Summary as Introduced
Amends the Illinois Insurance Code to create the Consumer Protection from Surprise Health Care Billing Act. Provides that, on or after July 1, 2025, notwithstanding any other applicable provision, 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. Provides that 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. Sets forth provisions concerning payment for ground ambulance services; calculating the recognized amount; limitations for the cost sharing amount for any occurrence in which a ground ambulance service is provided to a beneficiary; appeals for payments made by health insurance issuers; the maximum allowable payment amounts, by individual service types, for nonparticipating ground ambulance service providers owned, operated, or controlled by a private organization; and payments to nonparticipating ground ambulance service providers owned, operated, or controlled, by a unit of government which participates in the Ground Emergency Medical Transportation program administered by the Department of Healthcare and Family Services. Makes conforming changes. Provides that the failure by a health insurance issuer to comply with the specified requirements constitutes an unlawful practice under the Consumer Fraud and Deceptive Business Practices Act and enforcement authority is granted to the Attorney General. Amends the Health Maintenance Organization Act and the Consumer Fraud and Deceptive Business Practices Act to make corresponding changes. Effective July 1, 2025.
Staff Analysis
This legislation amends the Illinois Insurance Code to create the Consumer Protection from Surprise Health Care Billing Act, aimed at shielding patients from unexpected out-of-network charges specifically related to ground ambulance services. The Act introduces a series of new consumer protections and insurer responsibilities, set to take effect on July 1, 2025.
Key provisions include:
1. Limits on Patient Costs for Out-of-Network Ambulance Services:
If a patient receives care from a nonparticipating ground ambulance service provider, their out-of-pocket costs must be no greater than what they would have paid for the same services from an in-network provider. This ensures cost parity and prevents financial penalties for situations outside the patient’s control.
2. Cost-Sharing Application:
Insurance companies must treat services provided by nonparticipating ambulance providers as though they were in-network, applying cost-sharing (deductibles, copays, coinsurance) accordingly. This standardizes the patient experience and eliminates surprise billing for emergency ground transportation.
3. Payment Guidelines and Calculation Standards:
The bill establishes rules for:
• How insurers must pay ground ambulance providers, both private and publicly operated.
• How the recognized amount (the amount considered payable by the insurer) is calculated.
• Maximum allowable payments for specific service types provided by nonparticipating private ambulance providers.
• Separate provisions for government-operated providers that participate in the state’s Ground Emergency Medical Transportation (GEMT) program.
4. Appeals Process and Oversight:
The bill provides a process for ambulance providers to appeal payment decisions by insurance companies, ensuring fair compensation.
5. Enforcement and Legal Remedies:
Noncompliance by an insurer is considered an unlawful practice under the Consumer Fraud and Deceptive Business Practices Act, and the Attorney General is authorized to enforce these provisions. This adds a layer of regulatory oversight and consumer protection.
6. Conforming Changes to Related Acts:
The bill amends both the Health Maintenance Organization Act and the Consumer Fraud and Deceptive Business Practices Act to align them with the new ambulance billing protections.
In summary, the bill is designed to prevent patients from being burdened with unexpected and often costly bills for out-of-network ambulance services. It shifts the responsibility to health insurers and introduces safeguards to ensure fairness in billing, payment, and enforcement. The inclusion of both private and public ambulance providers ensures comprehensive coverage of ground emergency transport services.
Senate Amendment 1
Senate Floor Amendment 1 to SB 2405 replaces the original content of the bill and introduces a set of requirements in the Illinois Insurance Code related to ambulance services and insurance coverage. The amendment focuses on expanding insurance coverage and clarifying the billing and payment process for emergency and urgent ground ambulance services.
Key provisions include:
1. Coverage Mandate:
Starting January 1, 2027, any individual or group accident and health insurance policy that is amended, delivered, issued, or renewed in Illinois must include coverage for both emergency and urgent ground ambulance services. This ensures that insured individuals are protected in a wider range of situations requiring ambulance transport.
2. Payment Process:
Health insurance issuers are required to promptly approve the full amount billed by ambulance providers upon reasonable demand. Insurers must pay directly to the ambulance provider the portion of the charges they are contractually responsible for.
3. Balance Billing Protections:
Once an ambulance provider accepts payment from a health insurance issuer, they are prohibited from seeking additional payment from the patient beyond the usual cost-sharing amounts (such as deductibles, copayments, or coinsurance). This prevents balance billing and limits the financial burden on patients who receive covered ambulance services.
4. Defined Terms Update:
The amendment also includes changes to defined terms within the Illinois Insurance Code, likely to incorporate or clarify the definitions of “emergency ground ambulance services” and “urgent ground ambulance services,” though the specific changes are not detailed in this summary.
In summary, the amendment enhances consumer protections by mandating insurance coverage for a broader range of ambulance services and regulating the billing process to reduce surprise costs for patients. It also shifts payment responsibilities more clearly to insurers and limits post-service financial liability for insured individuals.