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1     AN ACT concerning regulation.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
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 and 356z.9 of the Illinois Insurance Code. The
15 program of health benefits must comply with Section 155.37 of
16 the Illinois Insurance Code.
17 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
18 95-520, eff. 8-28-07; revised 12-4-07.)
 
19     Section 10. The Counties Code is amended by changing
20 Section 5-1069.3 as follows:
 
21     (55 ILCS 5/5-1069.3)

 

 

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1     Sec. 5-1069.3. Required health benefits. If a county,
2 including a home rule county, is a self-insurer for purposes of
3 providing health insurance coverage for its employees, the
4 coverage shall include coverage for the post-mastectomy care
5 benefits required to be covered by a policy of accident and
6 health insurance under Section 356t and the coverage required
7 under Sections 356g.5, 356u, 356w, 356x, 356z.6, and 356z.9,
8 356z.10, and 356z.11 and 356z.9 of the Illinois Insurance Code.
9 The requirement that health benefits be covered as provided in
10 this Section is an exclusive power and function of the State
11 and is a denial and limitation under Article VII, Section 6,
12 subsection (h) of the Illinois Constitution. A home rule county
13 to which this Section applies must comply with every provision
14 of this Section.
15 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
16 95-520, eff. 8-28-07; revised 12-4-07.)
 
17     Section 15. The Illinois Municipal Code is amended by
18 changing Section 10-4-2.3 as follows:
 
19     (65 ILCS 5/10-4-2.3)
20     Sec. 10-4-2.3. Required health benefits. If a
21 municipality, including a home rule municipality, is a
22 self-insurer for purposes of providing health insurance
23 coverage for its employees, the coverage shall include coverage
24 for the post-mastectomy care benefits required to be covered by

 

 

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1 a policy of accident and health insurance under Section 356t
2 and the coverage required under Sections 356g.5, 356u, 356w,
3 356x, 356z.6, and 356z.9, 356z.10, and 356z.11 and 356z.9 of
4 the Illinois Insurance Code. The requirement that health
5 benefits be covered as provided in this is an exclusive power
6 and function of the State and is a denial and limitation under
7 Article VII, Section 6, subsection (h) of the Illinois
8 Constitution. A home rule municipality to which this Section
9 applies must comply with every provision of this Section.
10 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
11 95-520, eff. 8-28-07; revised 12-4-07.)
 
12     Section 20. The School Code is amended by changing Section
13 10-22.3f as follows:
 
14     (105 ILCS 5/10-22.3f)
15     Sec. 10-22.3f. Required health benefits. Insurance
16 protection and benefits for employees shall provide the
17 post-mastectomy care benefits required to be covered by a
18 policy of accident and health insurance under Section 356t and
19 the coverage required under Sections 356g.5, 356u, 356w, 356x,
20 356z.6, and 356z.9, and 356z.11 of the Illinois Insurance Code.
21 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
22 revised 12-4-07.)
 
23     Section 25. The Illinois Insurance Code is amended by

 

 

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1 adding Section 356z.11 as follows:
 
2     (215 ILCS 5/356z.11 new)
3     Sec. 356z.11. Habilitative services for children.
4     (a) As used in this Section, "habilitative services" means
5 occupational therapy, physical therapy, speech therapy, and
6 other services prescribed by the insured's treating physician
7 pursuant to a treatment plan to enhance the ability of a child
8 to function with a congenital, genetic, or early acquired
9 disorder. A congenital or genetic disorder includes, but is not
10 limited to, hereditary disorders. An early acquired disorder
11 refers to a disorder resulting from illness, trauma, injury, or
12 some other event or condition suffered by a child prior to that
13 child developing functional life skills such as, but not
14 limited to, walking, talking, or self-help skills. Congenital,
15 genetic, and early acquired disorders may include, but are not
16 limited to, autism or an autism spectrum disorder, cerebral
17 palsy, and other disorders resulting from early childhood
18 illness, trauma, or injury.
19     (b) A group or individual policy of accident and health
20 insurance or managed care plan amended, delivered, issued, or
21 renewed after the effective date of this amendatory Act of the
22 95th General Assembly must provide coverage for habilitative
23 services for children under 19 years of age with a congenital,
24 genetic, or early acquired disorder so long as all of the
25 following conditions are met:

 

 

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1         (1) A physician licensed to practice medicine in all
2     its branches has:
3             (A) diagnosed the child's congenital, genetic, or
4         early acquired disorder; and
5             (B) determined the treatment to be therapeutic and
6         not solely experimental or investigational.
7         (2) The treatment is administered under the
8     supervision of a physician licensed to practice medicine in
9     all its branches.
10     (c) The coverage required by this Section shall be subject
11 to other general exclusions and limitations of the policy,
12 including coordination of benefits, participating provider
13 requirements, restrictions on services provided by family or
14 household members, utilization review of health care services,
15 including review of medical necessity, case management,
16 experimental, and investigational treatments, and other
17 managed care provisions.
18     (d) Upon request of the reimbursing insurer, the provider
19 under whose supervision the habilitative services are being
20 provided shall furnish medical records, clinical notes, or
21 other necessary data to allow the insurer to substantiate that
22 initial or continued medical treatment is medically necessary
23 and that the patient's condition is clinically improving. When
24 the treating provider anticipates that continued treatment is
25 or will be required to permit the patient to achieve
26 demonstrable progress, the insurer may request that the

 

 

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1 provider furnish a treatment plan consisting of diagnosis,
2 proposed treatment by type, frequency, anticipated duration of
3 treatment, the anticipated goals of treatment, and how
4 frequently the treatment plan will be updated.
 
5     Section 30. The Health Maintenance Organization Act is
6 amended by changing Section 5-3 as follows:
 
7     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
8     Sec. 5-3. Insurance Code provisions.
9     (a) Health Maintenance Organizations shall be subject to
10 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
11 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
12 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
13 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
14 356z.11 356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
15 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2, 409,
16 412, 444, and 444.1, paragraph (c) of subsection (2) of Section
17 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
18 XXV, and XXVI of the Illinois Insurance Code.
19     (b) For purposes of the Illinois Insurance Code, except for
20 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
21 Maintenance Organizations in the following categories are
22 deemed to be "domestic companies":
23         (1) a corporation authorized under the Dental Service
24     Plan Act or the Voluntary Health Services Plans Act;

 

 

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1         (2) a corporation organized under the laws of this
2     State; or
3         (3) a corporation organized under the laws of another
4     state, 30% or more of the enrollees of which are residents
5     of this State, except a corporation subject to
6     substantially the same requirements in its state of
7     organization as is a "domestic company" under Article VIII
8     1/2 of the Illinois Insurance Code.
9     (c) In considering the merger, consolidation, or other
10 acquisition of control of a Health Maintenance Organization
11 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
12         (1) the Director shall give primary consideration to
13     the continuation of benefits to enrollees and the financial
14     conditions of the acquired Health Maintenance Organization
15     after the merger, consolidation, or other acquisition of
16     control takes effect;
17         (2)(i) the criteria specified in subsection (1)(b) of
18     Section 131.8 of the Illinois Insurance Code shall not
19     apply and (ii) the Director, in making his determination
20     with respect to the merger, consolidation, or other
21     acquisition of control, need not take into account the
22     effect on competition of the merger, consolidation, or
23     other acquisition of control;
24         (3) the Director shall have the power to require the
25     following information:
26             (A) certification by an independent actuary of the

 

 

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1         adequacy of the reserves of the Health Maintenance
2         Organization sought to be acquired;
3             (B) pro forma financial statements reflecting the
4         combined balance sheets of the acquiring company and
5         the Health Maintenance Organization sought to be
6         acquired as of the end of the preceding year and as of
7         a date 90 days prior to the acquisition, as well as pro
8         forma financial statements reflecting projected
9         combined operation for a period of 2 years;
10             (C) a pro forma business plan detailing an
11         acquiring party's plans with respect to the operation
12         of the Health Maintenance Organization sought to be
13         acquired for a period of not less than 3 years; and
14             (D) such other information as the Director shall
15         require.
16     (d) The provisions of Article VIII 1/2 of the Illinois
17 Insurance Code and this Section 5-3 shall apply to the sale by
18 any health maintenance organization of greater than 10% of its
19 enrollee population (including without limitation the health
20 maintenance organization's right, title, and interest in and to
21 its health care certificates).
22     (e) In considering any management contract or service
23 agreement subject to Section 141.1 of the Illinois Insurance
24 Code, the Director (i) shall, in addition to the criteria
25 specified in Section 141.2 of the Illinois Insurance Code, take
26 into account the effect of the management contract or service

 

 

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1 agreement on the continuation of benefits to enrollees and the
2 financial condition of the health maintenance organization to
3 be managed or serviced, and (ii) need not take into account the
4 effect of the management contract or service agreement on
5 competition.
6     (f) Except for small employer groups as defined in the
7 Small Employer Rating, Renewability and Portability Health
8 Insurance Act and except for medicare supplement policies as
9 defined in Section 363 of the Illinois Insurance Code, a Health
10 Maintenance Organization may by contract agree with a group or
11 other enrollment unit to effect refunds or charge additional
12 premiums under the following terms and conditions:
13         (i) the amount of, and other terms and conditions with
14     respect to, the refund or additional premium are set forth
15     in the group or enrollment unit contract agreed in advance
16     of the period for which a refund is to be paid or
17     additional premium is to be charged (which period shall not
18     be less than one year); and
19         (ii) the amount of the refund or additional premium
20     shall not exceed 20% of the Health Maintenance
21     Organization's profitable or unprofitable experience with
22     respect to the group or other enrollment unit for the
23     period (and, for purposes of a refund or additional
24     premium, the profitable or unprofitable experience shall
25     be calculated taking into account a pro rata share of the
26     Health Maintenance Organization's administrative and

 

 

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1     marketing expenses, but shall not include any refund to be
2     made or additional premium to be paid pursuant to this
3     subsection (f)). The Health Maintenance Organization and
4     the group or enrollment unit may agree that the profitable
5     or unprofitable experience may be calculated taking into
6     account the refund period and the immediately preceding 2
7     plan years.
8     The Health Maintenance Organization shall include a
9 statement in the evidence of coverage issued to each enrollee
10 describing the possibility of a refund or additional premium,
11 and upon request of any group or enrollment unit, provide to
12 the group or enrollment unit a description of the method used
13 to calculate (1) the Health Maintenance Organization's
14 profitable experience with respect to the group or enrollment
15 unit and the resulting refund to the group or enrollment unit
16 or (2) the Health Maintenance Organization's unprofitable
17 experience with respect to the group or enrollment unit and the
18 resulting additional premium to be paid by the group or
19 enrollment unit.
20     In no event shall the Illinois Health Maintenance
21 Organization Guaranty Association be liable to pay any
22 contractual obligation of an insolvent organization to pay any
23 refund authorized under this Section.
24 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
25 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
 

 

 

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1     Section 35. The Voluntary Health Services Plans Act is
2 amended by changing Section 10 as follows:
 
3     (215 ILCS 165/10)  (from Ch. 32, par. 604)
4     Sec. 10. Application of Insurance Code provisions. Health
5 services plan corporations and all persons interested therein
6 or dealing therewith shall be subject to the provisions of
7 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
8 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,
9 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
10 356z.9, 356z.10, 356z.11 356z.9, 364.01, 367.2, 368a, 401,
11 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
12 and (15) of Section 367 of the Illinois Insurance Code.
13 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
14 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
15 8-28-07; revised 12-5-07.)
 
16     Section 90. The State Mandates Act is amended by adding
17 Section 8.32 as follows:
 
18     (30 ILCS 805/8.32 new)
19     Sec. 8.32. Exempt mandate. Notwithstanding Sections 6 and 8
20 of this Act, no reimbursement by the State is required for the
21 implementation of any mandate created by this amendatory Act of
22 the 95th General Assembly.