Sen. James A. DeLeo

Filed: 7/10/2008

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 415

2     AMENDMENT NO. ______. Amend House Bill 415 by replacing
3 everything after the enacting clause with the following:
 
4     "Section 5. The State Employees Group Insurance Act of 1971
5 is amended by changing Section 6.11 as follows:
 
6     (5 ILCS 375/6.11)
7     Sec. 6.11. Required health benefits; Illinois Insurance
8 Code requirements. The program of health benefits shall provide
9 the post-mastectomy care benefits required to be covered by a
10 policy of accident and health insurance under Section 356t of
11 the Illinois Insurance Code. The program of health benefits
12 shall provide the coverage required under Sections 356g.5,
13 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10,
14 and 356z.11 356z.9 of the Illinois Insurance Code. The program
15 of health benefits must comply with Section 155.37 of the
16 Illinois Insurance Code.

 

 

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1 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
2 95-520, eff. 8-28-07; revised 12-4-07.)
 
3     Section 10. The Counties Code is amended by changing
4 Section 5-1069.3 as follows:
 
5     (55 ILCS 5/5-1069.3)
6     Sec. 5-1069.3. Required health benefits. If a county,
7 including a home rule county, is a self-insurer for purposes of
8 providing health insurance coverage for its employees, the
9 coverage shall include coverage for the post-mastectomy care
10 benefits required to be covered by a policy of accident and
11 health insurance under Section 356t and the coverage required
12 under Sections 356g.5, 356u, 356w, 356x, 356z.6, and 356z.9,
13 356z.10, and 356z.11 356z.9 of the Illinois Insurance Code. The
14 requirement that health benefits be covered as provided in this
15 Section is an exclusive power and function of the State and is
16 a denial and limitation under Article VII, Section 6,
17 subsection (h) of the Illinois Constitution. A home rule county
18 to which this Section applies must comply with every provision
19 of this Section.
20 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
21 95-520, eff. 8-28-07; revised 12-4-07.)
 
22     Section 15. The Illinois Municipal Code is amended by
23 changing Section 10-4-2.3 as follows:
 

 

 

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1     (65 ILCS 5/10-4-2.3)
2     Sec. 10-4-2.3. Required health benefits. If a
3 municipality, including a home rule municipality, is a
4 self-insurer for purposes of providing health insurance
5 coverage for its employees, the coverage shall include coverage
6 for the post-mastectomy care benefits required to be covered by
7 a policy of accident and health insurance under Section 356t
8 and the coverage required under Sections 356g.5, 356u, 356w,
9 356x, 356z.6, and 356z.9, 356z.10, and 356z.11 356z.9 of the
10 Illinois Insurance Code. The requirement that health benefits
11 be covered as provided in this is an exclusive power and
12 function of the State and is a denial and limitation under
13 Article VII, Section 6, subsection (h) of the Illinois
14 Constitution. A home rule municipality to which this Section
15 applies must comply with every provision of this Section.
16 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
17 95-520, eff. 8-28-07; revised 12-4-07.)
 
18     Section 20. The School Code is amended by changing Section
19 10-22.3f as follows:
 
20     (105 ILCS 5/10-22.3f)
21     Sec. 10-22.3f. Required health benefits. Insurance
22 protection and benefits for employees shall provide the
23 post-mastectomy care benefits required to be covered by a

 

 

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1 policy of accident and health insurance under Section 356t and
2 the coverage required under Sections 356g.5, 356u, 356w, 356x,
3 356z.6, and 356z.9, and 356z.11 of the Illinois Insurance Code.
4 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
5 revised 12-4-07.)
 
6     Section 25. The Illinois Insurance Code is amended by
7 adding Section 356z.11 as follows:
 
8     (215 ILCS 5/356z.11 new)
9     Sec. 356z.11. Autism spectrum disorders.
10     (a) A group or individual policy of accident and health
11 insurance or managed care plan amended, delivered, issued, or
12 renewed after the effective date of this amendatory Act of the
13 95th General Assembly must provide individuals under 21 years
14 of age coverage for the diagnosis of autism spectrum disorders
15 and for the treatment of autism spectrum disorders to the
16 extent that the diagnosis and treatment of autism spectrum
17 disorders are not already covered by the policy of accident and
18 health insurance or managed care plan.
19     (b) Coverage provided under this Section shall be subject
20 to a maximum benefit of $36,000 per year, but shall not be
21 subject to any limits on the number of visits to a service
22 provider. After December 30, 2009, the Director of the Division
23 of Insurance shall, on an annual basis, adjust the maximum
24 benefit for inflation using the Medical Care Component of the

 

 

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

 

 

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

 

 

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

 

 

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1 professional with expertise in treating effects of autism
2 spectrum disorders when the care is determined to be medically
3 necessary and ordered by a physician licensed to practice
4 medicine in all its branches:
5         (1) Psychiatric care, including diagnostic services.
6         (2) Psychological assessments and treatments.
7         (3) Rehabilitative treatments.
8         (4) Therapeutic care, including behavioral speech,
9     occupational, and physical therapies that provide
10     treatment in the following areas: (i) self care and
11     feeding, (ii) pragmatic, receptive, and expressive
12     language, (iii) cognitive functioning, (iv) applied
13     behavior analysis, intervention, and modification, (v)
14     motor planning, and (vi) sensory processing.
 
15     Section 30. The Health Maintenance Organization Act is
16 amended by changing Section 5-3 as follows:
 
17     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
18     Sec. 5-3. Insurance Code provisions.
19     (a) Health Maintenance Organizations shall be subject to
20 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
21 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
22 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
23 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10
24 356z.9, 356z.11, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,

 

 

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1 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2,
2 409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
3 Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
4 XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
5     (b) For purposes of the Illinois Insurance Code, except for
6 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
7 Maintenance Organizations in the following categories are
8 deemed to be "domestic companies":
9         (1) a corporation authorized under the Dental Service
10     Plan Act or the Voluntary Health Services Plans Act;
11         (2) a corporation organized under the laws of this
12     State; or
13         (3) a corporation organized under the laws of another
14     state, 30% or more of the enrollees of which are residents
15     of this State, except a corporation subject to
16     substantially the same requirements in its state of
17     organization as is a "domestic company" under Article VIII
18     1/2 of the Illinois Insurance Code.
19     (c) In considering the merger, consolidation, or other
20 acquisition of control of a Health Maintenance Organization
21 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
22         (1) the Director shall give primary consideration to
23     the continuation of benefits to enrollees and the financial
24     conditions of the acquired Health Maintenance Organization
25     after the merger, consolidation, or other acquisition of
26     control takes effect;

 

 

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1         (2)(i) the criteria specified in subsection (1)(b) of
2     Section 131.8 of the Illinois Insurance Code shall not
3     apply and (ii) the Director, in making his determination
4     with respect to the merger, consolidation, or other
5     acquisition of control, need not take into account the
6     effect on competition of the merger, consolidation, or
7     other acquisition of control;
8         (3) the Director shall have the power to require the
9     following information:
10             (A) certification by an independent actuary of the
11         adequacy of the reserves of the Health Maintenance
12         Organization sought to be acquired;
13             (B) pro forma financial statements reflecting the
14         combined balance sheets of the acquiring company and
15         the Health Maintenance Organization sought to be
16         acquired as of the end of the preceding year and as of
17         a date 90 days prior to the acquisition, as well as pro
18         forma financial statements reflecting projected
19         combined operation for a period of 2 years;
20             (C) a pro forma business plan detailing an
21         acquiring party's plans with respect to the operation
22         of the Health Maintenance Organization sought to be
23         acquired for a period of not less than 3 years; and
24             (D) such other information as the Director shall
25         require.
26     (d) The provisions of Article VIII 1/2 of the Illinois

 

 

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1 Insurance Code and this Section 5-3 shall apply to the sale by
2 any health maintenance organization of greater than 10% of its
3 enrollee population (including without limitation the health
4 maintenance organization's right, title, and interest in and to
5 its health care certificates).
6     (e) In considering any management contract or service
7 agreement subject to Section 141.1 of the Illinois Insurance
8 Code, the Director (i) shall, in addition to the criteria
9 specified in Section 141.2 of the Illinois Insurance Code, take
10 into account the effect of the management contract or service
11 agreement on the continuation of benefits to enrollees and the
12 financial condition of the health maintenance organization to
13 be managed or serviced, and (ii) need not take into account the
14 effect of the management contract or service agreement on
15 competition.
16     (f) Except for small employer groups as defined in the
17 Small Employer Rating, Renewability and Portability Health
18 Insurance Act and except for medicare supplement policies as
19 defined in Section 363 of the Illinois Insurance Code, a Health
20 Maintenance Organization may by contract agree with a group or
21 other enrollment unit to effect refunds or charge additional
22 premiums under the following terms and conditions:
23         (i) the amount of, and other terms and conditions with
24     respect to, the refund or additional premium are set forth
25     in the group or enrollment unit contract agreed in advance
26     of the period for which a refund is to be paid or

 

 

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1     additional premium is to be charged (which period shall not
2     be less than one year); and
3         (ii) the amount of the refund or additional premium
4     shall not exceed 20% of the Health Maintenance
5     Organization's profitable or unprofitable experience with
6     respect to the group or other enrollment unit for the
7     period (and, for purposes of a refund or additional
8     premium, the profitable or unprofitable experience shall
9     be calculated taking into account a pro rata share of the
10     Health Maintenance Organization's administrative and
11     marketing expenses, but shall not include any refund to be
12     made or additional premium to be paid pursuant to this
13     subsection (f)). The Health Maintenance Organization and
14     the group or enrollment unit may agree that the profitable
15     or unprofitable experience may be calculated taking into
16     account the refund period and the immediately preceding 2
17     plan years.
18     The Health Maintenance Organization shall include a
19 statement in the evidence of coverage issued to each enrollee
20 describing the possibility of a refund or additional premium,
21 and upon request of any group or enrollment unit, provide to
22 the group or enrollment unit a description of the method used
23 to calculate (1) the Health Maintenance Organization's
24 profitable experience with respect to the group or enrollment
25 unit and the resulting refund to the group or enrollment unit
26 or (2) the Health Maintenance Organization's unprofitable

 

 

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1 experience with respect to the group or enrollment unit and the
2 resulting additional premium to be paid by the group or
3 enrollment unit.
4     In no event shall the Illinois Health Maintenance
5 Organization Guaranty Association be liable to pay any
6 contractual obligation of an insolvent organization to pay any
7 refund authorized under this Section.
8 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
9 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
 
10     Section 35. The Voluntary Health Services Plans Act is
11 amended by changing Section 10 as follows:
 
12     (215 ILCS 165/10)  (from Ch. 32, par. 604)
13     Sec. 10. Application of Insurance Code provisions. Health
14 services plan corporations and all persons interested therein
15 or dealing therewith shall be subject to the provisions of
16 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
17 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,
18 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
19 356z.9, 356z.10 356z.9, 356z.11, 364.01, 367.2, 368a, 401,
20 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
21 and (15) of Section 367 of the Illinois Insurance Code.
22 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
23 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
24 8-28-07; revised 12-5-07.)
 

 

 

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