Sen. James A. DeLeo
Filed: 7/10/2008
 
 

 




 

 		












09500HB0415sam001

LRB095 04041 RPM 52058 a






1

AMENDMENT TO HOUSE BILL 415




2
    AMENDMENT NO. ______. Amend House Bill 415 by replacing 
3
everything after the enacting clause with the following:



 
4
    "Section 5. The State Employees Group Insurance Act of 1971 
5
is amended  by changing Section 6.11 as follows:
 


6
    (5 ILCS 375/6.11)


7
    Sec. 6.11. Required health benefits; Illinois Insurance 
8
Code
requirements.  The program of health
benefits shall provide 
9
the post-mastectomy care benefits required to be covered
by a 
10
policy of accident and health insurance under Section 356t of 
11
the Illinois
Insurance Code.  The program of health benefits 
12
shall provide the coverage
required under Sections 356g.5,

13
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, 
14
and 356z.11
356z.9 of the
Illinois Insurance Code.
The program 
15
of health benefits must comply with Section 155.37 of the

16
Illinois Insurance Code.

 


 






09500HB0415sam001
- 2 -
LRB095 04041 RPM 52058 a




1
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
2
95-520, eff. 8-28-07; revised 12-4-07.)



 
3
    Section 10. The Counties Code is amended  by changing 
4
Section 5-1069.3 as follows:
 
5
    (55 ILCS 5/5-1069.3)

6
    Sec. 5-1069.3. Required health benefits.   If a county, 
7
including a home
rule
county, is a self-insurer for purposes of 
8
providing health insurance coverage
for its employees, the 
9
coverage shall include coverage for the post-mastectomy
care 
10
benefits required to be covered by a policy of accident and 
11
health
insurance under Section 356t and the coverage required 
12
under Sections 356g.5, 356u,
356w, 356x, 356z.6, and 356z.9, 
13
356z.10, and
356z.11 356z.9 of
the Illinois Insurance Code.  The 
14
requirement that health benefits be covered
as provided in this 
15
Section is an
exclusive power and function of the State and is 
16
a denial and limitation under
Article VII, Section 6, 
17
subsection (h) of the Illinois Constitution.  A home
rule county 
18
to which this Section applies must comply with every provision 
19
of
this Section.


20
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
21
95-520, eff. 8-28-07; revised 12-4-07.)


 
22
    Section 15. The Illinois Municipal Code is amended  by 
23
changing Section 10-4-2.3 as follows:
 
 


 






09500HB0415sam001
- 3 -
LRB095 04041 RPM 52058 a




1
    (65 ILCS 5/10-4-2.3)

2
    Sec. 10-4-2.3. Required health benefits.   If a 
3
municipality, including a
home rule municipality, is a 
4
self-insurer for purposes of providing health
insurance 
5
coverage for its employees, the coverage shall include coverage 
6
for
the post-mastectomy care benefits required to be covered by 
7
a policy of
accident and health insurance under Section 356t 
8
and the coverage required
under Sections 356g.5, 356u, 356w, 
9
356x, 356z.6, and 356z.9, 356z.10, and  356z.11
356z.9 of the 
10
Illinois
Insurance
Code.  The requirement that health
benefits 
11
be covered as provided in this is an exclusive power and 
12
function of
the State and is a denial and limitation under 
13
Article VII, Section 6,
subsection (h) of the Illinois 
14
Constitution.  A home rule municipality to which
this Section 
15
applies must comply with every provision of this Section.


16
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
17
95-520, eff. 8-28-07; revised 12-4-07.)


 
18
    Section 20. The School Code is amended  by changing Section 
19
10-22.3f as follows:
 
20
    (105 ILCS 5/10-22.3f)

21
    Sec. 10-22.3f. Required health benefits.   Insurance 
22
protection and
benefits
for employees shall provide the 
23
post-mastectomy care benefits required to be
covered by a 
 


 






09500HB0415sam001
- 4 -
LRB095 04041 RPM 52058 a




1
policy of accident and health insurance under Section 356t and 
2
the
coverage required under Sections 356g.5, 356u, 356w, 356x,


3
356z.6, and 356z.9, and 356z.11 of
the
Illinois Insurance Code.


4
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
5
revised 12-4-07.)


 
6
    Section 25. The Illinois Insurance Code is amended  by 
7
adding Section 356z.11 as follows:
 
8
    (215 ILCS 5/356z.11 new)

9
    Sec. 356z.11. Autism spectrum disorders.
10
    (a)  A group or individual policy of accident and health 
11
insurance or managed care plan amended, delivered, issued, or 
12
renewed after the effective date of this amendatory Act of the 
13
95th General Assembly must provide individuals under 21 years 
14
of age coverage for the diagnosis of autism spectrum disorders 
15
and for the treatment of autism spectrum disorders to the 
16
extent that the diagnosis and treatment of autism spectrum 
17
disorders are not already covered by the policy of accident and 
18
health insurance or managed care plan.
19
    (b) Coverage provided under this Section shall be subject 
20
to a maximum benefit of $36,000 per year, but shall not be 
21
subject to any limits on the number of visits to a service 
22
provider. After December 30, 2009, the Director of the Division 
23
of Insurance shall, on an annual basis, adjust the maximum 
24
benefit for inflation using the Medical Care Component of the 
 


 






09500HB0415sam001
- 5 -
LRB095 04041 RPM 52058 a




1
United States Department of Labor Consumer Price Index for All 
2
Urban Consumers.  Payments made by an insurer on behalf of a 
3
covered individual for any care, treatment, intervention, 
4
service, or item, the provision of which was for the treatment 
5
of a health condition not diagnosed as an autism spectrum 
6
disorder, shall not be applied toward any maximum benefit 
7
established under this subsection.
8
    (c) Coverage under this Section shall be subject to 
9
co-payment, deductible, and coinsurance provisions of a policy 
10
of accident and health insurance or managed care plan to the 
11
extent that other medical services covered by the policy of 
12
accident and health insurance or managed care plan are subject 
13
to these provisions.
14
    (d)  This Section shall not be construed as limiting 
15
benefits that are otherwise available to an individual under a 
16
policy of accident and health insurance or managed care plan 
17
and benefits provided under this Section may not be subject to 
18
dollar limits, deductibles, copayments, or coinsurance 
19
provisions that are less favorable to the insured than the 
20
dollar limits, deductibles, or coinsurance provisions that 
21
apply to physical illness generally.
22
    (e) An insurer may not deny or refuse to provide otherwise 
23
covered services, or refuse to renew, refuse to reissue, or 
24
otherwise terminate or restrict coverage under an individual 
25
contract to provide services to an individual because the 
26
individual or their dependent is diagnosed with an autism 
 


 






09500HB0415sam001
- 6 -
LRB095 04041 RPM 52058 a




1
spectrum disorder or due to the individual utilizing benefits 
2
in this Section.
3
    (f) Upon request of the reimbursing insurer, a provider of 
4
treatment for autism spectrum disorders shall furnish medical 
5
records, clinical notes, or other necessary data that 
6
substantiate that initial or continued medical treatment is 
7
medically necessary and is resulting in improved clinical 
8
status.  When treatment is anticipated to require continued 
9
services to achieve demonstrable progress, the insurer may 
10
request a treatment plan consisting of diagnosis, proposed 
11
treatment by type, frequency, anticipated duration of 
12
treatment, the anticipated outcomes stated as goals, and the 
13
frequency by which the treatment plan will be updated. 
14
    (g) When making a determination of medical necessity for a 
15
treatment modality for autism spectrum disorders, an insurer 
16
must make the determination in a manner that is consistent with 
17
the manner used to make that determination with respect to 
18
other diseases or illnesses covered under the policy, including 
19
an appeals process.  During the appeals process, any challenge 
20
to medical necessity must be viewed as reasonable only if the 
21
review includes a physician with expertise in the most current 
22
and effective treatment modalities for autism spectrum 
23
disorders.
24
    (h) Coverage for medically necessary early intervention 
25
services must be delivered by certified early intervention 
26
specialists, as defined in the early intervention operational 
 


 






09500HB0415sam001
- 7 -
LRB095 04041 RPM 52058 a




1
standards by the Department of Human Services and in accordance 
2
with applicable certification requirements. 
3
    (i)  As used in this Section:
4
    "Autism spectrum disorders" means pervasive developmental 
5
disorders as defined in the most recent edition of the 
6
Diagnostic and Statistical Manual of Mental Disorders, 
7
including autism, Asperger's disorder, and pervasive 
8
developmental disorder not otherwise specified.
9
    "Diagnosis of autism spectrum disorders" means a diagnosis 
10
of an individual with an autism spectrum disorder by (A) a 
11
physician licensed to practice medicine in all its branches or 
12
(B) a licensed clinical psychologist with expertise in 
13
diagnosing autism spectrum disorders.
14
    "Medically necessary" means any care, treatment, 
15
intervention, service or item which will or is reasonably 
16
expected to do any of the following: (i) prevent the onset of 
17
an illness, condition, injury, disease or disability; (ii) 
18
reduce or ameliorate the physical, mental or developmental 
19
effects of an illness, condition, injury, disease or 
20
disability; or (iii) assist to achieve or maintain maximum 
21
functional activity in performing daily activities. 
22
    "Treatment for autism spectrum disorders" shall include 
23
the following care prescribed, provided, or ordered for an 
24
individual diagnosed with an autism spectrum disorder by (A) a 
25
physician licensed to practice medicine in all its branches or 
26
(B) a certified, registered, or licensed health care 
 


 






09500HB0415sam001
- 8 -
LRB095 04041 RPM 52058 a




1
professional with expertise in treating effects of autism 
2
spectrum disorders when the care is determined to be medically 
3
necessary and ordered by a physician licensed to practice 
4
medicine in all its branches:
5
        (1)  Psychiatric care, including diagnostic services.
6
        (2) Psychological assessments and treatments.
7
        (3)  Rehabilitative treatments.
8
        (4)  Therapeutic care, including behavioral speech, 
9
    occupational, and physical therapies that provide 
10
    treatment in the following areas: (i) self care and 
11
    feeding, (ii) pragmatic, receptive, and expressive 
12
    language, (iii) cognitive functioning, (iv) applied 
13
    behavior analysis, intervention, and modification, (v) 
14
    motor planning, and (vi) sensory processing.


 
15
    Section 30. The Health Maintenance Organization Act is 
16
amended  by changing Section 5-3 as follows:
 


17
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)


18
    Sec. 5-3. Insurance Code provisions. 

19
    (a) Health Maintenance Organizations
shall be subject to 
20
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
21
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
22
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
23
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10

24
356z.9, 356z.11, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 
 


 






09500HB0415sam001
- 9 -
LRB095 04041 RPM 52058 a




1
368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 
2
409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of 
3
Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, 
4
XIII 1/2, XXV, and XXVI of the Illinois 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;


 


 






09500HB0415sam001
- 10 -
LRB095 04041 RPM 52058 a




1
        (2)(i) the criteria specified in subsection (1)(b) of 
2
    Section 131.8 of
the Illinois Insurance Code shall not 
3
    apply and (ii) the Director, in making
his determination 
4
    with respect to the merger, consolidation, or other

5
    acquisition of control, need not take into account the 
6
    effect on
competition of the merger, consolidation, or 
7
    other acquisition of control;


8
        (3) the Director shall have the power to require the 
9
    following
information:


10
            (A) certification by an independent actuary of the 
11
        adequacy
of the reserves of the Health Maintenance 
12
        Organization sought to be acquired;


13
            (B) pro forma financial statements reflecting the 
14
        combined balance
sheets of the acquiring company and 
15
        the Health Maintenance Organization sought
to be 
16
        acquired as of the end of the preceding year and as of 
17
        a date 90 days
prior to the acquisition, as well as pro 
18
        forma financial statements
reflecting projected 
19
        combined operation for a period of 2 years;


20
            (C) a pro forma business plan detailing an 
21
        acquiring party's plans with
respect to the operation 
22
        of the Health Maintenance Organization sought to
be 
23
        acquired for a period of not less than 3 years; and


24
            (D) such other information as the Director shall 
25
        require.

26
    (d) The provisions of Article VIII 1/2 of the Illinois 
 


 






09500HB0415sam001
- 11 -
LRB095 04041 RPM 52058 a




1
Insurance Code
and this Section 5-3 shall apply to the sale by 
2
any health maintenance
organization of greater than 10% of its

3
enrollee population (including without limitation the health 
4
maintenance
organization's right, title, and interest in and to 
5
its health care
certificates).

6
    (e) In considering any management contract or service 
7
agreement subject
to Section 141.1 of the Illinois Insurance 
8
Code, the Director (i) shall, in
addition to the criteria 
9
specified in Section 141.2 of the Illinois
Insurance Code, take 
10
into account the effect of the management contract or
service 
11
agreement on the continuation of benefits to enrollees and the

12
financial condition of the health maintenance organization to 
13
be managed or
serviced, and (ii) need not take into account the 
14
effect of the management
contract or service agreement on 
15
competition.

16
    (f) Except for small employer groups as defined in the 
17
Small Employer
Rating, Renewability and Portability Health 
18
Insurance Act and except for
medicare supplement policies as 
19
defined in Section 363 of the Illinois
Insurance Code, a Health 
20
Maintenance Organization may by contract agree with a
group or 
21
other enrollment unit to effect refunds or charge additional 
22
premiums
under the following terms and conditions:


23
        (i) the amount of, and other terms and conditions with 
24
    respect to, the
refund or additional premium are set forth 
25
    in the group or enrollment unit
contract agreed in advance 
26
    of the period for which a refund is to be paid or

 


 






09500HB0415sam001
- 12 -
LRB095 04041 RPM 52058 a




1
    additional premium is to be charged (which period shall not 
2
    be less than one
year); and


3
        (ii) the amount of the refund or additional premium 
4
    shall not exceed 20%
of the Health Maintenance 
5
    Organization's profitable or unprofitable experience
with 
6
    respect to the group or other enrollment unit for the 
7
    period (and, for
purposes of a refund or additional 
8
    premium, the profitable or unprofitable
experience shall 
9
    be calculated taking into account a pro rata share of the

10
    Health Maintenance Organization's administrative and 
11
    marketing expenses, but
shall not include any refund to be 
12
    made or additional premium to be paid
pursuant to this 
13
    subsection (f)).  The Health Maintenance Organization and 
14
    the
group or enrollment unit may agree that the profitable 
15
    or unprofitable
experience may be calculated taking into 
16
    account the refund period and the
immediately preceding 2 
17
    plan years.

18
    The Health Maintenance Organization shall include a 
19
statement in the
evidence of coverage issued to each enrollee 
20
describing the possibility of a
refund or additional premium, 
21
and upon request of any group or enrollment unit,
provide to 
22
the group or enrollment unit a description of the method used 
23
to
calculate (1) the Health Maintenance Organization's 
24
profitable experience with
respect to the group or enrollment 
25
unit and the resulting refund to the group
or enrollment unit 
26
or (2) the Health Maintenance Organization's unprofitable

 


 






09500HB0415sam001
- 13 -
LRB095 04041 RPM 52058 a




1
experience with respect to the group or enrollment unit and the 
2
resulting
additional premium to be paid by the group or 
3
enrollment unit.

4
    In no event shall the Illinois Health Maintenance 
5
Organization
Guaranty Association be liable to pay any 
6
contractual obligation of an
insolvent organization to pay any 
7
refund authorized under this Section.

8
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; 
9
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)



 
10
    Section 35. The Voluntary Health Services Plans Act is 
11
amended  by changing Section 10 as follows:
 



12
    (215 ILCS 165/10)  (from Ch. 32, par. 604)


13
    Sec. 10. Application of Insurance Code provisions. Health 
14
services
plan corporations and all persons interested therein 
15
or dealing therewith
shall be subject to the provisions of 
16
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
17
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, 
18
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 
19
356z.9,
356z.10
356z.9, 356z.11, 364.01, 367.2, 368a, 401, 
20
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) 
21
and (15) of Section 367 of the Illinois
Insurance Code.

22
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; 
23
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. 
24
8-28-07; revised 12-5-07.)



 

 


 






09500HB0415sam001
- 14 -
LRB095 04041 RPM 52058 a




1
    Section 99. Effective date. This Act takes effect upon 
2
becoming law.".