HB3974 103RD GENERAL ASSEMBLY

LRB103 29802 BMS 56209 b

103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB3974

Introduced 2/17/2023, by Rep. Joyce Mason

SYNOPSIS AS INTRODUCED:

215 ILCS 5/356z.61 new

Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any service to functionally improve, repair, or restore any body part involving the cranial facial area that is medically necessary to achieve normal function or appearance. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Provides that the coverage does not apply to a policy that covers only dental care. Defines "treatment". Effective January 1, 2024.

A BILL FOR

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by adding Section 356z.61 as follows:

(215 ILCS 5/356z.61 new)

Sec. 356z.61. Coverage for congenital anomaly or birth defect.

(a) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 103rd General Assembly shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect, including, but not limited to, cleft lip and cleft palate.

(b) Coverage required under this Section includes any services to functionally improve, repair, or restore a body part involving the cranial facial area, including cleft lip and cleft palate, that is medically necessary to achieve normal function or appearance. Any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan.

(c) As used in this Section, "treatment" includes inpatient and outpatient care and services performed to improve or restore body function, or performed to approximate a normal appearance, due to a congenital anomaly, such as cleft lip or cleft palate, involving the cranial facial area and includes treatment of gross abnormalities of the lip and palate and any condition or illness that is related to or developed as a result of cleft lip or cleft palate. "Treatment" does not include cosmetic surgery performed to reshape normal facial structure or to improve appearance or self-esteem.

(d) Coverage shall include, but not be limited to, expenses for the following services up to the age of 19:

(1) oral surgery of the lip, palate, jaw, and related structures, including bone grafts;

(2) facial surgery of the lip, palate, jaw, nose, and related structures, including bone grafts;

(3) prosthetic treatment and appliances and prosthodontia, including obturators, speech appliances, and feeding appliances;

(4) orthodontic treatment and appliances and orthodontia;

(5) preventative and restorative dentistry;

(6) otolaryngology treatment and management; and

(7) anesthetics provided by a dentist with a permit provided under Section 8.1 of the Illinois Dental Practice Act when performed in conjunction with the treatment described in this Section.

Coverage shall not be denied solely on the grounds that the treatment is for cosmetic purposes or is not for a functional defect or impairment as provided in this Section.

(e) This Section does not apply to a policy that covers only dental care.

Section 99. Effective date. This Act takes effect January 1, 2024.