pursuant to the Medical Practice Act of 1997.

(7) As used in subsections (f-5) and (f-10):

(i) "Evaluation" means the provision of a medical screening examination to determine whether an emergency medical condition exists.

(ii) "Treatment" means the provision of an assessment and a therapy or therapeutic agent used to treat a medical condition, or a procedure used to treat a medical condition.

(iii) "Paramedic intercept" means a situation when a paramedic (advanced life support) staffed ambulance rendezvous with a non-paramedic (basic life support or intermediate life support) staffed ambulance to provide advanced life support care.

Advanced life support is warranted when a patient's condition and need for treatment exceeds the basic life support or intermediate life SB2405 - 18 - LRB104 10637 BAB 20714 b support level of care.

(iv) "Unit of government" means a county, as described in the Counties Code;

a township, as described in the Township Code;

a municipality, as described in the Municipal Code;

a fire protection district, as described in the Fire Protection District Act;

a rescue squad district, as described in the Rescue Squad District Act;

or an Emergency Services District, as described in the Emergency Services District Act.

(f-5) The maximum allowable payment amounts by individual service types for nonparticipating ground ambulance service providers owned, operated, or controlled by a private organization, to include both private for profit organizations and private not-for-profit organizations and nonparticipating ground ambulance service providers owned, operated, or controlled by a unit of government that does not participate in the Ground Emergency Medical Transportation (GEMT) program administered by the Department of Healthcare and Family Services, shall be as follows:

(i) basic life support, non-emergency base $2,030;

(ii) basic life support, emergency base $2,660;

(iii) advanced life support, non-emergency, level 1 base $2,800;

(iv) advanced life support, emergency, level 1 base $2,905;

(v) advanced life support, level 2 base $3,080;

(vi) specialty care transport base $7,140;

(vii) evaluation without transport, 25% of the basic life support, emergency SB2405 - 19 - LRB104 10637 BAB 20714 b base;

(vii) treatment without transport, 50% of the advanced life support, emergency, level 1 base;

(viii) paramedic intercept, 75% of the advanced life support, emergency, level 1 base;

and (ix) ground mileage, per loaded mile $56.

The amounts in this subsection shall be adjusted at a rate of 5% annually, effective on January 1 of each year, beginning on January 1, 2026.

(f-10) Payments to nonparticipating ground ambulance service providers owned, operated, or controlled by a unit of government that participates in the Ground Emergency Medical Transportation (GEMT) program administered by the Department of Healthcare and Family Services, shall be the cost-based amount, as reflected in the ground ambulance service provider's GEMT cost report for the applicable date of service.

Individual services types shall be as follows:

(i) basic life support, emergency base;

(ii) advanced life support, emergency, level 1 base;

(iii) advanced life support, level 2 base;

(iv) evaluation without transport, 100% of the basic life support, emergency base, no mileage;

(v) treatment without transport, 100% of the advanced life support, emergency, level 1 base, no mileage;

(vi) paramedic intercept, 100% of the advanced life support, emergency, level 1 base, no mileage;

and (vii) ground mileage, per loaded mile.

In situations where a ground ambulance service provider that qualifies for payments under this subsection charges for a services type, including a basic life support, non-emergency SB2405 - 20 - LRB104 10637 BAB 20714 b base, or an advanced life support, non-emergency base payments by the health insurance issuers shall be as described in subsection (f-5).

Any interest required to be paid to a provider under Section 368a shall not accrue until after 30 days of an arbitrator's decision as provided in subsection (d), but in no circumstances longer 10400SB2405sam002 -28- LRB104 10637 BAB 25960 a than 150 days from the date the nonparticipating facility-based provider billed for services rendered.

(j) Nothing in this Section shall preclude a beneficiary, insured, or enrollee from assigning benefits to a nonparticipating provider when the notice and consent criteria SB2405 - 21 - LRB104 10637 BAB 20714 b are satisfied under paragraph (2) of subsection (b-5) or in any other situation not described in subsection (b) or (b-5).

However, this subsection shall not be construed to preclude a provider contract with a health insurance issuer, or with an administrator or similar entity acting on the issuer's behalf, 10400SB2405sam002 -29- LRB104 10637 BAB 25960 a from imposing requirements on the participating provider, participating emergency facility, or participating health care facility relating to the referral of covered individuals to nonparticipating providers.

Chapter 6A, Subchapter XXV, Parts D or E and SB2405 - 22 - LRB104 10637 BAB 20714 b regulations promulgated thereunder would prohibit an individual from being billed or liable for emergency services furnished by a nonparticipating provider or nonparticipating emergency facility or for non-emergency health care services furnished by a nonparticipating provider at a participating health care facility.

(m-5) A failure by a health insurance issuer to comply with the requirements in this Section constitutes an unlawful practice under the Consumer Fraud and Deceptive Business Practices Act.

All remedies, penalties, and authority granted to the Attorney General by that Act shall be available to the Attorney General for the enforcement of this Section.

(o) A home rule unit may not regulate payments for ground ambulance service in a manner inconsistent with this Section.

This subsection is a limitation under subsection (i) of 10400SB2405sam002 -30- LRB104 10637 BAB 25960 a Section 6 of Article VII of the Illinois Constitution on the concurrent exercise by home rule units of powers and functions exercised by the State.

1-1-24.) (215 ILCS 5/370g)5/356z.80 (fromnew) Ch.Sec.

73,356z.80. par.

982g)Coverage Sec.for ground ambulance services.

370g.Any group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2027 shall provide coverage for ground ambulance service.

Definitions.Section 30.

AsThe usedHealth inMaintenance thisOrganization Article,Act theis followingamended definitionsby apply:changing Sections 4-15 and 5-3 as follows:

(a) "Health care services" means health care services or products rendered or sold by a provider within the scope of the provider's license or legal authorization.

The term includes, but is not limited to, hospital, medical, surgical, dental, SB2405 - 23 - LRB104 10637 BAB 20714 b vision, ground ambulance services, and pharmaceutical services or products.

(b) "Insurer" means an insurance company or a health service corporation authorized in this State to issue policies or subscriber contracts which reimburse for expenses of health care services.

(c) "Insured" means an individual entitled to reimbursement for expenses of health care services under a policy or subscriber contract issued or administered by an insurer.

(d) "Provider" means an individual or entity duly licensed or legally authorized to provide health care services.

(e) "Noninstitutional provider" means any person licensed under the Medical Practice Act of 1987, as now or hereafter amended.

(f) "Beneficiary" means an individual entitled to reimbursement for expenses of or the discount of provider fees for health care services under a program where the beneficiary has an incentive to utilize the services of a provider which has entered into an agreement or arrangement with an administrator.

(g) "Administrator" means any person, partnership or corporation, other than an insurer or health maintenance organization holding a certificate of authority under the "Health Maintenance Organization Act", as now or hereafter amended, that arranges, contracts with, or administers SB2405 - 24 - LRB104 10637 BAB 20714 b contracts with a provider whereby beneficiaries are provided an incentive to use the services of such provider.

(h) "Emergency medical condition" has the meaning given to that term in Section 10 of the Managed Care Reform and Patient Rights Act.

(Source:

P.A.

102-409, eff.

1-1-22.) Section 10.

The Health Maintenance Organization Act is amended by changing Section 4-15 as follows:

(a) No contract or evidence of coverage for basic health care services delivered, issued for delivery, renewed or amended by a Health Maintenance Organization shall exclude coverage for ground ambulance service as defined in Section 356z.3a of the Illinois Insurance Code emergency transportation by ambulance.

For the purposes of this Section, the term "emergency" means a need for immediate medical attention resulting from a life threatening condition or situation or a need for immediate medical attention as 10400SB2405sam002 -31- LRB104 10637 BAB 25960 a otherwise reasonably determined by a physician, public safety official or other emergency medical personnel.

(b) Payments to nonparticipating ground ambulance service providers shall be as described in subsections (f),(b-10) (f-5), and (f-10)(b-15) of Section 356z.3a of the Illinois Insurance Code.Code 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.

Upon reasonable demand by a provider of emergency transportation by ambulance, a Health Maintenance Organization shall promptly SB2405 - 25 - LRB104 10637 BAB 20714 b 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.

86-1028.) Section(215 15.ILCS 125/5-3) (from Ch.

The111 Consumer1/2, Fraudpar. and Deceptive Business Practices Act is amended by adding Section 2HHHH as follows:

(8151411.2) ILCS(Text 505/2HHHHof new)Section Sec.before amendment by P.A.

2HHHH.103-808) Sec.

Violations5-3. of the Consumer Protection from Surprise Health Care Billing Act.

A health insurer commits an unlawful practice within the meaning of this Act when it refuses to comply with the requirements of subsection (m-5) of Section 356z.3a of the Illinois Insurance Code.Code provisions.

(a) Health Maintenance Organizations shall be subject to the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a, 10400SB2405sam002 -32- LRB104 10637 BAB 25960 a 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77, 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois Insurance Code.

(b) For purposes of the Illinois Insurance Code, except for Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health Maintenance Organizations in the following categories are deemed to be "domestic companies":

(1) a corporation authorized under the Dental Service Plan Act or the Voluntary Health Services Plans Act;

(2) a corporation organized under the laws of this State;

or (3) a corporation organized under the laws of another state, 30% or more of the enrollees of which are residents 10400SB2405sam002 -33- LRB104 10637 BAB 25960 a of this State, except a corporation subject to substantially the same requirements in its state of organization as is a "domestic company" under Article VIII 1/2 of the Illinois Insurance Code.

(c) In considering the merger, consolidation, or other acquisition of control of a Health Maintenance Organization pursuant to Article VIII 1/2 of the Illinois Insurance Code, (1) the Director shall give primary consideration to the continuation of benefits to enrollees and the financial conditions of the acquired Health Maintenance Organization after the merger, consolidation, or other acquisition of control takes effect;

(2)(i) the criteria specified in subsection (1)(b) of Section 131.8 of the Illinois Insurance Code shall not apply and (ii) the Director, in making his determination with respect to the merger, consolidation, or other acquisition of control, need not take into account the effect on competition of the merger, consolidation, or other acquisition of control;

(3) the Director shall have the power to require the following information:

(A) certification by an independent actuary of the adequacy of the reserves of the Health Maintenance Organization sought to be acquired;

(B) pro forma financial statements reflecting the combined balance sheets of the acquiring company and 10400SB2405sam002 -34- LRB104 10637 BAB 25960 a the Health Maintenance Organization sought to be acquired as of the end of the preceding year and as of a date 90 days prior to the acquisition, as well as pro forma financial statements reflecting projected combined operation for a period of 2 years;

(C) a pro forma business plan detailing an acquiring party's plans with respect to the operation of the Health Maintenance Organization sought to be acquired for a period of not less than 3 years;

and (D) such other information as the Director shall require.

(d) The provisions of Article VIII 1/2 of the Illinois Insurance Code and this Section 5-3 shall apply to the sale by any health maintenance organization of greater than 10% of its enrollee population (including, without limitation, the health maintenance organization's right, title, and interest in and to its health care certificates).

(e) In considering any management contract or service agreement subject to Section 141.1 of the Illinois Insurance Code, the Director (i) shall, in addition to the criteria specified in Section 141.2 of the Illinois Insurance Code, take into account the effect of the management contract or service agreement on the continuation of benefits to enrollees and the financial condition of the health maintenance organization to be managed or serviced, and (ii) need not take into account the effect of the management contract or service 10400SB2405sam002 -35- LRB104 10637 BAB 25960 a agreement on competition.

(f) Except for small employer groups as defined in the Small Employer Rating, Renewability and Portability Health Insurance Act and except for medicare supplement policies as defined in Section 363 of the Illinois Insurance Code, a Health Maintenance Organization may by contract agree with a group or other enrollment unit to effect refunds or charge additional premiums under the following terms and conditions:

(i) the amount of, and other terms and conditions with respect to, the refund or additional premium are set forth in the group or enrollment unit contract agreed in advance of the period for which a refund is to be paid or additional premium is to be charged (which period shall not be less than one year);

and (ii) the amount of the refund or additional premium shall not exceed 20% of the Health Maintenance Organization's profitable or unprofitable experience with respect to the group or other enrollment unit for the period (and, for purposes of a refund or additional premium, the profitable or unprofitable experience shall be calculated taking into account a pro rata share of the Health Maintenance Organization's administrative and marketing expenses, but shall not include any refund to be made or additional premium to be paid pursuant to this subsection (f)).

The Health Maintenance Organization and the group or enrollment unit may agree that the profitable 10400SB2405sam002 -36- LRB104 10637 BAB 25960 a or unprofitable experience may be calculated taking into account the refund period and the immediately preceding 2 plan years.

The Health Maintenance Organization shall include a statement in the evidence of coverage issued to each enrollee describing the possibility of a refund or additional premium, and upon request of any group or enrollment unit, provide to the group or enrollment unit a description of the method used to calculate (1) the Health Maintenance Organization's profitable experience with respect to the group or enrollment unit and the resulting refund to the group or enrollment unit or (2) the Health Maintenance Organization's unprofitable experience with respect to the group or enrollment unit and the resulting additional premium to be paid by the group or enrollment unit.

In no event shall the Illinois Health Maintenance Organization Guaranty Association be liable to pay any contractual obligation of an insolvent organization to pay any refund authorized under this Section.

(g) Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules;

any purported rule not so adopted, for whatever reason, is unauthorized.

(Source:

P.A.

102-30, eff.

1-1-22;

102-34, eff.

6-25-21;

10400SB2405sam002 -37- LRB104 10637 BAB 25960 a 102-203, eff.

1-1-22;

102-306, eff.

1-1-22;

102-443, eff.

1-1-22;

102-589, eff.

1-1-22;

102-642, eff.

1-1-22;

102-665, eff.

10-8-21;

102-731, eff.

1-1-23;

102-775, eff.

5-13-22;

102-804, eff.

1-1-23;

102-813, eff.

5-13-22;

102-816, eff.

1-1-23;

102-860, eff.

1-1-23;

102-901, eff.

7-1-22;

102-1093, eff.

1-1-23;

102-1117, eff.

1-13-23;

103-84, eff.

1-1-24;

103-91, eff.

1-1-24;

103-123, eff.

1-1-24;