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94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006 HB0732
Introduced 2/1/2005, by Rep. Naomi D. Jakobsson SYNOPSIS AS INTRODUCED: |
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5 ILCS 375/6.11 |
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55 ILCS 5/5-1069.3 |
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65 ILCS 5/10-4-2.3 |
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105 ILCS 5/10-22.3f |
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215 ILCS 5/356z.7 new |
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215 ILCS 105/8 |
from Ch. 73, par. 1308 |
215 ILCS 125/5-3 |
from Ch. 111 1/2, par. 1411.2 |
215 ILCS 165/10 |
from Ch. 32, par. 604 |
305 ILCS 5/5-5 |
from Ch. 23, par. 5-5 |
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Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, Illinois Insurance Code, the Comprehensive Health Insurance Plan Act, the Health Maintenance Organization Act, the Voluntary Health Services Plans Act, and the Public Aid Code. Provides coverage for services rendered by a licensed athletic trainer in accordance with the Illinois Athletic Trainers Practice Act if those services are ordered by a physician licensed to practice medicine in all of its branches.
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| FISCAL NOTE ACT MAY APPLY | |
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A BILL FOR
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HB0732 |
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LRB094 05496 LJB 35543 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 State Employees Group Insurance Act of 1971 |
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| is amended by changing Section 6.11 as follows:
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| (5 ILCS 375/6.11)
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| Sec. 6.11. Required health benefits; Illinois Insurance |
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| Code
requirements. The program of health
benefits shall provide |
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| the post-mastectomy care benefits required to be covered
by a |
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| policy of accident and health insurance under Section 356t of |
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| the Illinois
Insurance Code. The program of health benefits |
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| shall provide the coverage
required under Sections 356u, 356w, |
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| 356x, 356z.2, 356z.4, and 356z.6 , and 356z.7 of the
Illinois |
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| Insurance Code.
The program of health benefits must comply with |
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| Section 155.37 of the
Illinois Insurance Code.
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| (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03; |
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| 93-102, eff. 1-1-04; 93-853, eff. 1-1-05.)
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| Section 10. The Counties Code is amended by changing |
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| Section 5-1069.3 as follows: |
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| (55 ILCS 5/5-1069.3)
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| Sec. 5-1069.3. Required health benefits. If a county, |
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| including a home
rule
county, is a self-insurer for purposes of |
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| providing health insurance coverage
for its employees, the |
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| coverage shall include coverage for the post-mastectomy
care |
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| benefits required to be covered by a policy of accident and |
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| health
insurance under Section 356t and the coverage required |
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| under Sections 356u,
356w, 356x ,
and 356z.6 , and 356z.7 of
the |
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| Illinois Insurance Code. The requirement that health benefits |
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| be covered
as provided in this Section is an
exclusive power |
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| and function of the State and is a denial and limitation under
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| Article VII, Section 6, subsection (h) of the Illinois |
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| Constitution. A home
rule county to which this Section applies |
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| must comply with every provision of
this Section.
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| (Source: P.A. 93-853, eff. 1-1-05.)
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| Section 15. The Illinois Municipal Code is amended by |
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| changing Section 10-4-2.3 as follows: |
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| (65 ILCS 5/10-4-2.3)
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| Sec. 10-4-2.3. Required health benefits. If a |
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| municipality, including a
home rule municipality, is a |
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| self-insurer for purposes of providing health
insurance |
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| coverage for its employees, the coverage shall include coverage |
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| for
the post-mastectomy care benefits required to be covered by |
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| a policy of
accident and health insurance under Section 356t |
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| and the coverage required
under Sections 356u, 356w, 356x ,
and |
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| 356z.6 , and 356z.7 of the Illinois
Insurance
Code. The |
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| requirement that health
benefits be covered as provided in this |
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| is an exclusive power and function of
the State and is a denial |
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| and limitation under Article VII, Section 6,
subsection (h) of |
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| the Illinois Constitution. A home rule municipality to which
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| this Section applies must comply with every provision of this |
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| Section.
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| (Source: P.A. 93-853, eff. 1-1-05.)
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| Section 20. The School Code is amended by changing Section |
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| 10-22.3f as follows: |
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| (105 ILCS 5/10-22.3f)
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| Sec. 10-22.3f. Required health benefits. Insurance |
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| protection and
benefits
for employees shall provide the |
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| post-mastectomy care benefits required to be
covered by a |
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| policy of accident and health insurance under Section 356t and |
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| the
coverage required under Sections 356u, 356w, 356x ,
and |
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| 356z.6 , and 356z.7 of
the
Illinois Insurance Code.
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| (Source: P.A. 93-853, eff. 1-1-05.)
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| Section 25. The Illinois Insurance Code is amended by |
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| adding Section 356z.7 as follows: |
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| (215 ILCS 5/356z.7 new)
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| Sec. 356z.7. Athletic Trainers. A group or individual |
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| policy of accident and health insurance or managed care plan |
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| amended, delivered, issued, or renewed after the effective date |
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| of this amendatory Act of the 94th General Assembly must |
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| provide coverage for services rendered by a licensed athletic |
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| trainer in accordance with the Illinois Athletic Trainers |
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| Practice Act if those services are ordered by a physician |
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| licensed to practice medicine in all of its branches.
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| Section 30. The Comprehensive Health Insurance Plan Act is |
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| amended by changing Section 8 as follows:
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| (215 ILCS 105/8) (from Ch. 73, par. 1308)
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| Sec. 8. Minimum benefits.
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| a. Availability. The Plan shall offer in an
annually |
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| renewable policy major medical expense coverage to every |
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| eligible
person who is not eligible for Medicare. Major medical
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| expense coverage offered by the Plan shall pay an eligible |
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| person's
covered expenses, subject to limit on the deductible |
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| and coinsurance
payments authorized under paragraph (4) of |
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| subsection d of this Section,
up to a lifetime benefit limit of |
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| $1,000,000 per covered
individual. The maximum
limit under this |
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| subsection shall not be altered by the Board, and no
actuarial |
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| equivalent benefit may be substituted by the Board.
Any person |
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| who otherwise would qualify for coverage under the Plan, but
is |
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| excluded because he or she is eligible for Medicare, shall be |
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| eligible
for any separate Medicare supplement policy or |
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| policies which the Board may
offer.
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| b. Outline of benefits. Covered expenses shall be
limited |
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| to the usual and customary charge, including negotiated fees, |
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| in
the locality for the following services and articles when |
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| prescribed by a
physician and determined by the Plan to be |
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| medically necessary
for the following areas of services, |
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| subject to such separate deductibles,
co-payments, exclusions, |
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| and other limitations on benefits as the Board shall
establish |
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| and approve, and the other provisions of this Section:
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| (1) Hospital
services, except that
any services |
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| provided by a hospital that is
located more than 75 miles |
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| outside the State of Illinois shall be covered only
for a |
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| maximum of 45 days in any calendar year. With respect to |
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| covered
expenses incurred during any calendar year ending |
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| on or after December 31,
1999, inpatient hospitalization of |
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| an eligible person for the
treatment of mental illness at a |
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| hospital located within the State of
Illinois
shall be |
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| subject to the same terms and conditions as for any other |
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| illness.
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| (2) Professional services for the diagnosis or |
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| treatment of injuries,
illnesses or conditions, other than |
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| dental and mental
and
nervous disorders as
described in |
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| paragraph (17), which are rendered by a physician, or by |
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| other
licensed professionals at the physician's
direction. |
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| This includes reconstruction of the breast on which a |
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| mastectomy
was performed; surgery and reconstruction of |
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| the other breast to produce a
symmetrical appearance; and |
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| prostheses and treatment of physical complications
at all |
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| stages of the mastectomy, including lymphedemas.
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| (2.5) Professional services provided by a physician to |
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| children under
the age of 16 years for physical |
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| examinations and age appropriate
immunizations ordered by |
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| a physician licensed to practice medicine in all its
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| branches.
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| (3) (Blank).
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| (4) Outpatient prescription drugs that by law require
a
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| prescription
written by a physician licensed to practice |
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| medicine in all its branches
subject to such separate |
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| deductible, copayment, and other limitations or
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| restrictions as the Board shall approve, including the use |
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| of a prescription
drug card or any other program, or both.
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| (5) Skilled nursing services of a licensed
skilled
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| nursing facility for not more than 120 days during a policy |
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| year.
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| (6) Services of a home health agency in accord with a |
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| home health care
plan, up to a maximum of 270 visits per |
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| year.
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| (7) Services of a licensed hospice for not more than |
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| 180
days during a policy year.
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| (8) Use of radium or other radioactive materials.
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| (9) Oxygen.
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| (10) Anesthetics.
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| (11) Orthoses and prostheses other than dental.
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| (12) Rental or purchase in accordance with Board |
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| policies or
procedures of durable medical equipment, other |
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| than eyeglasses or hearing
aids, for which there is no |
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| personal use in the absence of the condition
for which it |
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| is prescribed.
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| (13) Diagnostic x-rays and laboratory tests.
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| (14) Oral surgery (i) for excision of partially or |
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| completely unerupted
impacted teeth when not performed in
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| connection with the routine extraction or repair of teeth; |
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| (ii) for excision
of tumors or cysts of the jaws, cheeks, |
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| lips, tongue, and roof and floor of the
mouth; (iii) |
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| required for correction of cleft lip and palate
and
other |
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| craniofacial and maxillofacial birth defects; or (iv) for |
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| treatment of injuries to natural teeth or a fractured jaw |
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| due to an accident.
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| (15) Physical, speech, and functional occupational |
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| therapy as
medically necessary and provided by appropriate |
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| licensed professionals.
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| (16) Emergency and other medically necessary |
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| transportation provided
by a licensed ambulance service to |
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| the
nearest health care facility qualified to treat a |
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| covered
illness, injury, or condition, subject to the |
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| provisions of the
Emergency Medical Systems (EMS) Act.
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| (17) Outpatient services for
diagnosis and
treatment |
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| of mental and nervous disorders provided that a
covered |
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| person shall be required to make a copayment not to exceed |
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| 50% and that
the Plan's payment shall not exceed such |
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| amounts as are established by the
Board.
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| (18) Human organ or tissue transplants specified by the |
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| Board that
are performed at a hospital designated by the |
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| Board as a participating
transplant center for that |
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| specific organ or tissue transplant.
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| (19) Naprapathic services, as appropriate, provided by |
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| a licensed
naprapathic practitioner.
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| (20) Services rendered by a licensed athletic trainer |
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| in accordance with the Illinois Athletic Trainers Practice |
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| Act if those services are ordered by a physician licensed |
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| to practice medicine in all of its branches.
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| c. Exclusions. Covered expenses of the Plan shall not
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| include the following:
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| (1) Any charge for treatment for cosmetic purposes |
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| other than for
reconstructive surgery when the service is |
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| incidental to or follows
surgery resulting from injury, |
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| sickness or other diseases of the involved
part or surgery |
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| for the repair or treatment of a congenital bodily defect
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| to restore normal bodily functions.
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| (2) Any charge for care that is primarily for rest,
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| custodial, educational, or domiciliary purposes.
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| (3) Any charge for services in a private room to the |
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| extent it is in
excess of the institution's charge for its |
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| most common semiprivate room,
unless a private room is |
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| prescribed as medically necessary by a physician.
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| (4) That part of any charge for room and board or for |
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| services
rendered or articles prescribed by a physician, |
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| dentist, or other health
care personnel that exceeds the |
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| reasonable and customary charge in the
locality or for any |
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| services or supplies not medically necessary for the
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| diagnosed injury or illness.
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| (5) Any charge for services or articles the provision |
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| of which is not
within the scope of licensure of the |
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| institution or individual
providing the services or |
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| articles.
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| (6) Any expense incurred prior to the effective date of |
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| coverage by the
Plan for the person on whose behalf the |
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| expense is incurred.
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| (7) Dental care, dental surgery, dental treatment, any |
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| other dental
procedure involving the teeth or |
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| periodontium, or any dental appliances,
including crowns, |
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| bridges, implants, or partial or complete dentures,
except
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| as specifically provided in paragraph
(14) of subsection b |
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| of this Section.
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| (8) Eyeglasses, contact lenses, hearing aids or their |
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| fitting.
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| (9) Illness or injury due to acts of war.
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| (10) Services of blood donors and any fee for failure |
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| to replace the
first 3 pints of blood
provided to a covered |
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| person each policy year.
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| (11) Personal supplies or services provided by a |
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| hospital or nursing
home, or any other nonmedical or |
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| nonprescribed supply or service.
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| (12) Routine maternity charges for a pregnancy, except |
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| where added as
optional coverage with payment of an |
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| additional premium for pregnancy
resulting from conception |
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| occurring after the effective date of the
optional |
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| coverage.
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| (13) (Blank).
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| (14) Any expense or charge for services, drugs, or |
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| supplies that are:
(i) not provided in accord with |
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| generally accepted standards of current
medical practice; |
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| (ii) for procedures, treatments, equipment, transplants,
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| or implants, any of which are investigational, |
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| experimental, or for
research purposes; (iii) |
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| investigative and not proven safe and effective;
or (iv) |
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| for, or resulting from, a gender
transformation operation.
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| (15) Any expense or charge for routine physical |
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| examinations or tests
except as provided in item (2.5) of |
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| subsection b of this Section.
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| (16) Any expense for which a charge is not made in the |
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| absence of
insurance or for which there is no legal |
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| obligation on the part of the
patient to pay.
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| (17) Any expense incurred for benefits provided under |
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| the laws of the
United States and this State, including |
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| Medicare, Medicaid, and
other
medical assistance, maternal |
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| and child health services and any other program
that is |
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| administered or funded by the Department of Human Services, |
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| Department
of Public Aid, or Department of Public Health, |
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| military service-connected
disability payments, medical
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| services provided for members of the armed forces and their |
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| dependents or
employees of the armed forces of the United |
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| States, and medical services
financed on behalf of all |
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| citizens by the United States.
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| (18) Any expense or charge for in vitro fertilization, |
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| artificial
insemination, or any other artificial means |
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| used to cause pregnancy.
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| (19) Any expense or charge for oral contraceptives used |
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| for birth
control or any other temporary birth control |
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| measures.
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| (20) Any expense or charge for sterilization or |
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| sterilization reversals.
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| (21) Any expense or charge for weight loss programs, |
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| exercise
equipment, or treatment of obesity, except when |
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| certified by a physician as
morbid obesity (at least 2 |
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| times normal body weight).
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| (22) Any expense or charge for acupuncture treatment |
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| unless used as an
anesthetic agent for a covered surgery.
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| (23) Any expense or charge for or related to organ or |
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| tissue
transplants other than those performed at a hospital |
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| with a Board approved
organ transplant program that has |
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| been designated by the Board as a
preferred or exclusive |
35 |
| provider organization for that specific organ or tissue
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| transplant.
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| (24) Any expense or charge for procedures, treatments, |
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| equipment, or
services that are provided in special |
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| settings for research purposes or in
a controlled |
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| environment, are being studied for safety, efficiency, and
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| effectiveness, and are awaiting endorsement by the |
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| appropriate national
medical speciality college for |
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| general use within the medical community.
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| d. Deductibles and coinsurance.
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| The Plan coverage defined in Section 6 shall provide for a |
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| choice
of
deductibles per individual as authorized by the |
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| Board. If 2 individual members
of the same family
household, |
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| who are both covered persons under the Plan, satisfy the
same |
13 |
| applicable deductibles, no other member of that family who is
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| also a covered person under the Plan shall be
required to
meet |
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| any deductibles for the balance of that calendar year. The
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| deductibles must be applied first to the authorized amount of |
17 |
| covered expenses
incurred by the
covered person. A mandatory |
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| coinsurance requirement shall be imposed at
the rate authorized |
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| by the Board in excess of the mandatory
deductible, the |
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| coinsurance
in the aggregate not to exceed such amounts as are |
21 |
| authorized by the Board
per annum. At its discretion the Board |
22 |
| may, however, offer catastrophic
coverages or other policies |
23 |
| that provide for larger deductibles with or
without coinsurance |
24 |
| requirements. The deductibles and coinsurance
factors may be |
25 |
| adjusted annually according to the Medical Component of the
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| Consumer Price Index.
|
27 |
| e. Scope of coverage.
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| (1) In approving any of the benefit plans to be offered |
29 |
| by the Plan, the
Board shall establish such benefit levels, |
30 |
| deductibles, coinsurance factors,
exclusions, and |
31 |
| limitations as it may deem appropriate and that it believes |
32 |
| to
be generally reflective of and commensurate with health |
33 |
| insurance coverage that
is provided in the individual |
34 |
| market in this State.
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35 |
| (2) The benefit plans approved by the Board may also |
36 |
| provide for and
employ
various cost containment measures |
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| and other requirements including, but not
limited to, |
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| preadmission certification, prior approval, second |
3 |
| surgical
opinions, concurrent utilization review programs, |
4 |
| individual case management,
preferred provider |
5 |
| organizations, health maintenance organizations, and other
|
6 |
| cost effective arrangements for paying for covered |
7 |
| expenses.
|
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| f. Preexisting conditions.
|
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| (1) Except for federally eligible individuals |
10 |
| qualifying for Plan
coverage under Section 15 of this Act
|
11 |
| or eligible persons who qualify
for the waiver authorized |
12 |
| in paragraph (3) of this subsection,
plan coverage shall |
13 |
| exclude charges or expenses incurred
during the first 6 |
14 |
| months following the effective date of coverage as to
any |
15 |
| condition for which medical advice, care or treatment was |
16 |
| recommended or
received during the 6 month period
|
17 |
| immediately preceding the effective date
of coverage.
|
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| (2) (Blank).
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| (3) Waiver: The preexisting condition exclusions as |
20 |
| set forth in
paragraph (1) of this subsection shall be |
21 |
| waived to the extent to which
the eligible person (a) has |
22 |
| satisfied similar exclusions under any prior
individual |
23 |
| health insurance policy that was involuntarily terminated
|
24 |
| because of the insolvency of the issuer of the policy and |
25 |
| (b) has applied
for Plan coverage within 90 days following |
26 |
| the involuntary
termination of that individual health |
27 |
| insurance coverage.
|
28 |
| g. Other sources primary; nonduplication of benefits.
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| (1) The Plan shall be the last payor of benefits |
30 |
| whenever any other
benefit or source of third party payment |
31 |
| is available. Subject to the
provisions of subsection e of |
32 |
| Section 7, benefits
otherwise payable under Plan coverage |
33 |
| shall be reduced by
all amounts paid or payable by Medicare |
34 |
| or any other government program
or through any health |
35 |
| insurance coverage or group health plan,
whether by |
36 |
| insurance, reimbursement, or otherwise, or through
any |
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| third party liability,
settlement, judgment, or award,
|
2 |
| regardless of the date of the settlement, judgment, or |
3 |
| award, whether the
settlement, judgment, or award is in the |
4 |
| form of a contract, agreement, or
trust on behalf of a |
5 |
| minor or otherwise and whether the settlement,
judgment, or |
6 |
| award is payable to the covered person, his or her |
7 |
| dependent,
estate, personal representative, or guardian in |
8 |
| a lump sum or over time,
and by all hospital or medical |
9 |
| expense benefits
paid or payable under any worker's |
10 |
| compensation coverage, automobile
medical payment, or |
11 |
| liability insurance, whether provided on the basis of
fault |
12 |
| or nonfault, and by any hospital or medical benefits paid |
13 |
| or payable
under or provided pursuant to any State or |
14 |
| federal law or program.
|
15 |
| (2) The Plan shall have a cause of action against any
|
16 |
| covered person or any other person or entity for
the |
17 |
| recovery of any amount paid to the extent
the amount was |
18 |
| for treatment, services, or supplies not covered in this
|
19 |
| Section or in excess of benefits as set forth in this |
20 |
| Section.
|
21 |
| (3) Whenever benefits are due from the Plan because of |
22 |
| sickness or
an injury to a covered person resulting from a |
23 |
| third party's wrongful act
or negligence and the covered |
24 |
| person has recovered or may recover damages
from a third |
25 |
| party or its insurer, the Plan shall have the right to |
26 |
| reduce
benefits or to refuse to pay benefits that otherwise |
27 |
| may be payable by the
amount of damages that the covered |
28 |
| person has recovered or may recover
regardless of the date |
29 |
| of the sickness or injury or the date of any
settlement, |
30 |
| judgment, or award resulting from that sickness or injury.
|
31 |
| During the pendency of any action or claim that is |
32 |
| brought by or on
behalf of a covered person against a third |
33 |
| party or its insurer, any
benefits that would otherwise be |
34 |
| payable except for the provisions of this
paragraph (3) |
35 |
| shall be paid if payment by or for the third party has not |
36 |
| yet
been made and the covered person or, if incapable, that |
|
|
|
HB0732 |
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LRB094 05496 LJB 35543 b |
|
|
1 |
| person's legal
representative agrees in writing to pay back |
2 |
| promptly the benefits paid as
a result of the sickness or |
3 |
| injury to the extent of any future payments
made by or for |
4 |
| the third party for the sickness or injury. This agreement
|
5 |
| is to apply whether or not liability for the payments is |
6 |
| established or
admitted by the third party or whether those |
7 |
| payments are itemized.
|
8 |
| Any amounts due the plan to repay benefits may be |
9 |
| deducted from other
benefits payable by the Plan after |
10 |
| payments by or for the third party are made.
|
11 |
| (4) Benefits due from the Plan may be reduced or |
12 |
| refused as an offset
against any amount otherwise |
13 |
| recoverable under this Section.
|
14 |
| h. Right of subrogation; recoveries.
|
15 |
| (1) Whenever the Plan has paid benefits because of |
16 |
| sickness or an
injury to any covered person resulting from |
17 |
| a third party's wrongful act or
negligence, or for which an |
18 |
| insurer is liable in accordance with the
provisions of any |
19 |
| policy of insurance, and the covered person has recovered
|
20 |
| or may recover damages from a third party that is liable |
21 |
| for the damages,
the Plan shall have the right to recover |
22 |
| the benefits it paid from any
amounts that the covered |
23 |
| person has received or may receive regardless of
the date |
24 |
| of the sickness or injury or the date of any settlement, |
25 |
| judgment,
or award resulting from that sickness
or injury. |
26 |
| The Plan shall be subrogated to any right of recovery the
|
27 |
| covered person may have under the terms of any private or |
28 |
| public health
care coverage or liability coverage, |
29 |
| including coverage under the Workers'
Compensation Act or |
30 |
| the Workers' Occupational Diseases Act, without the
|
31 |
| necessity of assignment of claim or other authorization to |
32 |
| secure the right
of recovery. To enforce its subrogation |
33 |
| right, the Plan may (i) intervene
or join in an action or |
34 |
| proceeding brought by the covered person or his
personal |
35 |
| representative, including his guardian, conservator, |
36 |
| estate,
dependents, or survivors,
against any third party |
|
|
|
HB0732 |
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LRB094 05496 LJB 35543 b |
|
|
1 |
| or the third party's insurer that may be liable or
(ii) |
2 |
| institute and prosecute legal proceedings against any |
3 |
| third party or
the third party's insurer that may be liable |
4 |
| for the sickness or injury in
an appropriate court either |
5 |
| in the name of the Plan or in the name of the
covered |
6 |
| person or his personal representative, including his |
7 |
| guardian,
conservator, estate, dependents, or survivors.
|
8 |
| (2) If any action or claim is brought by or on behalf |
9 |
| of a covered
person against a third party or the third |
10 |
| party's insurer, the covered
person or his personal |
11 |
| representative, including his guardian,
conservator, |
12 |
| estate, dependents, or survivors, shall notify the Plan by
|
13 |
| personal service or registered mail of the action or claim |
14 |
| and of the name
of the court in which the action or claim |
15 |
| is brought, filing proof thereof
in the action or claim. |
16 |
| The Plan may, at any time thereafter, join in the
action or |
17 |
| claim upon its motion so that all orders of court after |
18 |
| hearing
and judgment shall be made for its protection. No |
19 |
| release or settlement of
a claim for damages and no |
20 |
| satisfaction of judgment in the action shall be
valid |
21 |
| without the written consent of the Plan to the extent of |
22 |
| its interest
in the settlement or judgment and of the |
23 |
| covered person or his
personal representative.
|
24 |
| (3) In the event that the covered person or his |
25 |
| personal
representative fails to institute a proceeding |
26 |
| against any appropriate
third party before the fifth month |
27 |
| before the action would be barred, the
Plan may, in its own |
28 |
| name or in the name of the covered person or personal
|
29 |
| representative, commence a proceeding against any |
30 |
| appropriate third party
for the recovery of damages on |
31 |
| account of any sickness, injury, or death to
the covered |
32 |
| person. The covered person shall cooperate in doing what is
|
33 |
| reasonably necessary to assist the Plan in any recovery and |
34 |
| shall not take
any action that would prejudice the Plan's |
35 |
| right to recovery. The Plan
shall pay to the covered person |
36 |
| or his personal representative all sums
collected from any |
|
|
|
HB0732 |
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LRB094 05496 LJB 35543 b |
|
|
1 |
| third party by judgment or otherwise in excess of
amounts |
2 |
| paid in benefits under the Plan and amounts paid or to be |
3 |
| paid as
costs, attorneys fees, and reasonable expenses |
4 |
| incurred by the Plan in
making the collection or enforcing |
5 |
| the judgment.
|
6 |
| (4) In the event that a covered person or his personal |
7 |
| representative,
including his guardian, conservator, |
8 |
| estate, dependents, or survivors,
recovers damages from a |
9 |
| third party for sickness or injury caused to the
covered |
10 |
| person, the covered person or the personal representative |
11 |
| shall pay to the Plan
from the damages recovered the amount |
12 |
| of benefits paid or to be paid on
behalf of the covered |
13 |
| person.
|
14 |
| (5) When the action or claim is brought by the covered |
15 |
| person alone
and the covered person incurs a personal |
16 |
| liability to pay attorney's fees
and costs of litigation, |
17 |
| the Plan's claim for reimbursement of the benefits
provided |
18 |
| to the covered person shall be the full amount of benefits |
19 |
| paid to
or on behalf of the covered person under this Act |
20 |
| less a pro rata share
that represents the Plan's reasonable |
21 |
| share of attorney's fees paid by the
covered person and |
22 |
| that portion of the cost of litigation expenses
determined |
23 |
| by multiplying by the ratio of the full amount of the
|
24 |
| expenditures to the full amount of the judgement, award, or |
25 |
| settlement.
|
26 |
| (6) In the event of judgment or award in a suit or |
27 |
| claim against a
third party or insurer, the court shall |
28 |
| first order paid from any judgement
or award the reasonable |
29 |
| litigation expenses incurred in preparation and
|
30 |
| prosecution of the action or claim, together with |
31 |
| reasonable attorney's
fees. After payment of those |
32 |
| expenses and attorney's fees, the court shall
apply out of |
33 |
| the balance of the judgment or award an amount sufficient |
34 |
| to
reimburse the Plan the full amount of benefits paid on |
35 |
| behalf of the
covered person under this Act, provided the |
36 |
| court may reduce and apportion
the Plan's portion of the |
|
|
|
HB0732 |
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LRB094 05496 LJB 35543 b |
|
|
1 |
| judgement proportionate to the recovery of the
covered |
2 |
| person. The burden of producing evidence sufficient to |
3 |
| support the
exercise by the court of its discretion to |
4 |
| reduce
the amount of a proven charge sought to be enforced |
5 |
| against the recovery
shall rest with the party seeking the |
6 |
| reduction. The court may consider
the nature and extent of |
7 |
| the injury, economic and non-economic loss,
settlement |
8 |
| offers, comparative negligence as it applies to the case at
|
9 |
| hand, hospital costs, physician costs, and all other |
10 |
| appropriate costs.
The Plan shall pay its pro rata share of |
11 |
| the attorney fees based on the
Plan's recovery as it |
12 |
| compares to the total judgment. Any reimbursement
rights of |
13 |
| the Plan shall take priority over all other liens and |
14 |
| charges
existing under the laws of this State with the |
15 |
| exception of any attorney
liens filed under the Attorneys |
16 |
| Lien Act.
|
17 |
| (7) The Plan may compromise or settle and release any |
18 |
| claim for
benefits provided under this Act or waive any |
19 |
| claims for benefits, in whole
or in part, for the |
20 |
| convenience of the Plan or if the Plan determines that
|
21 |
| collection would result in undue hardship upon the covered |
22 |
| person.
|
23 |
| (Source: P.A. 91-639, eff. 8-20-99; 91-735, eff. 6-2-00; 92-2, |
24 |
| eff.
5-1-01; 92-630, eff. 7-11-02.)
|
25 |
| Section 35. The Health Maintenance Organization Act is |
26 |
| amended by changing Section 5-3 as follows:
|
27 |
| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
|
28 |
| Sec. 5-3. Insurance Code provisions.
|
29 |
| (a) Health Maintenance Organizations
shall be subject to |
30 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
31 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
32 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, |
33 |
| 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01, 367.2, |
34 |
| 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e,
401, 401.1, 402, |
|
|
|
HB0732 |
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LRB094 05496 LJB 35543 b |
|
|
1 |
| 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) |
2 |
| of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
|
3 |
| XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois |
4 |
| Insurance Code.
|
5 |
| (b) For purposes of the Illinois Insurance Code, except for |
6 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
7 |
| Maintenance Organizations in
the following categories are |
8 |
| deemed to be "domestic companies":
|
9 |
| (1) a corporation authorized under the
Dental Service |
10 |
| Plan Act or the Voluntary Health Services Plans Act;
|
11 |
| (2) a corporation organized under the laws of this |
12 |
| State; or
|
13 |
| (3) a corporation organized under the laws of another |
14 |
| state, 30% or more
of the enrollees of which are residents |
15 |
| of this State, except a
corporation subject to |
16 |
| substantially the same requirements in its state of
|
17 |
| organization as is a "domestic company" under Article VIII |
18 |
| 1/2 of the
Illinois Insurance Code.
|
19 |
| (c) In considering the merger, consolidation, or other |
20 |
| acquisition of
control of a Health Maintenance Organization |
21 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
22 |
| (1) the Director shall give primary consideration to |
23 |
| the continuation of
benefits to enrollees and the financial |
24 |
| conditions of the acquired Health
Maintenance Organization |
25 |
| after the merger, consolidation, or other
acquisition of |
26 |
| control takes effect;
|
27 |
| (2)(i) the criteria specified in subsection (1)(b) of |
28 |
| Section 131.8 of
the Illinois Insurance Code shall not |
29 |
| apply and (ii) the Director, in making
his determination |
30 |
| with respect to the merger, consolidation, or other
|
31 |
| acquisition of control, need not take into account the |
32 |
| effect on
competition of the merger, consolidation, or |
33 |
| other acquisition of control;
|
34 |
| (3) the Director shall have the power to require the |
35 |
| following
information:
|
36 |
| (A) certification by an independent actuary of the |
|
|
|
HB0732 |
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LRB094 05496 LJB 35543 b |
|
|
1 |
| adequacy
of the reserves of the Health Maintenance |
2 |
| Organization sought to be acquired;
|
3 |
| (B) pro forma financial statements reflecting the |
4 |
| combined balance
sheets of the acquiring company and |
5 |
| the Health Maintenance Organization sought
to be |
6 |
| acquired as of the end of the preceding year and as of |
7 |
| a date 90 days
prior to the acquisition, as well as pro |
8 |
| forma financial statements
reflecting projected |
9 |
| combined operation for a period of 2 years;
|
10 |
| (C) a pro forma business plan detailing an |
11 |
| acquiring party's plans with
respect to the operation |
12 |
| of the Health Maintenance Organization sought to
be |
13 |
| acquired for a period of not less than 3 years; and
|
14 |
| (D) such other information as the Director shall |
15 |
| require.
|
16 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
17 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
18 |
| any health maintenance
organization of greater than 10% of its
|
19 |
| enrollee population (including without limitation the health |
20 |
| maintenance
organization's right, title, and interest in and to |
21 |
| its health care
certificates).
|
22 |
| (e) In considering any management contract or service |
23 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
24 |
| Code, the Director (i) shall, in
addition to the criteria |
25 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
26 |
| into account the effect of the management contract or
service |
27 |
| agreement on the continuation of benefits to enrollees and the
|
28 |
| financial condition of the health maintenance organization to |
29 |
| be managed or
serviced, and (ii) need not take into account the |
30 |
| effect of the management
contract or service agreement on |
31 |
| competition.
|
32 |
| (f) Except for small employer groups as defined in the |
33 |
| Small Employer
Rating, Renewability and Portability Health |
34 |
| Insurance Act and except for
medicare supplement policies as |
35 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
36 |
| Maintenance Organization may by contract agree with a
group or |
|
|
|
HB0732 |
- 18 - |
LRB094 05496 LJB 35543 b |
|
|
1 |
| other enrollment unit to effect refunds or charge additional |
2 |
| premiums
under the following terms and conditions:
|
3 |
| (i) the amount of, and other terms and conditions with |
4 |
| respect to, the
refund or additional premium are set forth |
5 |
| in the group or enrollment unit
contract agreed in advance |
6 |
| of the period for which a refund is to be paid or
|
7 |
| additional premium is to be charged (which period shall not |
8 |
| be less than one
year); and
|
9 |
| (ii) the amount of the refund or additional premium |
10 |
| shall not exceed 20%
of the Health Maintenance |
11 |
| Organization's profitable or unprofitable experience
with |
12 |
| respect to the group or other enrollment unit for the |
13 |
| period (and, for
purposes of a refund or additional |
14 |
| premium, the profitable or unprofitable
experience shall |
15 |
| be calculated taking into account a pro rata share of the
|
16 |
| Health Maintenance Organization's administrative and |
17 |
| marketing expenses, but
shall not include any refund to be |
18 |
| made or additional premium to be paid
pursuant to this |
19 |
| subsection (f)). The Health Maintenance Organization and |
20 |
| the
group or enrollment unit may agree that the profitable |
21 |
| or unprofitable
experience may be calculated taking into |
22 |
| account the refund period and the
immediately preceding 2 |
23 |
| plan years.
|
24 |
| The Health Maintenance Organization shall include a |
25 |
| statement in the
evidence of coverage issued to each enrollee |
26 |
| describing the possibility of a
refund or additional premium, |
27 |
| and upon request of any group or enrollment unit,
provide to |
28 |
| the group or enrollment unit a description of the method used |
29 |
| to
calculate (1) the Health Maintenance Organization's |
30 |
| profitable experience with
respect to the group or enrollment |
31 |
| unit and the resulting refund to the group
or enrollment unit |
32 |
| or (2) the Health Maintenance Organization's unprofitable
|
33 |
| experience with respect to the group or enrollment unit and the |
34 |
| resulting
additional premium to be paid by the group or |
35 |
| enrollment unit.
|
36 |
| In no event shall the Illinois Health Maintenance |
|
|
|
HB0732 |
- 19 - |
LRB094 05496 LJB 35543 b |
|
|
1 |
| Organization
Guaranty Association be liable to pay any |
2 |
| contractual obligation of an
insolvent organization to pay any |
3 |
| refund authorized under this Section.
|
4 |
| (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, |
5 |
| eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, |
6 |
| eff. 1-1-05; 93-1000, eff. 1-1-05; revised 10-14-04.)
|
7 |
| Section 40. The Voluntary Health Services Plans Act is |
8 |
| amended by changing Section 10 as follows:
|
9 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
|
10 |
| Sec. 10. Application of Insurance Code provisions. Health |
11 |
| services
plan corporations and all persons interested therein |
12 |
| or dealing therewith
shall be subject to the provisions of |
13 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
14 |
| 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, |
15 |
| 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01, |
16 |
| 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, |
17 |
| and paragraphs (7) and (15) of Section 367 of the Illinois
|
18 |
| Insurance Code.
|
19 |
| (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01; |
20 |
| 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; |
21 |
| 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; 93-1000, eff. |
22 |
| 1-1-05; revised 10-14-04.)
|
23 |
| Section 45. The Illinois Public Aid Code is amended by |
24 |
| changing Section 5-5 as follows: |
25 |
| (305 ILCS 5/5-5) (from Ch. 23, par. 5-5) |
26 |
| Sec. 5-5. Medical services. The Illinois Department, by |
27 |
| rule, shall
determine the quantity and quality of and the rate |
28 |
| of reimbursement for the
medical assistance for which
payment |
29 |
| will be authorized, and the medical services to be provided,
|
30 |
| which may include all or part of the following: (1) inpatient |
31 |
| hospital
services; (2) outpatient hospital services; (3) other |
32 |
| laboratory and
X-ray services; (4) skilled nursing home |
|
|
|
HB0732 |
- 20 - |
LRB094 05496 LJB 35543 b |
|
|
1 |
| services; (5) physicians'
services whether furnished in the |
2 |
| office, the patient's home, a
hospital, a skilled nursing home, |
3 |
| or elsewhere; (6) medical care, or any
other type of remedial |
4 |
| care furnished by licensed practitioners; (7)
home health care |
5 |
| services; (8) private duty nursing service; (9) clinic
|
6 |
| services; (10) dental services, including prevention and |
7 |
| treatment of periodontal disease and dental caries disease for |
8 |
| pregnant women; (11) physical therapy and related
services; |
9 |
| (12) prescribed drugs, dentures, and prosthetic devices; and
|
10 |
| eyeglasses prescribed by a physician skilled in the diseases of |
11 |
| the eye,
or by an optometrist, whichever the person may select; |
12 |
| (13) other
diagnostic, screening, preventive, and |
13 |
| rehabilitative services; (14)
transportation and such other |
14 |
| expenses as may be necessary; (15) medical
treatment of sexual |
15 |
| assault survivors, as defined in
Section 1a of the Sexual |
16 |
| Assault Survivors Emergency Treatment Act, for
injuries |
17 |
| sustained as a result of the sexual assault, including
|
18 |
| examinations and laboratory tests to discover evidence which |
19 |
| may be used in
criminal proceedings arising from the sexual |
20 |
| assault; (16) the
diagnosis and treatment of sickle cell |
21 |
| anemia; and (17)
any other medical care, and any other type of |
22 |
| remedial care recognized
under the laws of this State, but not |
23 |
| including abortions, or induced
miscarriages or premature |
24 |
| births, unless, in the opinion of a physician,
such procedures |
25 |
| are necessary for the preservation of the life of the
woman |
26 |
| seeking such treatment, or except an induced premature birth
|
27 |
| intended to produce a live viable child and such procedure is |
28 |
| necessary
for the health of the mother or her unborn child. The |
29 |
| Illinois Department,
by rule, shall prohibit any physician from |
30 |
| providing medical assistance
to anyone eligible therefor under |
31 |
| this Code where such physician has been
found guilty of |
32 |
| performing an abortion procedure in a wilful and wanton
manner |
33 |
| upon a woman who was not pregnant at the time such abortion
|
34 |
| procedure was performed. The term "any other type of remedial |
35 |
| care" shall
include nursing care and nursing home service for |
36 |
| persons who rely on
treatment by spiritual means alone through |
|
|
|
HB0732 |
- 21 - |
LRB094 05496 LJB 35543 b |
|
|
1 |
| prayer for healing.
|
2 |
| Notwithstanding any other provision of this Section, a |
3 |
| comprehensive
tobacco use cessation program that includes |
4 |
| purchasing prescription drugs or
prescription medical devices |
5 |
| approved by the Food and Drug administration shall
be covered |
6 |
| under the medical assistance
program under this Article for |
7 |
| persons who are otherwise eligible for
assistance under this |
8 |
| Article.
|
9 |
| For persons eligible for assistance under this Article, the |
10 |
| Illinois Department shall require coverage for services |
11 |
| rendered by a licensed athletic trainer in accordance with the |
12 |
| Illinois Athletic Trainers Practice Act if those services are |
13 |
| ordered by a physician licensed to practice medicine in all of |
14 |
| its branches.
|
15 |
| Notwithstanding any other provision of this Code, the |
16 |
| Illinois
Department may not require, as a condition of payment |
17 |
| for any laboratory
test authorized under this Article, that a |
18 |
| physician's handwritten signature
appear on the laboratory |
19 |
| test order form. The Illinois Department may,
however, impose |
20 |
| other appropriate requirements regarding laboratory test
order |
21 |
| documentation.
|
22 |
| The Illinois Department of Public Aid shall provide the |
23 |
| following services to
persons
eligible for assistance under |
24 |
| this Article who are participating in
education, training or |
25 |
| employment programs operated by the Department of Human
|
26 |
| Services as successor to the Department of Public Aid:
|
27 |
| (1) dental services, which shall include but not be |
28 |
| limited to
prosthodontics; and
|
29 |
| (2) eyeglasses prescribed by a physician skilled in the |
30 |
| diseases of the
eye, or by an optometrist, whichever the |
31 |
| person may select.
|
32 |
| The Illinois Department, by rule, may distinguish and |
33 |
| classify the
medical services to be provided only in accordance |
34 |
| with the classes of
persons designated in Section 5-2.
|
35 |
| The Illinois Department shall authorize the provision of, |
36 |
| and shall
authorize payment for, screening by low-dose |
|
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LRB094 05496 LJB 35543 b |
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1 |
| mammography for the presence of
occult breast cancer for women |
2 |
| 35 years of age or older who are eligible
for medical |
3 |
| assistance under this Article, as follows: a baseline
mammogram |
4 |
| for women 35 to 39 years of age and an
annual mammogram for |
5 |
| women 40 years of age or older. All screenings
shall
include a |
6 |
| physical breast exam, instruction on self-examination and
|
7 |
| information regarding the frequency of self-examination and |
8 |
| its value as a
preventative tool. As used in this Section, |
9 |
| "low-dose mammography" means
the x-ray examination of the |
10 |
| breast using equipment dedicated specifically
for mammography, |
11 |
| including the x-ray tube, filter, compression device,
image |
12 |
| receptor, and cassettes, with an average radiation exposure |
13 |
| delivery
of less than one rad mid-breast, with 2 views for each |
14 |
| breast.
|
15 |
| Any medical or health care provider shall immediately |
16 |
| recommend, to
any pregnant woman who is being provided prenatal |
17 |
| services and is suspected
of drug abuse or is addicted as |
18 |
| defined in the Alcoholism and Other Drug Abuse
and Dependency |
19 |
| Act, referral to a local substance abuse treatment provider
|
20 |
| licensed by the Department of Human Services or to a licensed
|
21 |
| hospital which provides substance abuse treatment services. |
22 |
| The Department of
Public Aid shall assure coverage for the cost |
23 |
| of treatment of the drug abuse or
addiction for pregnant |
24 |
| recipients in accordance with the Illinois Medicaid
Program in |
25 |
| conjunction with the Department of Human Services.
|
26 |
| All medical providers providing medical assistance to |
27 |
| pregnant women
under this Code shall receive information from |
28 |
| the Department on the
availability of services under the Drug |
29 |
| Free Families with a Future or any
comparable program providing |
30 |
| case management services for addicted women,
including |
31 |
| information on appropriate referrals for other social services
|
32 |
| that may be needed by addicted women in addition to treatment |
33 |
| for addiction.
|
34 |
| The Illinois Department, in cooperation with the |
35 |
| Departments of Human
Services (as successor to the Department |
36 |
| of Alcoholism and Substance
Abuse) and Public Health, through a |
|
|
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| public awareness campaign, may
provide information concerning |
2 |
| treatment for alcoholism and drug abuse and
addiction, prenatal |
3 |
| health care, and other pertinent programs directed at
reducing |
4 |
| the number of drug-affected infants born to recipients of |
5 |
| medical
assistance.
|
6 |
| Neither the Illinois Department of Public Aid nor the |
7 |
| Department of Human
Services shall sanction the recipient |
8 |
| solely on the basis of
her substance abuse.
|
9 |
| The Illinois Department shall establish such regulations |
10 |
| governing
the dispensing of health services under this Article |
11 |
| as it shall deem
appropriate. The Department
should
seek the |
12 |
| advice of formal professional advisory committees appointed by
|
13 |
| the Director of the Illinois Department for the purpose of |
14 |
| providing regular
advice on policy and administrative matters, |
15 |
| information dissemination and
educational activities for |
16 |
| medical and health care providers, and
consistency in |
17 |
| procedures to the Illinois Department.
|
18 |
| The Illinois Department may develop and contract with |
19 |
| Partnerships of
medical providers to arrange medical services |
20 |
| for persons eligible under
Section 5-2 of this Code. |
21 |
| Implementation of this Section may be by
demonstration projects |
22 |
| in certain geographic areas. The Partnership shall
be |
23 |
| represented by a sponsor organization. The Department, by rule, |
24 |
| shall
develop qualifications for sponsors of Partnerships. |
25 |
| Nothing in this
Section shall be construed to require that the |
26 |
| sponsor organization be a
medical organization.
|
27 |
| The sponsor must negotiate formal written contracts with |
28 |
| medical
providers for physician services, inpatient and |
29 |
| outpatient hospital care,
home health services, treatment for |
30 |
| alcoholism and substance abuse, and
other services determined |
31 |
| necessary by the Illinois Department by rule for
delivery by |
32 |
| Partnerships. Physician services must include prenatal and
|
33 |
| obstetrical care. The Illinois Department shall reimburse |
34 |
| medical services
delivered by Partnership providers to clients |
35 |
| in target areas according to
provisions of this Article and the |
36 |
| Illinois Health Finance Reform Act,
except that:
|
|
|
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| (1) Physicians participating in a Partnership and |
2 |
| providing certain
services, which shall be determined by |
3 |
| the Illinois Department, to persons
in areas covered by the |
4 |
| Partnership may receive an additional surcharge
for such |
5 |
| services.
|
6 |
| (2) The Department may elect to consider and negotiate |
7 |
| financial
incentives to encourage the development of |
8 |
| Partnerships and the efficient
delivery of medical care.
|
9 |
| (3) Persons receiving medical services through |
10 |
| Partnerships may receive
medical and case management |
11 |
| services above the level usually offered
through the |
12 |
| medical assistance program.
|
13 |
| Medical providers shall be required to meet certain |
14 |
| qualifications to
participate in Partnerships to ensure the |
15 |
| delivery of high quality medical
services. These |
16 |
| qualifications shall be determined by rule of the Illinois
|
17 |
| Department and may be higher than qualifications for |
18 |
| participation in the
medical assistance program. Partnership |
19 |
| sponsors may prescribe reasonable
additional qualifications |
20 |
| for participation by medical providers, only with
the prior |
21 |
| written approval of the Illinois Department.
|
22 |
| Nothing in this Section shall limit the free choice of |
23 |
| practitioners,
hospitals, and other providers of medical |
24 |
| services by clients.
In order to ensure patient freedom of |
25 |
| choice, the Illinois Department shall
immediately promulgate |
26 |
| all rules and take all other necessary actions so that
provided |
27 |
| services may be accessed from therapeutically certified |
28 |
| optometrists
to the full extent of the Illinois Optometric |
29 |
| Practice Act of 1987 without
discriminating between service |
30 |
| providers.
|
31 |
| The Department shall apply for a waiver from the United |
32 |
| States Health
Care Financing Administration to allow for the |
33 |
| implementation of
Partnerships under this Section.
|
34 |
| The Illinois Department shall require health care |
35 |
| providers to maintain
records that document the medical care |
36 |
| and services provided to recipients
of Medical Assistance under |
|
|
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LRB094 05496 LJB 35543 b |
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| this Article. The Illinois Department shall
require health care |
2 |
| providers to make available, when authorized by the
patient, in |
3 |
| writing, the medical records in a timely fashion to other
|
4 |
| health care providers who are treating or serving persons |
5 |
| eligible for
Medical Assistance under this Article. All |
6 |
| dispensers of medical services
shall be required to maintain |
7 |
| and retain business and professional records
sufficient to |
8 |
| fully and accurately document the nature, scope, details and
|
9 |
| receipt of the health care provided to persons eligible for |
10 |
| medical
assistance under this Code, in accordance with |
11 |
| regulations promulgated by
the Illinois Department. The rules |
12 |
| and regulations shall require that proof
of the receipt of |
13 |
| prescription drugs, dentures, prosthetic devices and
|
14 |
| eyeglasses by eligible persons under this Section accompany |
15 |
| each claim
for reimbursement submitted by the dispenser of such |
16 |
| medical services.
No such claims for reimbursement shall be |
17 |
| approved for payment by the Illinois
Department without such |
18 |
| proof of receipt, unless the Illinois Department
shall have put |
19 |
| into effect and shall be operating a system of post-payment
|
20 |
| audit and review which shall, on a sampling basis, be deemed |
21 |
| adequate by
the Illinois Department to assure that such drugs, |
22 |
| dentures, prosthetic
devices and eyeglasses for which payment |
23 |
| is being made are actually being
received by eligible |
24 |
| recipients. Within 90 days after the effective date of
this |
25 |
| amendatory Act of 1984, the Illinois Department shall establish |
26 |
| a
current list of acquisition costs for all prosthetic devices |
27 |
| and any
other items recognized as medical equipment and |
28 |
| supplies reimbursable under
this Article and shall update such |
29 |
| list on a quarterly basis, except that
the acquisition costs of |
30 |
| all prescription drugs shall be updated no
less frequently than |
31 |
| every 30 days as required by Section 5-5.12.
|
32 |
| The rules and regulations of the Illinois Department shall |
33 |
| require
that a written statement including the required opinion |
34 |
| of a physician
shall accompany any claim for reimbursement for |
35 |
| abortions, or induced
miscarriages or premature births. This |
36 |
| statement shall indicate what
procedures were used in providing |
|
|
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HB0732 |
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LRB094 05496 LJB 35543 b |
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| such medical services.
|
2 |
| The Illinois Department shall require all dispensers of |
3 |
| medical
services, other than an individual practitioner or |
4 |
| group of practitioners,
desiring to participate in the Medical |
5 |
| Assistance program
established under this Article to disclose |
6 |
| all financial, beneficial,
ownership, equity, surety or other |
7 |
| interests in any and all firms,
corporations, partnerships, |
8 |
| associations, business enterprises, joint
ventures, agencies, |
9 |
| institutions or other legal entities providing any
form of |
10 |
| health care services in this State under this Article.
|
11 |
| The Illinois Department may require that all dispensers of |
12 |
| medical
services desiring to participate in the medical |
13 |
| assistance program
established under this Article disclose, |
14 |
| under such terms and conditions as
the Illinois Department may |
15 |
| by rule establish, all inquiries from clients
and attorneys |
16 |
| regarding medical bills paid by the Illinois Department, which
|
17 |
| inquiries could indicate potential existence of claims or liens |
18 |
| for the
Illinois Department.
|
19 |
| Enrollment of a vendor that provides non-emergency medical |
20 |
| transportation,
defined by the Department by rule,
shall be
|
21 |
| conditional for 180 days. During that time, the Department of |
22 |
| Public Aid may
terminate the vendor's eligibility to |
23 |
| participate in the medical assistance
program without cause. |
24 |
| That termination of eligibility is not subject to the
|
25 |
| Department's hearing process.
|
26 |
| The Illinois Department shall establish policies, |
27 |
| procedures,
standards and criteria by rule for the acquisition, |
28 |
| repair and replacement
of orthotic and prosthetic devices and |
29 |
| durable medical equipment. Such
rules shall provide, but not be |
30 |
| limited to, the following services: (1)
immediate repair or |
31 |
| replacement of such devices by recipients without
medical |
32 |
| authorization; and (2) rental, lease, purchase or |
33 |
| lease-purchase of
durable medical equipment in a |
34 |
| cost-effective manner, taking into
consideration the |
35 |
| recipient's medical prognosis, the extent of the
recipient's |
36 |
| needs, and the requirements and costs for maintaining such
|
|
|
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HB0732 |
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LRB094 05496 LJB 35543 b |
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|
1 |
| equipment. Such rules shall enable a recipient to temporarily |
2 |
| acquire and
use alternative or substitute devices or equipment |
3 |
| pending repairs or
replacements of any device or equipment |
4 |
| previously authorized for such
recipient by the Department.
|
5 |
| The Department shall execute, relative to the nursing home |
6 |
| prescreening
project, written inter-agency agreements with the |
7 |
| Department of Human
Services and the Department on Aging, to |
8 |
| effect the following: (i) intake
procedures and common |
9 |
| eligibility criteria for those persons who are receiving
|
10 |
| non-institutional services; and (ii) the establishment and |
11 |
| development of
non-institutional services in areas of the State |
12 |
| where they are not currently
available or are undeveloped.
|
13 |
| The Illinois Department shall develop and operate, in |
14 |
| cooperation
with other State Departments and agencies and in |
15 |
| compliance with
applicable federal laws and regulations, |
16 |
| appropriate and effective
systems of health care evaluation and |
17 |
| programs for monitoring of
utilization of health care services |
18 |
| and facilities, as it affects
persons eligible for medical |
19 |
| assistance under this Code.
|
20 |
| The Illinois Department shall report annually to the |
21 |
| General Assembly,
no later than the second Friday in April of |
22 |
| 1979 and each year
thereafter, in regard to:
|
23 |
| (a) actual statistics and trends in utilization of |
24 |
| medical services by
public aid recipients;
|
25 |
| (b) actual statistics and trends in the provision of |
26 |
| the various medical
services by medical vendors;
|
27 |
| (c) current rate structures and proposed changes in |
28 |
| those rate structures
for the various medical vendors; and
|
29 |
| (d) efforts at utilization review and control by the |
30 |
| Illinois Department.
|
31 |
| The period covered by each report shall be the 3 years |
32 |
| ending on the June
30 prior to the report. The report shall |
33 |
| include suggested legislation
for consideration by the General |
34 |
| Assembly. The filing of one copy of the
report with the |
35 |
| Speaker, one copy with the Minority Leader and one copy
with |
36 |
| the Clerk of the House of Representatives, one copy with the |
|
|
|
HB0732 |
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LRB094 05496 LJB 35543 b |
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|
1 |
| President,
one copy with the Minority Leader and one copy with |
2 |
| the Secretary of the
Senate, one copy with the Legislative |
3 |
| Research Unit, and such additional
copies
with the State |
4 |
| Government Report Distribution Center for the General
Assembly |
5 |
| as is required under paragraph (t) of Section 7 of the State
|
6 |
| Library Act shall be deemed sufficient to comply with this |
7 |
| Section.
|
8 |
| (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02; |
9 |
| 92-789, eff. 8-6-02; 93-632, eff. 2-1-04; 93-841, eff. 7-30-04; |
10 |
| 93-981, eff. 8-23-04; revised 10-22-04.)
|