HB4931 Summary

• Amends the Illinois Insurance Code Section 356z.3a to require health insurance issuers to include expenditures for items and health care services in annual cost-sharing limitations if those items/services are covered under a policy and fall within essential health benefits categories, regardless of how the issuer classifies them.

• Applies to enrollees utilizing participating health care facilities when nonparticipating providers furnish covered services, as well as when calculating contributions to annual out-of-pocket maximums under federal law (42 U.S.C. 18022(c) and 42 U.S.C. 300gg-6(b)).

• Requires cost-sharing calculations based on recognized amounts (lesser of billed amount or qualifying payment amount) and prohibits balance billing beyond the calculated cost-sharing amounts.

• Establishes binding arbitration procedures through the Department of Insurance for payment disputes between health insurance issuers and nonparticipating providers or facilities, with decisions required within 45 days.

• Effective immediately upon enactment.