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Public Act 096-0833
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| HB2652 Enrolled |
LRB096 10389 RPM 20559 b |
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by |
renumbering Section 356z.14 as added by Public Act 95-1005, by |
changing and renumbering Section 356z.15 as added by Public Act |
96-639, and by adding Section 356z.18 as follows:
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(215 ILCS 5/356z.15) |
Sec. 356z.15 356z.14. Habilitative services for children. |
(a) As used in this Section, "habilitative services" means |
occupational therapy, physical therapy, speech therapy, and |
other services prescribed by the insured's treating physician |
pursuant to a treatment plan to enhance the ability of a child |
to function with a congenital, genetic, or early acquired |
disorder. A congenital or genetic disorder includes, but is not |
limited to, hereditary disorders. An early acquired disorder |
refers to a disorder resulting from illness, trauma, injury, or |
some other event or condition suffered by a child prior to that |
child developing functional life skills such as, but not |
limited to, walking, talking, or self-help skills. Congenital, |
genetic, and early acquired disorders may include, but are not |
limited to, autism or an autism spectrum disorder, cerebral |
palsy, and other disorders resulting from early childhood |
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illness, trauma, or injury. |
(b) A group or individual policy of accident and health |
insurance or managed care plan amended, delivered, issued, or |
renewed after the effective date of this amendatory Act of the |
95th General Assembly must provide coverage for habilitative |
services for children under 19 years of age with a congenital, |
genetic, or early acquired disorder so long as all of the |
following conditions are met: |
(1) A physician licensed to practice medicine in all |
its branches has diagnosed the child's congenital, |
genetic, or early acquired disorder. |
(2) The treatment is administered by a licensed |
speech-language pathologist, licensed audiologist, |
licensed occupational therapist, licensed physical |
therapist, licensed physician, licensed nurse, licensed |
optometrist, licensed nutritionist, licensed social |
worker, or licensed psychologist upon the referral of a |
physician licensed to practice medicine in all its |
branches. |
(3) The initial or continued treatment must be |
medically necessary and therapeutic and not experimental |
or investigational. |
(c) The coverage required by this Section shall be subject |
to other general exclusions and limitations of the policy, |
including coordination of benefits, participating provider |
requirements, restrictions on services provided by family or |
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household members, utilization review of health care services, |
including review of medical necessity, case management, |
experimental, and investigational treatments, and other |
managed care provisions. |
(d) Coverage under this Section does not apply to those |
services that are solely educational in nature or otherwise |
paid under State or federal law for purely educational |
services. Nothing in this subsection (d) relieves an insurer or |
similar third party from an otherwise valid obligation to |
provide or to pay for services provided to a child with a |
disability. |
(e) Coverage under this Section for children under age 19 |
shall not apply to treatment of mental or emotional disorders |
or illnesses as covered under Section 370 of this Code as well |
as any other benefit based upon a specific diagnosis that may |
be otherwise required by law. |
(f) The provisions of this Section do not apply to |
short-term travel, accident-only, limited, or specific disease |
policies. |
(g) Any denial of care for habilitative services shall be |
subject to appeal and external independent review procedures as |
provided by Section 45 of the Managed Care Reform and Patient |
Rights Act. |
(h) Upon request of the reimbursing insurer, the provider |
under whose supervision the habilitative services are being |
provided shall furnish medical records, clinical notes, or |
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other necessary data to allow the insurer to substantiate that |
initial or continued medical treatment is medically necessary |
and that the patient's condition is clinically improving. When |
the treating provider anticipates that continued treatment is |
or will be required to permit the patient to achieve |
demonstrable progress, the insurer may request that the |
provider furnish a treatment plan consisting of diagnosis, |
proposed treatment by type, frequency, anticipated duration of |
treatment, the anticipated goals of treatment, and how |
frequently the treatment plan will be updated. |
(i) Rulemaking authority to implement this amendatory Act |
of the 95th General Assembly, 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.
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(Source: P.A. 95-1049, eff. 1-1-10; revised 10-23-09.)
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(215 ILCS 5/356z.17) |
Sec. 356z.17 356z.15. Wellness coverage. |
(a) A group or individual policy of accident and health |
insurance or managed care plan amended, delivered, issued, or |
renewed after January 1, 2010 (the effective date of Public Act |
96-639) this amendatory Act of the 96th General Assembly that |
provides coverage for hospital or medical treatment on an |
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expense incurred basis may offer a reasonably designed program |
for wellness coverage that allows for a reward, a contribution, |
a reduction in premiums or reduced medical, prescription drug, |
or equipment copayments, coinsurance, or deductibles, or a |
combination of these incentives, for participation in any |
health behavior wellness, maintenance, or improvement program |
approved or offered by the insurer or managed care plan. The |
insured or enrollee may be required to provide evidence of |
participation in a program. Individuals unable to participate |
in these incentives due to an adverse health factor shall not |
be penalized based upon an adverse health status. |
(b) For purposes of this Section, "wellness coverage" means |
health care coverage with the primary purpose to engage and |
motivate the insured or enrollee through: incentives; |
provision of health education, counseling, and self-management |
skills; identification of modifiable health risks; and other |
activities to influence health behavior changes. |
For the purposes of this Section, "reasonably designed |
program" means a program of wellness coverage that has a |
reasonable chance of improving health or preventing disease; is |
not overly burdensome; does not discriminate based upon factors |
of health; and is not otherwise contrary to law. |
(c) Incentives as outlined in this Section are specific and |
unique to the offering of wellness coverage and have no |
application to any other required or optional health care |
benefit. |
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(d) Such wellness coverage must satisfy the requirements |
for an exception from the general prohibition against |
discrimination based on a health factor under the federal |
Health Insurance Portability and Accountability Act of 1996 |
(P.L. 104-191; 110 Stat. 1936), including any federal |
regulations that are adopted pursuant to that Act. |
(e) A plan offering wellness coverage must do the |
following: |
(i) give participants the opportunity to qualify for |
offered incentives at least once a year; |
(ii) allow a reasonable alternative to any individual |
for whom it is unreasonably difficult, due to a medical |
condition, to satisfy otherwise applicable wellness |
program standards. Plans may seek physician verification |
that health factors make it unreasonably difficult or |
medically inadvisable for the participant to satisfy the |
standards; and |
(iii) not provide a total incentive that exceeds 20% of |
the cost of employee-only coverage. The cost of |
employee-only coverage includes both employer and employee |
contributions. For plans offering family coverage, the 20% |
limitation applies to cost of family coverage and applies |
to the entire family. |
(f) A reward, contribution, or reduction established under |
this Section and included in the policy or certificate does not |
violate Section 151 of this Code.
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(Source: P.A. 96-639, eff. 1-1-10; revised 10-21-09.)
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(215 ILCS 5/356z.18 new) |
Sec. 356z.18. Prosthetic and customized orthotic devices. |
(a) For the purposes of this Section: |
"Customized orthotic device" means a supportive device for |
the body or a part of the body, the head, neck, or extremities, |
and includes the replacement or repair of the device based on |
the patient's physical condition as medically necessary, |
excluding foot orthotics defined as an in-shoe device designed |
to support the structural components of the foot during |
weight-bearing activities. |
"Licensed provider" means a prosthetist, orthotist, or |
pedorthist licensed to practice in this State. |
"Prosthetic device" means an artificial device to replace, |
in whole or in part, an arm or leg and includes accessories |
essential to the effective use of the device and the |
replacement or repair of the device based on the patient's |
physical condition as medically necessary. |
(b) This amendatory Act of the 96th General Assembly shall |
provide benefits to any person covered thereunder for expenses |
incurred in obtaining a prosthetic or custom orthotic device |
from any Illinois licensed prosthetist, licensed orthotist, or |
licensed pedorthist as required under the Orthotics, |
Prosthetics, and Pedorthics Practice Act. |
(c) A group or individual major medical policy of accident |
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or health insurance or managed care plan or medical, health, or |
hospital service corporation contract that provides coverage |
for prosthetic or custom orthotic care and is amended, |
delivered, issued, or renewed 6 months after the effective date |
of this amendatory Act of the 96th General Assembly must |
provide coverage for prosthetic and orthotic devices in |
accordance with this subsection (c). The coverage required |
under this Section shall be subject to the other general |
exclusions, limitations, and financial requirements of the |
policy, including coordination of benefits, participating |
provider requirements, utilization review of health care |
services, including review of medical necessity, case |
management, and experimental and investigational treatments, |
and other managed care provisions under terms and conditions |
that are no less favorable than the terms and conditions that |
apply to substantially all medical and surgical benefits |
provided under the plan or coverage. |
(d) The policy or plan or contract may require prior |
authorization for the prosthetic or orthotic devices in the |
same manner that prior authorization is required for any other |
covered benefit. |
(e) Repairs and replacements of prosthetic and orthotic |
devices are also covered, subject to the co-payments and |
deductibles, unless necessitated by misuse or loss. |
(f) A policy or plan or contract may require that, if |
coverage is provided through a managed care plan, the benefits |
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mandated pursuant to this Section shall be covered benefits |
only if the prosthetic or orthotic devices are provided by a |
licensed provider employed by a provider service who contracts |
with or is designated by the carrier, to the extent that the |
carrier provides in-network and out-of-network service, the |
coverage for the prosthetic or orthotic device shall be offered |
no less extensively. |
(g) The policy or plan or contract shall also meet adequacy |
requirements as established by the Health Care Reimbursement |
Reform Act of 1985 of the Illinois Insurance Code. |
(h) This Section shall not apply to accident only, |
specified disease, short-term hospital or medical, hospital |
confinement indemnity, credit, dental, vision, Medicare |
supplement, long-term care, basic hospital and |
medical-surgical expense coverage, disability income insurance |
coverage, coverage issued as a supplement to liability |
insurance, workers' compensation insurance, or automobile |
medical payment insurance.
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Section 10. The Health Maintenance Organization Act is |
amended by changing Section 5-3 as follows:
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(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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Sec. 5-3. Insurance Code provisions.
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(a) Health Maintenance Organizations
shall be subject to |
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
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141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14, |
356z.17 356z.15, 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a, |
368b, 368c, 368d, 368e, 370c,
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, and XXVI of the Illinois Insurance Code.
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(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":
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(1) a corporation authorized under the
Dental Service |
Plan Act or the Voluntary Health Services Plans Act;
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(2) a corporation organized under the laws of this |
State; or
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(3) a corporation organized under the laws of another |
state, 30% or more
of the enrollees of which are residents |
of this State, except a
corporation subject to |
substantially the same requirements in its state of
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organization as is a "domestic company" under Article VIII |
1/2 of the
Illinois Insurance Code.
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(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,
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(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;
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(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
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acquisition of control, need not take into account the |
effect on
competition of the merger, consolidation, or |
other acquisition of control;
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(3) the Director shall have the power to require the |
following
information:
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(A) certification by an independent actuary of the |
adequacy
of the reserves of the Health Maintenance |
Organization sought to be acquired;
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(B) pro forma financial statements reflecting the |
combined balance
sheets of the acquiring company and |
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;
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(C) a pro forma business plan detailing an |
acquiring party's plans with
respect to the operation |
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of the Health Maintenance Organization sought to
be |
acquired for a period of not less than 3 years; and
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(D) such other information as the Director shall |
require.
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(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
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enrollee population (including without limitation the health |
maintenance
organization's right, title, and interest in and to |
its health care
certificates).
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(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
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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 agreement on |
competition.
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(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 |
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premiums
under the following terms and conditions:
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(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
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additional premium is to be charged (which period shall not |
be less than one
year); and
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(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
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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 |
or unprofitable
experience may be calculated taking into |
account the refund period and the
immediately preceding 2 |
plan years.
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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 |
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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
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experience with respect to the group or enrollment unit and the |
resulting
additional premium to be paid by the group or |
enrollment unit.
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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.
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(g) Rulemaking authority to implement Public Act 95-1045 |
this amendatory Act of the 95th General Assembly, 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. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised |
10-23-09.)
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Section 15. The Voluntary Health Services Plans Act is |
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amended by changing Section 10 as follows:
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(215 ILCS 165/10) (from Ch. 32, par. 604)
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Sec. 10. Application of Insurance Code provisions. Health |
services
plan corporations and all persons interested therein |
or dealing therewith
shall be subject to the provisions of |
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, |
356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, |
356z.14, 356z.15
356z.14, 356z.18, 364.01, 367.2, 368a, 401, |
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
and (15) of Section 367 of the Illinois
Insurance Code.
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Rulemaking authority to implement Public Act 95-1045
this |
amendatory Act of the 95th General Assembly, 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. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, |
eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
96-328, eff. 8-11-09; revised 9-25-09.)
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