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Rep. Mary E. Flowers
Filed: 3/22/2010
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| AMENDMENT TO HOUSE BILL 6417
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| AMENDMENT NO. ______. Amend House Bill 6417 by replacing |
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| everything after the enacting clause with the following:
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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 356g, |
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| 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
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| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and |
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| 356z.13, and 356z.14, 356z.15 and 356z.14 , and 356z.17, 356z.15 |
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| 356z.19, 356z.20, and 356z.21 of the
Illinois Insurance Code.
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| The program of health benefits must comply with Section 155.37 |
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| of the
Illinois Insurance Code.
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, |
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| eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
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| 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; |
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| revised 10-22-09.)
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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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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
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| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and |
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| 356z.13, and 356z.14, and 356z.15, 356z.14 356z.19, 356z.20, |
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| and 356z.21 of
the Illinois Insurance Code. The requirement |
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| that health benefits be covered
as provided in this Section is |
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| 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 county to which this |
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| Section applies must comply with every provision of
this |
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| Section.
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
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| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
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| 96-328, eff. 8-11-09; revised 10-22-09.)
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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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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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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 356g, 356g.5, |
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| 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
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| 356z.11, 356z.12, and 356z.13, and 356z.14, and 356z.15, |
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| 356z.14 356z.19, 356z.20, and 356z.21 of the Illinois
Insurance
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| Code. The requirement that health
benefits be covered as |
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| provided in this is an exclusive power and function of
the |
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| State and is a denial and limitation under Article VII, Section |
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| 6,
subsection (h) of the Illinois Constitution. A home rule |
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| municipality to which
this Section applies must comply with |
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| every provision of this Section.
|
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
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| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
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| 96-328, eff. 8-11-09; revised 10-23-09.)
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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 356g, 356g.5, 356g.5-1, |
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| 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
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| 356z.13, and 356z.14, and 356z.15, 356z.14 356z.19, and 356z.20 |
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| of
the
Illinois Insurance Code.
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
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| 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; revised |
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| 10-23-09.)
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| Section 25. The Emergency Medical Treatment Act is amended |
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| by changing Section 1 as follows:
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| (210 ILCS 70/1) (from Ch. 111 1/2, par. 6151)
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| Sec. 1.
No hospital, physician, dentist or other provider |
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| of professional
health care licensed under the laws of this |
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| State may refuse to provide
needed emergency treatment to any |
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| person whose life would be threatened
in the absence of such |
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| treatment, because of that person's inability to
pay therefor, |
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| nor because of the source of any payment promised therefor. |
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| Every hospital licensed under the Hospital Licensing Act shall |
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| comply with the Hospital Emergency Service Act.
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| (Source: P.A. 83-723.)
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| Section 30. The Hospital Emergency Service Act is amended |
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| by changing Section 1 as follows:
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| (210 ILCS 80/1) (from Ch. 111 1/2, par. 86)
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| Sec. 1.
Every hospital required to be licensed by the |
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| Department of Public
Health pursuant to the Hospital Licensing |
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| Act which provides general medical
and surgical
hospital |
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| services shall provide a hospital emergency service in |
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| accordance
with rules and regulations adopted by the Department |
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| of Public Health which shall be consistent with the federal |
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| Emergency Medical Treatment and Active Labor Act (42 U.S.C. |
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| 1395dd) and
shall furnish such hospital emergency services to |
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| any applicant who applies
for the same in case of injury or |
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| acute medical condition where the same is
liable to cause death |
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| or severe injury or serious illness.
For purposes of this Act, |
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| "applicant" includes any person who is brought
to a hospital by |
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| ambulance or specialized emergency medical services
vehicle as |
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| defined in the Emergency Medical Services (EMS) Systems Act.
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| (Source: P.A. 86-1461.)
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| Section 35. The Illinois Insurance Code is amended by |
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| adding Sections
356z.19, 356z.20, and
356z.21
as
follows:
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| (215 ILCS 5/356z.19 new)
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| Sec. 356z.19. Intravenous feeding. 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 96th General
Assembly must |
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| provide coverage for intravenous feeding. The benefits under
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| this Section shall be at least as favorable as for other |
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| coverages under the
policy and may be subject to the same |
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| dollar amount limits, deductibles, and
co-insurance |
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| requirements applicable generally to other coverages under the
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| policy. |
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| (215 ILCS 5/356z.20 new)
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| Sec. 356z.20. Prescription nutritional supplements. A |
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| group or individual
policy of
accident and health insurance or |
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| managed care plan amended, delivered, issued,
or renewed
after |
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| the effective date of this amendatory Act of the 96th General |
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| Assembly
that provides
coverage for prescription drugs must |
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| provide coverage for reimbursement for
medically
appropriate |
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| prescription nutritional supplements when ordered by a |
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| physician
licensed to
practice medicine in all its branches and |
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| the insured suffers from a condition
that prevents
him or her |
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| from taking sufficient oral nourishment to sustain life. |
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| (215 ILCS 5/356z.21 new) |
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| Sec. 356z.21. Hospital patient assessments. A group or |
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| individual policy of accident and health insurance or managed |
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| care plan amended, delivered, issued, or renewed after the |
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| effective date of this amendatory Act of the 96th General |
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| Assembly that provides coverage for hospital care shall include |
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| in that coverage all services ordered by a physician and |
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| provided in the hospital that are considered medically |
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| necessary for the evaluation, assessment, and diagnosis of the |
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| illness or condition that resulted in the hospital stay of the |
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| enrollee or recipient. Such services are subject to reasonable |
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| review and utilization standards required by the policy or plan |
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| for all hospital services, as defined by the Department of |
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| Insurance or its successor agency.
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| Section 40. The Health Maintenance Organization Act is |
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| amended by changing
Section 5-3 as follows:
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| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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| (Text of Section before amendment by P.A. 96-833 ) |
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| Sec. 5-3. Insurance Code provisions.
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| (a) Health Maintenance Organizations
shall be subject to |
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| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
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| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
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| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
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| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
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| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14 , |
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| 356z.17 356z.15 , 356z.19, 356z.20, 364.01, 367.2, 367.2-5, |
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| 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, |
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| 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of |
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| subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
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| XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois |
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| Insurance Code.
|
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| (b) For purposes of the Illinois Insurance Code, except for |
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| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
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| Maintenance Organizations in
the following categories are |
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| deemed to be "domestic companies":
|
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| (1) a corporation authorized under the
Dental Service |
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| Plan Act or the Voluntary Health Services Plans Act;
|
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| (2) a corporation organized under the laws of this |
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| State; or
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| (3) a corporation organized under the laws of another |
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| state, 30% or more
of the enrollees of which are residents |
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| of this State, except a
corporation subject to |
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| substantially the same requirements in its state of
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| organization as is a "domestic company" under Article VIII |
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| 1/2 of the
Illinois Insurance Code.
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| (c) In considering the merger, consolidation, or other |
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| acquisition of
control of a Health Maintenance Organization |
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| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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| (1) the Director shall give primary consideration to |
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| the continuation of
benefits to enrollees and the financial |
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| conditions of the acquired Health
Maintenance Organization |
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| after the merger, consolidation, or other
acquisition of |
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| control takes effect;
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| (2)(i) the criteria specified in subsection (1)(b) of |
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| Section 131.8 of
the Illinois Insurance Code shall not |
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| apply and (ii) the Director, in making
his determination |
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| with respect to the merger, consolidation, or other
|
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| acquisition of control, need not take into account the |
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| effect on
competition of the merger, consolidation, or |
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| other acquisition of control;
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| (3) the Director shall have the power to require the |
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| following
information:
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| (A) certification by an independent actuary of the |
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| adequacy
of the reserves of the Health Maintenance |
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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| Organization sought to be acquired;
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| (B) pro forma financial statements reflecting the |
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| combined balance
sheets of the acquiring company and |
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| the Health Maintenance Organization sought
to be |
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| acquired as of the end of the preceding year and as of |
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| a date 90 days
prior to the acquisition, as well as pro |
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| forma financial statements
reflecting projected |
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| combined operation for a period of 2 years;
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| (C) a pro forma business plan detailing an |
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| acquiring party's plans with
respect to the operation |
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| of the Health Maintenance Organization sought to
be |
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| acquired for a period of not less than 3 years; and
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| (D) such other information as the Director shall |
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| require.
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| (d) The provisions of Article VIII 1/2 of the Illinois |
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| Insurance Code
and this Section 5-3 shall apply to the sale by |
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| any health maintenance
organization of greater than 10% of its
|
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| enrollee population (including without limitation the health |
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| maintenance
organization's right, title, and interest in and to |
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| its health care
certificates).
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| (e) In considering any management contract or service |
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| agreement subject
to Section 141.1 of the Illinois Insurance |
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| Code, the Director (i) shall, in
addition to the criteria |
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| specified in Section 141.2 of the Illinois
Insurance Code, take |
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| into account the effect of the management contract or
service |
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| agreement on the continuation of benefits to enrollees and the
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09600HB6417ham001 |
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| financial condition of the health maintenance organization to |
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| be managed or
serviced, and (ii) need not take into account the |
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| effect of the management
contract or service agreement on |
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| competition.
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| (f) Except for small employer groups as defined in the |
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| Small Employer
Rating, Renewability and Portability Health |
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| Insurance Act and except for
medicare supplement policies as |
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| defined in Section 363 of the Illinois
Insurance Code, a Health |
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| Maintenance Organization may by contract agree with a
group or |
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| other enrollment unit to effect refunds or charge additional |
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| premiums
under the following terms and conditions:
|
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| (i) the amount of, and other terms and conditions with |
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| respect to, the
refund or additional premium are set forth |
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| in the group or enrollment unit
contract agreed in advance |
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| of the period for which a refund is to be paid or
|
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| additional premium is to be charged (which period shall not |
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| be less than one
year); and
|
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| (ii) the amount of the refund or additional premium |
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| shall not exceed 20%
of the Health Maintenance |
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| Organization's profitable or unprofitable experience
with |
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| respect to the group or other enrollment unit for the |
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| period (and, for
purposes of a refund or additional |
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| premium, the profitable or unprofitable
experience shall |
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| be calculated taking into account a pro rata share of the
|
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| Health Maintenance Organization's administrative and |
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| marketing expenses, but
shall not include any refund to be |
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| made or additional premium to be paid
pursuant to this |
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| subsection (f)). The Health Maintenance Organization and |
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| the
group or enrollment unit may agree that the profitable |
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| or unprofitable
experience may be calculated taking into |
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| account the refund period and the
immediately preceding 2 |
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| plan years.
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| The Health Maintenance Organization shall include a |
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| statement in the
evidence of coverage issued to each enrollee |
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| describing the possibility of a
refund or additional premium, |
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| and upon request of any group or enrollment unit,
provide to |
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| the group or enrollment unit a description of the method used |
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| to
calculate (1) the Health Maintenance Organization's |
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| profitable experience with
respect to the group or enrollment |
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| unit and the resulting refund to the group
or enrollment unit |
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| or (2) the Health Maintenance Organization's unprofitable
|
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| experience with respect to the group or enrollment unit and the |
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| resulting
additional premium to be paid by the group or |
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| enrollment unit.
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| In no event shall the Illinois Health Maintenance |
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| Organization
Guaranty Association be liable to pay any |
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| contractual obligation of an
insolvent organization to pay any |
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| refund authorized under this Section.
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| (g) Rulemaking authority to implement Public Act 95-1045 |
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| this amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
26 |
| provisions of the Illinois Administrative Procedure Act and all |
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09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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|
1 |
| rules and procedures of the Joint Committee on Administrative |
2 |
| Rules; any purported rule not so adopted, for whatever reason, |
3 |
| is unauthorized. |
4 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
5 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
6 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
7 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised |
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| 10-23-09.) |
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| (Text of Section after amendment by P.A. 96-833 ) |
10 |
| Sec. 5-3. Insurance Code provisions.
|
11 |
| (a) Health Maintenance Organizations
shall be subject to |
12 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
13 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
14 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
15 |
| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
16 |
| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, |
17 |
| 356z.18, 356z.19, 356z.20, 364.01, 367.2, 367.2-5, 367i, 368a, |
18 |
| 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, |
19 |
| 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection |
20 |
| (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, |
21 |
| XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
|
22 |
| (b) For purposes of the Illinois Insurance Code, except for |
23 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
24 |
| Maintenance Organizations in
the following categories are |
25 |
| deemed to be "domestic companies":
|
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| (1) a corporation authorized under the
Dental Service |
2 |
| Plan Act or the Voluntary Health Services Plans Act;
|
3 |
| (2) a corporation organized under the laws of this |
4 |
| State; or
|
5 |
| (3) a corporation organized under the laws of another |
6 |
| state, 30% or more
of the enrollees of which are residents |
7 |
| of this State, except a
corporation subject to |
8 |
| substantially the same requirements in its state of
|
9 |
| organization as is a "domestic company" under Article VIII |
10 |
| 1/2 of the
Illinois Insurance Code.
|
11 |
| (c) In considering the merger, consolidation, or other |
12 |
| acquisition of
control of a Health Maintenance Organization |
13 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
14 |
| (1) the Director shall give primary consideration to |
15 |
| the continuation of
benefits to enrollees and the financial |
16 |
| conditions of the acquired Health
Maintenance Organization |
17 |
| after the merger, consolidation, or other
acquisition of |
18 |
| control takes effect;
|
19 |
| (2)(i) the criteria specified in subsection (1)(b) of |
20 |
| Section 131.8 of
the Illinois Insurance Code shall not |
21 |
| apply and (ii) the Director, in making
his determination |
22 |
| with respect to the merger, consolidation, or other
|
23 |
| acquisition of control, need not take into account the |
24 |
| effect on
competition of the merger, consolidation, or |
25 |
| other acquisition of control;
|
26 |
| (3) the Director shall have the power to require the |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| following
information:
|
2 |
| (A) certification by an independent actuary of the |
3 |
| adequacy
of the reserves of the Health Maintenance |
4 |
| Organization sought to be acquired;
|
5 |
| (B) pro forma financial statements reflecting the |
6 |
| combined balance
sheets of the acquiring company and |
7 |
| the Health Maintenance Organization sought
to be |
8 |
| acquired as of the end of the preceding year and as of |
9 |
| a date 90 days
prior to the acquisition, as well as pro |
10 |
| forma financial statements
reflecting projected |
11 |
| combined operation for a period of 2 years;
|
12 |
| (C) a pro forma business plan detailing an |
13 |
| acquiring party's plans with
respect to the operation |
14 |
| of the Health Maintenance Organization sought to
be |
15 |
| acquired for a period of not less than 3 years; and
|
16 |
| (D) such other information as the Director shall |
17 |
| require.
|
18 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
19 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
20 |
| any health maintenance
organization of greater than 10% of its
|
21 |
| enrollee population (including without limitation the health |
22 |
| maintenance
organization's right, title, and interest in and to |
23 |
| its health care
certificates).
|
24 |
| (e) In considering any management contract or service |
25 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
26 |
| Code, the Director (i) shall, in
addition to the criteria |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
2 |
| into account the effect of the management contract or
service |
3 |
| agreement on the continuation of benefits to enrollees and the
|
4 |
| financial condition of the health maintenance organization to |
5 |
| be managed or
serviced, and (ii) need not take into account the |
6 |
| effect of the management
contract or service agreement on |
7 |
| competition.
|
8 |
| (f) Except for small employer groups as defined in the |
9 |
| Small Employer
Rating, Renewability and Portability Health |
10 |
| Insurance Act and except for
medicare supplement policies as |
11 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
12 |
| Maintenance Organization may by contract agree with a
group or |
13 |
| other enrollment unit to effect refunds or charge additional |
14 |
| premiums
under the following terms and conditions:
|
15 |
| (i) the amount of, and other terms and conditions with |
16 |
| respect to, the
refund or additional premium are set forth |
17 |
| in the group or enrollment unit
contract agreed in advance |
18 |
| of the period for which a refund is to be paid or
|
19 |
| additional premium is to be charged (which period shall not |
20 |
| be less than one
year); and
|
21 |
| (ii) the amount of the refund or additional premium |
22 |
| shall not exceed 20%
of the Health Maintenance |
23 |
| Organization's profitable or unprofitable experience
with |
24 |
| respect to the group or other enrollment unit for the |
25 |
| period (and, for
purposes of a refund or additional |
26 |
| premium, the profitable or unprofitable
experience shall |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| be calculated taking into account a pro rata share of the
|
2 |
| Health Maintenance Organization's administrative and |
3 |
| marketing expenses, but
shall not include any refund to be |
4 |
| made or additional premium to be paid
pursuant to this |
5 |
| subsection (f)). The Health Maintenance Organization and |
6 |
| the
group or enrollment unit may agree that the profitable |
7 |
| or unprofitable
experience may be calculated taking into |
8 |
| account the refund period and the
immediately preceding 2 |
9 |
| plan years.
|
10 |
| The Health Maintenance Organization shall include a |
11 |
| statement in the
evidence of coverage issued to each enrollee |
12 |
| describing the possibility of a
refund or additional premium, |
13 |
| and upon request of any group or enrollment unit,
provide to |
14 |
| the group or enrollment unit a description of the method used |
15 |
| to
calculate (1) the Health Maintenance Organization's |
16 |
| profitable experience with
respect to the group or enrollment |
17 |
| unit and the resulting refund to the group
or enrollment unit |
18 |
| or (2) the Health Maintenance Organization's unprofitable
|
19 |
| experience with respect to the group or enrollment unit and the |
20 |
| resulting
additional premium to be paid by the group or |
21 |
| enrollment unit.
|
22 |
| In no event shall the Illinois Health Maintenance |
23 |
| Organization
Guaranty Association be liable to pay any |
24 |
| contractual obligation of an
insolvent organization to pay any |
25 |
| refund authorized under this Section.
|
26 |
| (g) Rulemaking authority to implement Public Act 95-1045, |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| if any, is conditioned on the rules being adopted in accordance |
2 |
| with all provisions of the Illinois Administrative Procedure |
3 |
| Act and all rules and procedures of the Joint Committee on |
4 |
| Administrative Rules; any purported rule not so adopted, for |
5 |
| whatever reason, is unauthorized. |
6 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
7 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
8 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
9 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. |
10 |
| 6-1-10.)
|
11 |
| Section 45. The Voluntary Health Services Plans Act is |
12 |
| amended by changing
Section 10 as follows:
|
13 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
|
14 |
| (Text of Section before amendment by P.A. 96-833 ) |
15 |
| Sec. 10. Application of Insurance Code provisions. Health |
16 |
| services
plan corporations and all persons interested therein |
17 |
| or dealing therewith
shall be subject to the provisions of |
18 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
19 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
20 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, |
21 |
| 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, |
22 |
| 356z.14, 356z.15
356z.14 , 356z.19, 356z.20, 364.01, 367.2, |
23 |
| 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and |
24 |
| paragraphs (7) and (15) of Section 367 of the Illinois
|
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| Insurance Code.
|
2 |
| Rulemaking authority to implement Public Act 95-1045
this |
3 |
| amendatory Act of the 95th General Assembly , if any, is |
4 |
| conditioned on the rules being adopted in accordance with all |
5 |
| provisions of the Illinois Administrative Procedure Act and all |
6 |
| rules and procedures of the Joint Committee on Administrative |
7 |
| Rules; any purported rule not so adopted, for whatever reason, |
8 |
| is unauthorized. |
9 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
10 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
11 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, |
12 |
| eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
13 |
| 96-328, eff. 8-11-09; revised 9-25-09.) |
14 |
| (Text of Section after amendment by P.A. 96-833 ) |
15 |
| Sec. 10. Application of Insurance Code provisions. Health |
16 |
| services
plan corporations and all persons interested therein |
17 |
| or dealing therewith
shall be subject to the provisions of |
18 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
19 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
20 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, |
21 |
| 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, |
22 |
| 356z.14, 356z.15, 356z.18, 356z.19, 356z.20, 364.01, 367.2, |
23 |
| 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and |
24 |
| paragraphs (7) and (15) of Section 367 of the Illinois
|
25 |
| Insurance Code.
|
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| Rulemaking authority to implement Public Act 95-1045, if |
2 |
| any, is conditioned on the rules being adopted in accordance |
3 |
| with all provisions of the Illinois Administrative Procedure |
4 |
| Act and all rules and procedures of the Joint Committee on |
5 |
| Administrative Rules; any purported rule not so adopted, for |
6 |
| whatever reason, is unauthorized. |
7 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
8 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
9 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, |
10 |
| eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
11 |
| 96-328, eff. 8-11-09; 96-833, eff. 6-1-10.)
|
12 |
| Section 50. The Health Carrier External Review Act is |
13 |
| amended by changing Section 35 and by adding Sections 25.1, |
14 |
| 25.2, 25.3, 25.4, 25.5, and 25.6 as follows: |
15 |
| (215 ILCS 180/25.1 new) |
16 |
| Sec. 25.1. Standard
information for application forms. |
17 |
| (a) The Director shall establish standard
information and |
18 |
| health history questions that shall be used by all
health care |
19 |
| service plans for their individual health care coverage
|
20 |
| application forms for individual health plan contracts and
|
21 |
| individual health insurance policies. The health care service |
22 |
| plan
and health insurance application forms for individual |
23 |
| health plan
contracts and health insurance policies may only |
24 |
| contain questions
approved by the Director. |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| (b) The standard information and health history questions
|
2 |
| developed by the Director shall contain clear and unambiguous
|
3 |
| information and questions designed to ascertain the health |
4 |
| history of
the applicant and shall be based on the medical |
5 |
| information that is
reasonable and necessary for medical |
6 |
| underwriting purposes. |
7 |
| (c) The application form shall include a prominently |
8 |
| displayed
notice that shall read:
"Illinois law prohibits an |
9 |
| HIV test from being required or used
by health care service |
10 |
| plans as a condition of obtaining coverage.". |
11 |
| (d) No later than 6 months after the adoption of the |
12 |
| regulation
under subsection (a) of this Section, all individual |
13 |
| health care service plan
application forms shall utilize only |
14 |
| the pool of approved questions
and the standardized information |
15 |
| established pursuant to subsection (a). |
16 |
| (e) On and after January 1, 2011, all individual health |
17 |
| care
service plan applications shall be reviewed and approved |
18 |
| by the
Director before they may be used by a health care |
19 |
| service plan. |
20 |
| (215 ILCS 180/25.2 new) |
21 |
| Sec. 25.2. Medical
underwriting. |
22 |
| (a) "Medical underwriting" means the completion of a |
23 |
| reasonable
investigation of the applicant's health history |
24 |
| information, which
includes, but is not limited to, the |
25 |
| following: |
|
|
|
09600HB6417ham001 |
- 23 - |
LRB096 21045 AMC 39407 a |
|
|
1 |
| (1) Ensuring that the information submitted on the |
2 |
| application
form and the material submitted with the |
3 |
| application form are
complete and accurate. |
4 |
| (2) Resolving all reasonable questions arising from |
5 |
| the
application form or any materials submitted with the |
6 |
| application form or
any information obtained by the health |
7 |
| care service plan as part of
its verification of the |
8 |
| accuracy and completeness of the application
form. |
9 |
| (b) A health care service plan shall complete medical
|
10 |
| underwriting prior to issuing an enrollee or subscriber health |
11 |
| care
service plan contract. |
12 |
| (c) A health care service plan shall adopt and implement |
13 |
| written
medical underwriting policies and procedures to ensure |
14 |
| that the
health care service plan does all of the following |
15 |
| with respect to an
application for health care coverage: |
16 |
| (1) Reviews all of the following:
|
17 |
| (A) Information on the application and any |
18 |
| materials submitted
with the application form for |
19 |
| accuracy and completeness.
|
20 |
| (B) Claims information about the applicant that is |
21 |
| within the
health care service plan's own claims |
22 |
| information.
|
23 |
| (C) At least one commercially available |
24 |
| prescription drug database
for information about the |
25 |
| applicant.
|
26 |
| (2) Identifies and makes inquiries, including |
|
|
|
09600HB6417ham001 |
- 24 - |
LRB096 21045 AMC 39407 a |
|
|
1 |
| contacting the
applicant about any questions raised by |
2 |
| omissions, ambiguities, or
inconsistencies based upon the |
3 |
| information collected pursuant to
item (1) of this |
4 |
| subsection (c).
|
5 |
| (d) The plan shall document all information collected |
6 |
| during the
underwriting review process.
|
7 |
| (e) On or before January 1, 2011, a health care service |
8 |
| plan shall
file its medical underwriting policies and |
9 |
| procedures with the
Department.
|
10 |
| (215 ILCS 180/25.3 new) |
11 |
| Sec. 25.3. Copies of application and contract; notice. |
12 |
| (a) Within 10 business days after issuing a health care
|
13 |
| service plan contract, the health care service plan shall send |
14 |
| a copy
of the completed written application to the applicant |
15 |
| with a copy of
the health care service plan contract issued by |
16 |
| the health care
service plan, along with a notice that states |
17 |
| all of the following:
|
18 |
| (1) The applicant should review the completed |
19 |
| application
carefully and notify the health care service |
20 |
| plan within 30 days of
any inaccuracy in the application.
|
21 |
| (2) Any intentional material misrepresentation or |
22 |
| intentional
material omission in the information submitted |
23 |
| in the application may
result in the cancellation or |
24 |
| rescission of the plan contract.
|
25 |
| (3) The applicant should retain a copy of the completed |
|
|
|
09600HB6417ham001 |
- 25 - |
LRB096 21045 AMC 39407 a |
|
|
1 |
| written
application for the applicant's records.
|
2 |
| (b) If new information is provided by the applicant within |
3 |
| the
30-day period permitted by subsection (a), then the |
4 |
| provisions concerning medical underwriting shall apply to the |
5 |
| new information.
|
6 |
| (215 ILCS 180/25.4 new) |
7 |
| Sec. 25.4. Rescission; cancellation. |
8 |
| (a) Once a plan has issued an individual health care
|
9 |
| service plan contract, the health care service plan shall not |
10 |
| rescind
or cancel the health care service plan contract unless |
11 |
| all of the
following apply:
|
12 |
| (1) There was a material misrepresentation or material |
13 |
| omission in
the information submitted by the applicant in |
14 |
| the written
application to the health care service plan |
15 |
| prior to the issuance of
the health care service plan |
16 |
| contract that would have prevented the
contract from being |
17 |
| entered into.
|
18 |
| (2) The health care service plan completed medical |
19 |
| underwriting before issuing the plan contract.
|
20 |
| (3) The health care service plan demonstrates that the |
21 |
| applicant
intentionally misrepresented or intentionally |
22 |
| omitted material
information on the application prior to |
23 |
| the issuance of the plan
contract with the purpose of |
24 |
| misrepresenting his or her health
history in order to |
25 |
| obtain health care coverage.
|
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| (4) The application form was approved by the |
2 |
| Department.
|
3 |
| (5) The health care service plan sent a copy of the |
4 |
| completed
written application to the applicant with a copy |
5 |
| of the health care
service plan contract issued by the |
6 |
| health care service plan.
|
7 |
| (b) Notwithstanding subsection (a) of this Section, an |
8 |
| enrollment or subscription
may be canceled or not renewed for |
9 |
| failure to pay the fees for
that coverage.
|
10 |
| (215 ILCS 180/25.5 new) |
11 |
| Sec. 25.5. Postcontract investigation. |
12 |
| (a) If a health care service plan obtains information
after |
13 |
| issuing an individual health care service plan contract that
|
14 |
| the subscriber or enrollee may have intentionally omitted or
|
15 |
| intentionally misrepresented material information during the
|
16 |
| application for coverage process, then the health care service |
17 |
| plan may
investigate the potential omissions or |
18 |
| misrepresentations in order to
determine whether the |
19 |
| subscriber's or enrollee's health care service
plan contract |
20 |
| may be rescinded or canceled.
|
21 |
| (b) The following provisions shall apply to a postcontract |
22 |
| issuance investigation: |
23 |
| (1) Upon initiating a postcontract issuance |
24 |
| investigation for
potential rescission or cancellation of |
25 |
| health care coverage, the
plan shall provide a written |
|
|
|
09600HB6417ham001 |
- 27 - |
LRB096 21045 AMC 39407 a |
|
|
1 |
| notice to the enrollee or subscriber by
regular and |
2 |
| certified mail that it has initiated an investigation of
|
3 |
| intentional material misrepresentation or intentional |
4 |
| material
omission on the part of the enrollee or subscriber |
5 |
| and that the
investigation could lead to the rescission or |
6 |
| cancellation of the
enrollee's or subscriber's health care |
7 |
| service plan contract. The
notice shall be provided by the |
8 |
| health care service plan within 5
days of the initiation of |
9 |
| the investigation.
|
10 |
| (2) The written notice required under item (1) of this |
11 |
| subsection (b) shall include
full disclosure of the |
12 |
| allegedly intentional material omission or
|
13 |
| misrepresentation and a clear and concise explanation of |
14 |
| why the
information has resulted in the health care service |
15 |
| plan's initiation
of an investigation to determine whether |
16 |
| rescission or cancellation
is warranted. The notice shall |
17 |
| invite the enrollee or subscriber to
provide any evidence |
18 |
| or information within 45 business days to negate
the plan's |
19 |
| reasons for initiating the postissuance investigation.
|
20 |
| (3) The plan shall complete its investigation no later |
21 |
| than 90
days after the date that the notice is sent to the |
22 |
| enrollee or subscriber
pursuant to item (1) of this |
23 |
| subsection (b).
|
24 |
| (4) Upon completion of its postissuance investigation, |
25 |
| the plan
shall provide written notice by regular and |
26 |
| certified mail to the
subscriber or enrollee that it has |
|
|
|
09600HB6417ham001 |
- 28 - |
LRB096 21045 AMC 39407 a |
|
|
1 |
| concluded its investigation and
has made one of the |
2 |
| following determinations:
|
3 |
| (A) The plan has determined that the enrollee or |
4 |
| subscriber did
not intentionally misrepresent or |
5 |
| intentionally omit material
information during the |
6 |
| application process and that the subscriber's
or |
7 |
| enrollee's health care coverage will not be canceled or |
8 |
| rescinded.
|
9 |
| (B) The plan intends to seek approval from the |
10 |
| Director to cancel
or rescind the enrollee's or |
11 |
| subscriber's health care service plan
contract for |
12 |
| intentional misrepresentation or intentional omission |
13 |
| of
material information during the application for |
14 |
| coverage process.
|
15 |
| (5) The written notice required under paragraph (B) of
|
16 |
| item (4) of this subsection (b) shall do all of the |
17 |
| following:
|
18 |
| (A) Include full disclosure of the nature and |
19 |
| substance of any
information that led to the plan's |
20 |
| determination that the enrollee or
subscriber |
21 |
| intentionally misrepresented or intentionally omitted
|
22 |
| material information on the application form.
|
23 |
| (B) Provide the enrollee or subscriber with |
24 |
| information indicating
that the health plan's |
25 |
| determination shall not become final until it
is |
26 |
| reviewed and approved by the Department's independent |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| review
process.
|
2 |
| (C) Provide the enrollee or subscriber with |
3 |
| information regarding
the Department's independent |
4 |
| review process and the right of the
enrollee or |
5 |
| subscriber to opt out of that review process within 45
|
6 |
| days of the date upon which an independent review |
7 |
| organization
receives a request for independent |
8 |
| review.
|
9 |
| (D) Provide a statement that the health care |
10 |
| service plan's
proposed decision to cancel or rescind |
11 |
| the health care service plan
contract shall not become |
12 |
| effective unless the Department's
independent review |
13 |
| organization upholds the health care service plan'
s |
14 |
| decision or unless the enrollee or subscriber has opted |
15 |
| out of the
independent review. |
16 |
| (215 ILCS 180/25.6 new) |
17 |
| Sec. 25.6. Continuation. |
18 |
| (a) A health care service plan shall continue to
authorize |
19 |
| and provide all medically necessary health care services
|
20 |
| required to be covered under an enrollee's or subscriber's |
21 |
| health
care service plan contract until the effective date of |
22 |
| cancellation
or rescission.
|
23 |
| (b) The effective date of the health care service plan's
|
24 |
| cancellation or the date upon which the plan may initiate a
|
25 |
| rescission shall be no earlier than the date that the enrollee |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| or
subscriber receives notification via regular and certified |
2 |
| mail that
the independent review organization has made a |
3 |
| determination
upholding the health care service plan's |
4 |
| decision to rescind or
cancel.
|
5 |
| (215 ILCS 180/35) |
6 |
| (This Section may contain text from a Public Act with a |
7 |
| delayed effective date )
|
8 |
| Sec. 35. Standard external review. |
9 |
| (a) Within 4 months after the date of receipt of a notice |
10 |
| of an adverse determination or final adverse determination, a |
11 |
| covered person or the covered person's authorized |
12 |
| representative may file a request for an external review with |
13 |
| the health carrier. |
14 |
| (b) Within 5 business days following the date of receipt of |
15 |
| the external review request, the health carrier shall complete |
16 |
| a preliminary review of the request to determine whether:
|
17 |
| (1) the individual is or was a covered person in the |
18 |
| health benefit plan at the time the health care service was |
19 |
| requested or at the time the health care service was |
20 |
| provided; |
21 |
| (2) the health care service that is the subject of the |
22 |
| adverse determination or the final adverse determination |
23 |
| is a covered service under the covered person's health |
24 |
| benefit plan, but the health carrier has determined that |
25 |
| the health care service is not covered because it does not |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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|
1 |
| meet the health carrier's requirements for medical |
2 |
| necessity, appropriateness, health care setting, level of |
3 |
| care, or effectiveness; |
4 |
| (3) the covered person has exhausted the health |
5 |
| carrier's internal grievance process as set forth in this |
6 |
| Act; |
7 |
| (4) for appeals relating to a determination based on |
8 |
| treatment being experimental or investigational, the |
9 |
| requested health care service or treatment that is the |
10 |
| subject of the adverse determination or final adverse |
11 |
| determination is a covered benefit under the covered |
12 |
| person's health benefit plan except for the health |
13 |
| carrier's determination that the service or treatment is |
14 |
| experimental or investigational for a particular medical |
15 |
| condition and is not explicitly listed as an excluded |
16 |
| benefit under the covered person's health benefit plan with |
17 |
| the health carrier and that the covered person's health |
18 |
| care provider, who is a physician licensed to practice |
19 |
| medicine in all its branches, has certified that one of the |
20 |
| following situations is applicable: |
21 |
| (A) standard health care services or treatments |
22 |
| have not been effective in improving the condition of |
23 |
| the covered person; |
24 |
| (B) standard health care services or treatments |
25 |
| are not medically appropriate for the covered person; |
26 |
| (C) there is no available standard health care |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| service or treatment covered by the health carrier that |
2 |
| is more beneficial than the recommended or requested |
3 |
| health care service or treatment;
|
4 |
| (D) the health care service or treatment is likely |
5 |
| to be more beneficial to the covered person, in the |
6 |
| health care provider's opinion, than any available |
7 |
| standard health care services or treatments; or |
8 |
| (E) that scientifically valid studies using |
9 |
| accepted protocols demonstrate that the health care |
10 |
| service or treatment requested is likely to be more |
11 |
| beneficial to the covered person than any available |
12 |
| standard health care services or treatments; and |
13 |
| (5) the covered person has provided all the information |
14 |
| and forms required to process an external review, as |
15 |
| specified in this Act. |
16 |
| (c) Within one business day after completion of the |
17 |
| preliminary review, the health carrier shall notify the covered |
18 |
| person and, if applicable, the covered person's authorized |
19 |
| representative in writing whether the request is complete and |
20 |
| eligible for external review. If the request: |
21 |
| (1) is not complete, the health carrier shall inform |
22 |
| the covered person and, if applicable, the covered person's |
23 |
| authorized representative in writing and include in the |
24 |
| notice what information or materials are required by this |
25 |
| Act to make the request complete; or |
26 |
| (2) is not eligible for external review, the health |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| carrier shall inform the covered person and, if applicable, |
2 |
| the covered person's authorized representative in writing |
3 |
| and include in the notice the reasons for its |
4 |
| ineligibility.
|
5 |
| The notice of initial determination of ineligibility shall |
6 |
| include a statement informing the covered person and, if |
7 |
| applicable, the covered person's authorized representative |
8 |
| that a health carrier's initial determination that the external |
9 |
| review request is ineligible for review may be appealed to the |
10 |
| Director by filing a complaint with the Director. |
11 |
| Notwithstanding a health carrier's initial determination |
12 |
| that the request is ineligible for external review, the |
13 |
| Director may determine that a request is eligible for external |
14 |
| review and require that it be referred for external review. In |
15 |
| making such determination, the Director's decision shall be in |
16 |
| accordance with the terms of the covered person's health |
17 |
| benefit plan and shall be subject to all applicable provisions |
18 |
| of this Act. |
19 |
| (d) Whenever a request is eligible for external review the |
20 |
| health carrier shall, within 5 business days: |
21 |
| (1) assign an independent review organization from the |
22 |
| list of approved independent review organizations compiled |
23 |
| and maintained by the Director; and |
24 |
| (2) notify in writing the covered person and, if |
25 |
| applicable, the covered person's authorized representative |
26 |
| of the request's eligibility and acceptance for external |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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|
1 |
| review and the name of the independent review organization. |
2 |
| The health carrier shall include in the notice provided to |
3 |
| the covered person and, if applicable, the covered person's |
4 |
| authorized representative a statement that the covered person |
5 |
| or the covered person's authorized representative may, within 5 |
6 |
| business days following the date of receipt of the notice |
7 |
| provided pursuant to item (2) of this subsection (d), submit in |
8 |
| writing to the assigned independent review organization |
9 |
| additional information that the independent review |
10 |
| organization shall consider when conducting the external |
11 |
| review. The independent review organization is not required to, |
12 |
| but may, accept and consider additional information submitted |
13 |
| after 5 business days. |
14 |
| (e) The assignment of an approved independent review |
15 |
| organization to conduct an external review in accordance with |
16 |
| this Section shall be made from those approved independent |
17 |
| review organizations qualified to conduct external review as |
18 |
| required by Sections 50 and 55 of this Act. |
19 |
| (f) Upon assignment of an independent review organization, |
20 |
| the health carrier or its designee utilization review |
21 |
| organization shall, within 5 business days, provide to the |
22 |
| assigned independent review organization the documents and any |
23 |
| information considered in making the adverse determination or |
24 |
| final adverse determination; in such cases, the following |
25 |
| provisions shall apply: |
26 |
| (1) Except as provided in item (2) of this subsection |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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|
1 |
| (f), failure by the health carrier or its utilization |
2 |
| review organization to provide the documents and |
3 |
| information within the specified time frame shall not delay |
4 |
| the conduct of the external review. |
5 |
| (2) If the health carrier or its utilization review |
6 |
| organization fails to provide the documents and |
7 |
| information within the specified time frame, the assigned |
8 |
| independent review organization may terminate the external |
9 |
| review and make a decision to reverse the adverse |
10 |
| determination or final adverse determination. |
11 |
| (3) Within one business day after making the decision |
12 |
| to terminate the external review and make a decision to |
13 |
| reverse the adverse determination or final adverse |
14 |
| determination under item (2) of this subsection (f), the |
15 |
| independent review organization shall notify the health |
16 |
| carrier, the covered person and, if applicable, the covered |
17 |
| person's authorized representative, of its decision to |
18 |
| reverse the adverse determination. |
19 |
| (g) Upon receipt of the information from the health carrier |
20 |
| or its utilization review organization, the assigned |
21 |
| independent review organization shall review all of the |
22 |
| information and documents and any other information submitted |
23 |
| in writing to the independent review organization by the |
24 |
| covered person and the covered person's authorized |
25 |
| representative. |
26 |
| (h) Upon receipt of any information submitted by the |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
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|
1 |
| covered person or the covered person's authorized |
2 |
| representative, the independent review organization shall |
3 |
| forward the information to the health carrier within 1 business |
4 |
| day. |
5 |
| (1) Upon receipt of the information, if any, the health |
6 |
| carrier may reconsider its adverse determination or final |
7 |
| adverse determination that is the subject of the external |
8 |
| review.
|
9 |
| (2) Reconsideration by the health carrier of its |
10 |
| adverse determination or final adverse determination shall |
11 |
| not delay or terminate the external review.
|
12 |
| (3) The external review may only be terminated if the |
13 |
| health carrier decides, upon completion of its |
14 |
| reconsideration, to reverse its adverse determination or |
15 |
| final adverse determination and provide coverage or |
16 |
| payment for the health care service that is the subject of |
17 |
| the adverse determination or final adverse determination. |
18 |
| In such cases, the following provisions shall apply: |
19 |
| (A) Within one business day after making the |
20 |
| decision to reverse its adverse determination or final |
21 |
| adverse determination, the health carrier shall notify |
22 |
| the covered person and if applicable, the covered |
23 |
| person's authorized representative, and the assigned |
24 |
| independent review organization in writing of its |
25 |
| decision. |
26 |
| (B) Upon notice from the health carrier that the |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| health carrier has made a decision to reverse its |
2 |
| adverse determination or final adverse determination, |
3 |
| the assigned independent review organization shall |
4 |
| terminate the external review. |
5 |
| (i) In addition to the documents and information provided |
6 |
| by the health carrier or its utilization review organization |
7 |
| and the covered person and the covered person's authorized |
8 |
| representative, if any, the independent review organization, |
9 |
| to the extent the information or documents are available and |
10 |
| the independent review organization considers them |
11 |
| appropriate, shall consider the following in reaching a |
12 |
| decision: |
13 |
| (1) the covered person's pertinent medical records; |
14 |
| (2) the covered person's health care provider's |
15 |
| recommendation; |
16 |
| (3) consulting reports from appropriate health care |
17 |
| providers and other documents submitted by the health |
18 |
| carrier, the covered person, the covered person's |
19 |
| authorized representative, or the covered person's |
20 |
| treating provider; |
21 |
| (4) the terms of coverage under the covered person's |
22 |
| health benefit plan with the health carrier to ensure that |
23 |
| the independent review organization's decision is not |
24 |
| contrary to the terms of coverage under the covered |
25 |
| person's health benefit plan with the health carrier; |
26 |
| (5) the most appropriate practice guidelines, which |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| shall include applicable evidence-based standards and may |
2 |
| include any other practice guidelines developed by the |
3 |
| federal government, national or professional medical |
4 |
| societies, boards, and associations; |
5 |
| (6) any applicable clinical review criteria developed |
6 |
| and used by the health carrier or its designee utilization |
7 |
| review organization; and |
8 |
| (7) the opinion of the independent review |
9 |
| organization's clinical reviewer or reviewers after |
10 |
| considering items (1) through (6) of this subsection (i) to |
11 |
| the extent the information or documents are available and |
12 |
| the clinical reviewer or reviewers considers the |
13 |
| information or documents appropriate; and |
14 |
| (8) for a denial of coverage based on a determination |
15 |
| that the health care service or treatment recommended or |
16 |
| requested is experimental or investigational, whether and |
17 |
| to what extent: |
18 |
| (A) the recommended or requested health care |
19 |
| service or treatment has been approved by the federal |
20 |
| Food and Drug Administration, if applicable, for the |
21 |
| condition; |
22 |
| (B) medical or scientific evidence or |
23 |
| evidence-based standards demonstrate that the expected |
24 |
| benefits of the recommended or requested health care |
25 |
| service or treatment is more likely than not to be |
26 |
| beneficial to the covered person than any available |
|
|
|
09600HB6417ham001 |
- 39 - |
LRB096 21045 AMC 39407 a |
|
|
1 |
| standard health care service or treatment and the |
2 |
| adverse risks of the recommended or requested health |
3 |
| care service or treatment would not be substantially |
4 |
| increased over those of available standard health care |
5 |
| services or treatments; or |
6 |
| (C) the terms of coverage under the covered |
7 |
| person's health benefit plan with the health carrier to |
8 |
| ensure that the health care service or treatment that |
9 |
| is the subject of the opinion is experimental or |
10 |
| investigational would otherwise be covered under the |
11 |
| terms of coverage of the covered person's health |
12 |
| benefit plan with the health carrier. |
13 |
| (j) Within 5 days after the date of receipt of all |
14 |
| necessary information, the assigned independent review |
15 |
| organization shall provide written notice of its decision to |
16 |
| uphold or reverse the adverse determination or the final |
17 |
| adverse determination to the health carrier, the covered person |
18 |
| and, if applicable, the covered person's authorized |
19 |
| representative. In reaching a decision, the assigned |
20 |
| independent review organization is not bound by any claim |
21 |
| determinations reached prior to the submission of information |
22 |
| to the independent review organization. The assigned |
23 |
| independent review organization shall independently determine |
24 |
| if the health care services under review are the medically |
25 |
| necessary health care services that a physician, exercising |
26 |
| prudent clinical judgment, would provide to a patient for the |
|
|
|
09600HB6417ham001 |
- 40 - |
LRB096 21045 AMC 39407 a |
|
|
1 |
| purpose of preventing, evaluating, diagnosing, or treating an |
2 |
| illness, injury, disease, or its symptoms and are: (i) in |
3 |
| accordance with generally accepted standards of medical |
4 |
| practice; (ii) clinically appropriate, in terms of type, |
5 |
| frequency, extent, site, and duration and considered effective |
6 |
| for the patient's illness, injury, or disease; and (iii) not |
7 |
| primarily for the convenience of the patient, physician, or |
8 |
| other health care provider. For the purposes of this subsection |
9 |
| (j), "generally accepted standards of medical practice" means |
10 |
| standards that are based on credible scientific evidence |
11 |
| published in peer-reviewed medical literature generally |
12 |
| recognized by the relevant medical community, physician |
13 |
| specialty society recommendations, and the views of physicians |
14 |
| practicing in relevant clinical areas and any other relevant |
15 |
| factors. In such cases, the following provisions shall apply: |
16 |
| (1) The independent review organization shall include |
17 |
| in the notice: |
18 |
| (A) a general description of the reason for the |
19 |
| request for external review; |
20 |
| (B) the date the independent review organization |
21 |
| received the assignment from the health carrier to |
22 |
| conduct the external review; |
23 |
| (C) the time period during which the external |
24 |
| review was conducted; |
25 |
| (D) references to the evidence or documentation, |
26 |
| including the evidence-based standards, considered in |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| reaching its decision; |
2 |
| (E) the date of its decision; and |
3 |
| (F) the principal reason or reasons for its |
4 |
| decision, including what applicable, if any, |
5 |
| evidence-based standards that were a basis for its |
6 |
| decision.
|
7 |
| (2) For reviews of experimental or investigational |
8 |
| treatments, the notice shall include the following |
9 |
| information: |
10 |
| (A) a description of the covered person's medical |
11 |
| condition; |
12 |
| (B) a description of the indicators relevant to |
13 |
| whether there is sufficient evidence to demonstrate |
14 |
| that the recommended or requested health care service |
15 |
| or treatment is more likely than not to be more |
16 |
| beneficial to the covered person than any available |
17 |
| standard health care services or treatments and the |
18 |
| adverse risks of the recommended or requested health |
19 |
| care service or treatment would not be substantially |
20 |
| increased over those of available standard health care |
21 |
| services or treatments; |
22 |
| (C) a description and analysis of any medical or |
23 |
| scientific evidence considered in reaching the |
24 |
| opinion; |
25 |
| (D) a description and analysis of any |
26 |
| evidence-based standards; |
|
|
|
09600HB6417ham001 |
- 42 - |
LRB096 21045 AMC 39407 a |
|
|
1 |
| (E) whether the recommended or requested health |
2 |
| care service or treatment has been approved by the |
3 |
| federal Food and Drug Administration, for the |
4 |
| condition; |
5 |
| (F) whether medical or scientific evidence or |
6 |
| evidence-based standards demonstrate that the expected |
7 |
| benefits of the recommended or requested health care |
8 |
| service or treatment is more likely than not to be more |
9 |
| beneficial to the covered person than any available |
10 |
| standard health care service or treatment and the |
11 |
| adverse risks of the recommended or requested health |
12 |
| care service or treatment would not be substantially |
13 |
| increased over those of available standard health care |
14 |
| services or treatments; and |
15 |
| (G) the written opinion of the clinical reviewer, |
16 |
| including the reviewer's recommendation as to whether |
17 |
| the recommended or requested health care service or |
18 |
| treatment should be covered and the rationale for the |
19 |
| reviewer's recommendation. |
20 |
| (3) In reaching a decision, the assigned independent |
21 |
| review organization is not bound by any decisions or |
22 |
| conclusions reached during the health carrier's |
23 |
| utilization review process or the health carrier's |
24 |
| internal grievance or appeals process. |
25 |
| (4) Upon receipt of a notice of a decision reversing |
26 |
| the adverse determination or final adverse determination, |
|
|
|
09600HB6417ham001 |
- 43 - |
LRB096 21045 AMC 39407 a |
|
|
1 |
| the health carrier immediately shall approve the coverage |
2 |
| that was the subject of the adverse determination or final |
3 |
| adverse determination.
|
4 |
| (Source: P.A. 96-857, eff. 7-1-10.) |
5 |
| Section 55. The Illinois Public Aid Code is amended by |
6 |
| changing Section 5-16.8 as follows:
|
7 |
| (305 ILCS 5/5-16.8)
|
8 |
| Sec. 5-16.8. Required health benefits. The medical |
9 |
| assistance program
shall
(i) provide 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, and 356z.6 , and |
13 |
| 356z.21 of the Illinois
Insurance Code and (ii) be subject to |
14 |
| the provisions of Section 364.01 of the Illinois
Insurance |
15 |
| Code.
|
16 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07.)
|
17 |
| Section 60. The Medical Patient Rights Act is amended by |
18 |
| changing Sections 2.04, 3, and 5 and adding Sections 2.06, 5.1, |
19 |
| and 5.2 as follows:
|
20 |
| (410 ILCS 50/2.04) (from Ch. 111 1/2, par. 5402.04)
|
21 |
| Sec. 2.04.
"Insurance company" means (1) an insurance |
22 |
| company, fraternal
benefit society, and any other insurer |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| subject to regulation under the
Illinois Insurance Code; or (2) |
2 |
| a health maintenance organization , a limited health service |
3 |
| organization under the Limited Health Service Organization |
4 |
| Act, or a voluntary health services plan under the Voluntary |
5 |
| Health Services Plans Act .
|
6 |
| (Source: P.A. 85-677; 85-679.)
|
7 |
| (410 ILCS 50/2.06 new) |
8 |
| Sec. 2.06. "Health insurance policy or health care plan" |
9 |
| means any policy of health or accident insurance provided by a |
10 |
| health insurance company or under the Counties Code, the |
11 |
| Municipal Code, the State Employees Group Insurance Act or |
12 |
| Medical Assistance provided under the Public Aid Code.
|
13 |
| (410 ILCS 50/3) (from Ch. 111 1/2, par. 5403)
|
14 |
| Sec. 3. The following rights are hereby established:
|
15 |
| (a) The right of each patient to care consistent with sound |
16 |
| nursing and
medical practices, to be informed of the name of |
17 |
| the physician responsible
for coordinating his or her care, to |
18 |
| receive information concerning his or
her condition and |
19 |
| proposed treatment, to refuse any treatment to the extent
|
20 |
| permitted by law, and to privacy and confidentiality of records |
21 |
| except as
otherwise provided by law. Each patient has a right |
22 |
| to be informed of his or her inpatient or outpatient status |
23 |
| while undergoing evaluation, assessment, diagnosis, treatment, |
24 |
| or observation in a hospital. The patient must be informed of |
|
|
|
09600HB6417ham001 |
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LRB096 21045 AMC 39407 a |
|
|
1 |
| this status and put on notice that this admission status may |
2 |
| affect coverage by his or her health insurance policy or health |
3 |
| care plan or his or her personal responsibility for payment.
|
4 |
| (b) The right of each patient, regardless of source of |
5 |
| payment, to examine
and receive a reasonable explanation of his |
6 |
| total bill for services rendered
by his physician or health |
7 |
| care provider, including the itemized charges
for specific |
8 |
| services received. Each physician or health care provider
shall |
9 |
| be responsible only for a reasonable explanation of those |
10 |
| specific
services provided by such physician or health care |
11 |
| provider.
|
12 |
| (c) In the event an insurance company or health services |
13 |
| corporation cancels
or refuses to renew an individual policy or |
14 |
| plan, the insured patient shall
be entitled to timely, prior |
15 |
| notice of the termination of such policy or plan.
|
16 |
| An insurance company or health services corporation that |
17 |
| requires any
insured patient or applicant for new or continued |
18 |
| insurance or coverage to
be tested for infection with human |
19 |
| immunodeficiency virus (HIV) or any
other identified causative |
20 |
| agent of acquired immunodeficiency syndrome
(AIDS) shall (1) |
21 |
| give the patient or applicant prior written notice of such
|
22 |
| requirement, (2) proceed with such testing only upon the |
23 |
| written
authorization of the applicant or patient, and (3) keep |
24 |
| the results of such
testing confidential. Notice of an adverse |
25 |
| underwriting or coverage
decision may be given to any |
26 |
| appropriately interested party, but the
insurer may only |
|
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| disclose the test result itself to a physician designated
by |
2 |
| the applicant or patient, and any such disclosure shall be in a |
3 |
| manner
that assures confidentiality.
|
4 |
| The Department of Insurance shall enforce the provisions of |
5 |
| this subsection.
|
6 |
| (d) The right of each patient to privacy and |
7 |
| confidentiality in health
care. Each physician, health care |
8 |
| provider, health services corporation and
insurance company |
9 |
| shall refrain from disclosing the nature or details of
services |
10 |
| provided to patients, except that such information may be |
11 |
| disclosed to the
patient, the party making treatment decisions |
12 |
| if the patient is incapable
of making decisions regarding the |
13 |
| health services provided, those parties
directly involved with |
14 |
| providing treatment to the patient or processing the
payment |
15 |
| for that treatment, those parties responsible for peer review,
|
16 |
| utilization review and quality assurance, and those parties |
17 |
| required to
be notified under the Abused and Neglected Child |
18 |
| Reporting Act, the
Illinois Sexually Transmissible Disease |
19 |
| Control Act or where otherwise
authorized or required by law. |
20 |
| This right may be waived in writing by the
patient or the |
21 |
| patient's guardian, but a physician or other health care
|
22 |
| provider may not condition the provision of services on the |
23 |
| patient's or
guardian's agreement to sign such a waiver.
|
24 |
| (Source: P.A. 86-895; 86-902; 86-1028; 87-334.)
|
25 |
| (410 ILCS 50/5)
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| Sec. 5. Statement of hospital patient's rights.
|
2 |
| (a) Each patient admitted to a hospital, and the guardian |
3 |
| or authorized
representative or parent of a minor patient, |
4 |
| shall be given a written
statement of all the rights enumerated |
5 |
| in this Act, or a similar statement of
patients' rights |
6 |
| required of the hospital by the Joint Commission on
|
7 |
| Accreditation of Healthcare Organizations or a similar |
8 |
| accrediting
organization. The statement shall be given at the |
9 |
| time of admission or as soon
thereafter as the condition of the |
10 |
| patient permits.
|
11 |
| (b) If a patient is unable to read the written statement, a |
12 |
| hospital
shall make a reasonable effort to provide it to the |
13 |
| guardian or authorized
representative of the patient.
|
14 |
| (c) The statement shall also include the right not to be |
15 |
| discriminated against by the hospital due to the patient's |
16 |
| race, color, or national origin where such characteristics are |
17 |
| not relevant to the patient's medical diagnosis and treatment. |
18 |
| The statement shall further provide each admitted patient or |
19 |
| the patient's representative or guardian with notice of how to |
20 |
| initiate a grievance regarding improper discrimination with |
21 |
| the hospital and how the patient may lodge a grievance with the |
22 |
| Illinois Department of Public Health regardless of whether the |
23 |
| patient has first used the hospital's grievance process. |
24 |
| (Source: P.A. 88-56; 88-670, eff. 12-2-94.)
|
25 |
| (410 ILCS 50/5.1 new)
|
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| Sec. 5.1. Discrimination grievance procedures. Upon |
2 |
| receipt of a grievance alleging unlawful discrimination on the |
3 |
| basis of race, color, or national origin, the hospital must |
4 |
| investigate the claim and work with the patient to address |
5 |
| valid or proven concerns in accordance with the hospital's |
6 |
| grievance process. At the conclusion of the hospital's |
7 |
| grievance process, the hospital shall inform the patient that |
8 |
| such grievances may be reported to the Illinois Department of |
9 |
| Public Health if not resolved to the patient's satisfaction at |
10 |
| the hospital level. |
11 |
| (410 ILCS 50/5.2 new)
|
12 |
| Sec. 5.2. Emergency room antidiscrimination notice. Every |
13 |
| hospital shall post a sign next to or in close proximity of its |
14 |
| sign required by Section 489.20 (q)(1) of Title 42 of the Code |
15 |
| of Federal Regulations stating the following: |
16 |
| "You have the right not to be discriminated against by the |
17 |
| hospital due to your race, color, or national origin if these |
18 |
| characteristics are unrelated to your diagnosis or treatment. |
19 |
| If you believe this right has been violated, please call |
20 |
| (insert number for hospital grievance officer).". |
21 |
| Section 90. The State Mandates Act is amended by adding |
22 |
| Section 8.34 as follows: |
23 |
| (30 ILCS 805/8.34 new) |
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| Sec. 8.34. Exempt mandate. Notwithstanding Sections 6 and 8 |
2 |
| of this Act, no reimbursement by the State is required for the |
3 |
| implementation of any mandate created by this amendatory Act of |
4 |
| the 96th General Assembly. |
5 |
| Section 95. No acceleration or delay. Where this Act makes |
6 |
| changes in a statute that is represented in this Act by text |
7 |
| that is not yet or no longer in effect (for example, a Section |
8 |
| represented by multiple versions), the use of that text does |
9 |
| not accelerate or delay the taking effect of (i) the changes |
10 |
| made by this Act or (ii) provisions derived from any other |
11 |
| Public Act.
|
12 |
| Section 99. Effective date. This Act takes effect upon |
13 |
| becoming law.".
|