Aug. 16, 2023
Illinois House Bill 4703: Surprise Medical Bill Protection
Applies to fully insured groups, Individual & Family
Applies to:
- Illinois individual/family plans
- Student plans
- Fully insured group plans including small group, mid-market, large and national accounts (does not include county/municipality/school or state employee plans)
- Grandfathered & transitional plans.
As previously communicated, Illinois House Bill 4703 (PA 102-0901) reinforces provisions of the federal No Surprises Act (NSA) on a state level and sets an Illinois-specific dispute process for out-of-network providers/facilities and insurers. See below for an overview of key HB 4703 provisions compared to the NSA.
Protections consistent with the NSA
- Members can’t be surprise-billed for emergency services from an out-of-network (OON) provider or OON emergency facility
- Member cost sharing can’t be more for OON emergency services than in-network (INN) services, and should be applied as though the service was provided at in-network
- Member cost sharing must be calculated based on the recognized amount (an amount set by state law for the service in a specific geographic area) for the emergency service
- Administrative requirements such as claim processes can’t be greater for OON emergency services than INN emergency services
- Certain ancillary services at INN facilities must also be treated as INN even when obtained from an OON provider:
- Emergency medicine, anesthesiology, pathology, radiology, and neonatology provided by any health care provider
- Assistant surgeons, hospitalists, and intensivists
- Diagnostic services, including radiology and laboratory, except for advanced diagnostic laboratory tests*
- Items/services provided by other specialty practitioners*
- Services provided by an OON provider if there is not an available INN provider at the facility who can deliver the service
- Members are protected unless the OON provider obtains notice and consent from the member to balance bill
Protections that differ from the NSA (for applicable segments as noted above, this is not applicable to ASO groups)
- Additional ancillary facility type – The types of facilities that can provide ancillary services include four that the NSA protects, and one additional type specific to the Illinois law:
- Hospitals
- Outpatient hospitals
- Critical access hospitals
- Ambulatory surgical centers
- Other facilities licensed under the Hospital Licensing Act
(this type differs from the NSA)
- “Unforeseen urgent medical need” protections – Member protections against surprise billing also apply to covered services resulting from an unforeseen, urgent medical need that occurs while other items or services are being furnished
- For example, a member visits the doctor for routine care and suffers a heart attack.
- While the NSA covers emergency services, this language is unique to the Illinois law.
- Benefit plan language – HB 4703 requires adding specific language to member benefit plan materials
- Dispute Resolution Process**:
- Time period to settle before arbitration – NSA requires “30 business days,” HB 4703 requires “30 days”
- Negotiation documentation – NSA requires open negotiation using a federal form, Illinois requires a final offer and response before proceeding to arbitration
- Arbitration request – NSA uses a federal portal and a federal list of arbitrators, HB 4703 requires the request be submitted to the Illinois Department of Insurance (IDOI) and the IDOI has its own list of arbitrators
- Arbitration filing – NSA requires filing via the federal portal, HB 4703 requires filing through the electronic filing system of the American Health Law Association or American Arbitration Association, with a copy sent to the IDOI
- Time period for arbitration – NSA requires 30 days, HB 4703 required decisions to be reached within 45 days
*As defined by the United States Secretary of Health and Human Services
**When state law provides a method for determining the amount payable to a provider in a dispute, providers should follow the state process.
