HB1530 EngrossedLRB097 09356 RPM 49491 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Sections 356z.14, 356z.15, and 370c and by adding
6Section 370c.1 as follows:
 
7    (215 ILCS 5/356z.14)
8    Sec. 356z.14. Autism spectrum disorders.
9    (a) A group or individual policy of accident and health
10insurance or managed care plan amended, delivered, issued, or
11renewed after the effective date of this amendatory Act of the
1295th General Assembly must provide individuals under 21 years
13of age coverage for the diagnosis of autism spectrum disorders
14and for the treatment of autism spectrum disorders to the
15extent that the diagnosis and treatment of autism spectrum
16disorders are not already covered by the policy of accident and
17health insurance or managed care plan.
18    (b) Coverage provided under this Section through a group or
19individual policy of accident and health insurance or managed
20care plan shall be subject to the parity requirements of
21Section 370c.1 of this Code; provided, however, that a group or
22individual policy of accident and health insurance or managed
23care plan amended, delivered, issued, or renewed on or after

 

 

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1the effective date of this amendatory Act of the 97th General
2Assembly must provide a minimum maximum benefit of $36,000 per
3year, and but shall not be subject to any limits on the number
4of visits to a service provider. After December 30, 2009, the
5Director of the Division of Insurance shall, on an annual
6basis, adjust the minimum maximum benefit for inflation using
7the Medical Care Component of the United States Department of
8Labor Consumer Price Index for All Urban Consumers. Payments
9made by an insurer on behalf of a covered individual for any
10care, treatment, intervention, service, or item, the provision
11of which was for the treatment of a health condition not
12diagnosed as an autism spectrum disorder, shall not be applied
13toward any minimum maximum benefit established under this
14subsection.
15    (c) (Blank). Coverage under this Section shall be subject
16to copayment, deductible, and coinsurance provisions of a
17policy of accident and health insurance or managed care plan to
18the extent that other medical services covered by the policy of
19accident and health insurance or managed care plan are subject
20to these provisions.
21    (d) This Section shall not be construed as limiting
22benefits that are otherwise available to an individual under a
23policy of accident and health insurance or managed care plan
24and benefits provided under this Section may not be subject to
25dollar limits, deductibles, copayments, or coinsurance
26provisions that are less favorable to the insured than the

 

 

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1dollar limits, deductibles, or coinsurance provisions that
2apply to physical illness generally.
3    (e) An insurer may not deny or refuse to provide otherwise
4covered services, or refuse to renew, refuse to reissue, or
5otherwise terminate or restrict coverage under an individual
6contract to provide services to an individual because the
7individual or their dependent is diagnosed with an autism
8spectrum disorder or due to the individual utilizing benefits
9in this Section.
10    (f) Upon request of the reimbursing insurer, a provider of
11treatment for autism spectrum disorders shall furnish medical
12records, clinical notes, or other necessary data that
13substantiate that initial or continued medical treatment is
14medically necessary and is resulting in improved clinical
15status. When treatment is anticipated to require continued
16services to achieve demonstrable progress, the insurer may
17request a treatment plan consisting of diagnosis, proposed
18treatment by type, frequency, anticipated duration of
19treatment, the anticipated outcomes stated as goals, and the
20frequency by which the treatment plan will be updated.
21    (g) When making a determination of medical necessity for a
22treatment modality for autism spectrum disorders, an insurer
23must make the determination in a manner that is consistent with
24the manner used to make that determination with respect to
25other diseases or illnesses covered under the policy, including
26an appeals process. During the appeals process, any challenge

 

 

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1to medical necessity must be viewed as reasonable only if the
2review includes a physician with expertise in the most current
3and effective treatment modalities for autism spectrum
4disorders.
5    (h) Coverage for medically necessary early intervention
6services must be delivered by certified early intervention
7specialists, as defined in 89 Ill. Admin. Code 500 and any
8subsequent amendments thereto.
9    (i) As used in this Section:
10    "Autism spectrum disorders" means pervasive developmental
11disorders as defined in the most recent edition of the
12Diagnostic and Statistical Manual of Mental Disorders,
13including autism, Asperger's disorder, and pervasive
14developmental disorder not otherwise specified.
15    "Diagnosis of autism spectrum disorders" means one or more
16tests, evaluations, or assessments to diagnose whether an
17individual has autism spectrum disorder that is prescribed,
18performed, or ordered by (A) a physician licensed to practice
19medicine in all its branches or (B) a licensed clinical
20psychologist with expertise in diagnosing autism spectrum
21disorders.
22    "Medically necessary" means any care, treatment,
23intervention, service or item which will or is reasonably
24expected to do any of the following: (i) prevent the onset of
25an illness, condition, injury, disease or disability; (ii)
26reduce or ameliorate the physical, mental or developmental

 

 

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1effects of an illness, condition, injury, disease or
2disability; or (iii) assist to achieve or maintain maximum
3functional activity in performing daily activities.
4    "Treatment for autism spectrum disorders" shall include
5the following care prescribed, provided, or ordered for an
6individual diagnosed with an autism spectrum disorder by (A) a
7physician licensed to practice medicine in all its branches or
8(B) a certified, registered, or licensed health care
9professional with expertise in treating effects of autism
10spectrum disorders when the care is determined to be medically
11necessary and ordered by a physician licensed to practice
12medicine in all its branches:
13        (1) Psychiatric care, meaning direct, consultative, or
14    diagnostic services provided by a licensed psychiatrist.
15        (2) Psychological care, meaning direct or consultative
16    services provided by a licensed psychologist.
17        (3) Habilitative or rehabilitative care, meaning
18    professional, counseling, and guidance services and
19    treatment programs, including applied behavior analysis,
20    that are intended to develop, maintain, and restore the
21    functioning of an individual. As used in this subsection
22    (i), "applied behavior analysis" means the design,
23    implementation, and evaluation of environmental
24    modifications using behavioral stimuli and consequences to
25    produce socially significant improvement in human
26    behavior, including the use of direct observation,

 

 

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1    measurement, and functional analysis of the relations
2    between environment and behavior.
3        (4) Therapeutic care, including behavioral, speech,
4    occupational, and physical therapies that provide
5    treatment in the following areas: (i) self care and
6    feeding, (ii) pragmatic, receptive, and expressive
7    language, (iii) cognitive functioning, (iv) applied
8    behavior analysis, intervention, and modification, (v)
9    motor planning, and (vi) sensory processing.
10    (j) Rulemaking authority to implement this amendatory Act
11of the 95th General Assembly, if any, is conditioned on the
12rules being adopted in accordance with all provisions of the
13Illinois Administrative Procedure Act and all rules and
14procedures of the Joint Committee on Administrative Rules; any
15purported rule not so adopted, for whatever reason, is
16unauthorized.
17(Source: P.A. 95-1005, eff. 12-12-08; 96-1000, eff. 7-2-10.)
 
18    (215 ILCS 5/356z.15)
19    Sec. 356z.15. Habilitative services for children.
20    (a) As used in this Section, "habilitative services" means
21occupational therapy, physical therapy, speech therapy, and
22other services prescribed by the insured's treating physician
23pursuant to a treatment plan to enhance the ability of a child
24to function with a congenital, genetic, or early acquired
25disorder. A congenital or genetic disorder includes, but is not

 

 

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1limited to, hereditary disorders. An early acquired disorder
2refers to a disorder resulting from illness, trauma, injury, or
3some other event or condition suffered by a child prior to that
4child developing functional life skills such as, but not
5limited to, walking, talking, or self-help skills. Congenital,
6genetic, and early acquired disorders may include, but are not
7limited to, autism or an autism spectrum disorder, cerebral
8palsy, and other disorders resulting from early childhood
9illness, trauma, or injury.
10    (b) A group or individual policy of accident and health
11insurance or managed care plan amended, delivered, issued, or
12renewed after the effective date of this amendatory Act of the
1395th General Assembly must provide coverage for habilitative
14services for children under 19 years of age with a congenital,
15genetic, or early acquired disorder so long as all of the
16following conditions are met:
17        (1) A physician licensed to practice medicine in all
18    its branches has diagnosed the child's congenital,
19    genetic, or early acquired disorder.
20        (2) The treatment is administered by a licensed
21    speech-language pathologist, licensed audiologist,
22    licensed occupational therapist, licensed physical
23    therapist, licensed physician, licensed nurse, licensed
24    optometrist, licensed nutritionist, licensed social
25    worker, or licensed psychologist upon the referral of a
26    physician licensed to practice medicine in all its

 

 

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1    branches.
2        (3) The initial or continued treatment must be
3    medically necessary and therapeutic and not experimental
4    or investigational.
5    (c) The coverage required by this Section shall be subject
6to other general exclusions and limitations of the policy,
7including coordination of benefits, participating provider
8requirements, restrictions on services provided by family or
9household members, utilization review of health care services,
10including review of medical necessity, case management,
11experimental, and investigational treatments, and other
12managed care provisions.
13    (d) Coverage under this Section does not apply to those
14services that are solely educational in nature or otherwise
15paid under State or federal law for purely educational
16services. Nothing in this subsection (d) relieves an insurer or
17similar third party from an otherwise valid obligation to
18provide or to pay for services provided to a child with a
19disability.
20    (e) Coverage under this Section for children under age 19
21shall not apply to treatment of mental or emotional disorders
22or illnesses as covered under Section 370 of this Code as well
23as any other benefit based upon a specific diagnosis that may
24be otherwise required by law.
25    (f) The provisions of this Section do not apply to
26short-term travel, accident-only, limited, or specific disease

 

 

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1policies.
2    (g) Any denial of care for habilitative services shall be
3subject to appeal and external independent review procedures as
4provided by Section 45 of the Managed Care Reform and Patient
5Rights Act.
6    (h) Upon request of the reimbursing insurer, the provider
7under whose supervision the habilitative services are being
8provided shall furnish medical records, clinical notes, or
9other necessary data to allow the insurer to substantiate that
10initial or continued medical treatment is medically necessary
11and that the patient's condition is clinically improving. When
12the treating provider anticipates that continued treatment is
13or will be required to permit the patient to achieve
14demonstrable progress, the insurer may request that the
15provider furnish a treatment plan consisting of diagnosis,
16proposed treatment by type, frequency, anticipated duration of
17treatment, the anticipated goals of treatment, and how
18frequently the treatment plan will be updated.
19    (i) Rulemaking authority to implement this amendatory Act
20of the 95th General Assembly, if any, is conditioned on the
21rules being adopted in accordance with all provisions of the
22Illinois Administrative Procedure Act and all rules and
23procedures of the Joint Committee on Administrative Rules; any
24purported rule not so adopted, for whatever reason, is
25unauthorized.
26    (j) Coverage provided under this Section through a group or

 

 

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1individual policy of accident and health insurance or managed
2care plan for the treatment of mental, emotional, nervous, or
3substance use disorders or conditions shall be subject to the
4parity requirements of Section 370c.1 of this Code.
5(Source: P.A. 95-1049, eff. 1-1-10; 96-833, eff. 6-1-10;
696-1000, eff. 7-2-10.)
 
7    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
8    Sec. 370c. Mental and emotional disorders.
9    (a) (1) On and after the effective date of this amendatory
10Act of the 97th General Assembly Section, every insurer which
11amends, delivers, issues, or renews delivers, issues for
12delivery or renews or modifies group accident and health A&H
13policies providing coverage for hospital or medical treatment
14or services for illness on an expense-incurred basis shall
15offer to the applicant or group policyholder subject to the
16insurer's insurers standards of insurability, coverage for
17reasonable and necessary treatment and services for mental,
18emotional or nervous disorders or conditions, other than
19serious mental illnesses as defined in item (2) of subsection
20(b), consistent with the parity requirements of Section 370c.1
21of this Code up to the limits provided in the policy for other
22disorders or conditions, except (i) the insured may be required
23to pay up to 50% of expenses incurred as a result of the
24treatment or services, and (ii) the annual benefit limit may be
25limited to the lesser of $10,000 or 25% of the lifetime policy

 

 

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1limit.
2    (2) Each insured that is covered for mental, emotional, or
3nervous, or substance use disorders or conditions shall be free
4to select the physician licensed to practice medicine in all
5its branches, licensed clinical psychologist, licensed
6clinical social worker, licensed clinical professional
7counselor, or licensed marriage and family therapist, licensed
8speech-language pathologist, or other licensed or certified
9professional at a program licensed pursuant to the Illinois
10Alcoholism and Other Drug Abuse and Dependency Act of his
11choice to treat such disorders, and the insurer shall pay the
12covered charges of such physician licensed to practice medicine
13in all its branches, licensed clinical psychologist, licensed
14clinical social worker, licensed clinical professional
15counselor, or licensed marriage and family therapist, licensed
16speech-language pathologist, or other licensed or certified
17professional at a program licensed pursuant to the Illinois
18Alcoholism and Other Drug Abuse and Dependency Act up to the
19limits of coverage, provided (i) the disorder or condition
20treated is covered by the policy, and (ii) the physician,
21licensed psychologist, licensed clinical social worker,
22licensed clinical professional counselor, or licensed marriage
23and family therapist, licensed speech-language pathologist, or
24other licensed or certified professional at a program licensed
25pursuant to the Illinois Alcoholism and Other Drug Abuse and
26Dependency Act is authorized to provide said services under the

 

 

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1statutes of this State and in accordance with accepted
2principles of his profession.
3    (3) Insofar as this Section applies solely to licensed
4clinical social workers, licensed clinical professional
5counselors, and licensed marriage and family therapists,
6licensed speech-language pathologist, and other licensed or
7certified professionals at programs licensed pursuant to the
8Illinois Alcoholism and Other Drug Abuse and Dependency Act,
9those persons who may provide services to individuals shall do
10so after the licensed clinical social worker, licensed clinical
11professional counselor, or licensed marriage and family
12therapist, licensed speech-language pathologist, or other
13licensed or certified professional at a program licensed
14pursuant to the Illinois Alcoholism and Other Drug Abuse and
15Dependency Act has informed the patient of the desirability of
16the patient conferring with the patient's primary care
17physician and the licensed clinical social worker, licensed
18clinical professional counselor, or licensed marriage and
19family therapist, licensed speech-language pathologist, or
20other licensed or certified professional at a program licensed
21pursuant to the Illinois Alcoholism and Other Drug Abuse and
22Dependency Act has provided written notification to the
23patient's primary care physician, if any, that services are
24being provided to the patient. That notification may, however,
25be waived by the patient on a written form. Those forms shall
26be retained by the licensed clinical social worker, licensed

 

 

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1clinical professional counselor, or licensed marriage and
2family therapist, licensed speech-language pathologist, or
3other licensed or certified professional at a program licensed
4pursuant to the Illinois Alcoholism and Other Drug Abuse and
5Dependency Act for a period of not less than 5 years.
6    (b) (1) An insurer that provides coverage for hospital or
7medical expenses under a group policy of accident and health
8insurance or health care plan amended, delivered, issued, or
9renewed on or after the effective date of this amendatory Act
10of the 97th 92nd General Assembly shall provide coverage under
11the policy for treatment of serious mental illness and
12substance use disorders consistent with the parity
13requirements of Section 370c.1 of this Code under the same
14terms and conditions as coverage for hospital or medical
15expenses related to other illnesses and diseases. The coverage
16required under this Section must provide for same durational
17limits, amount limits, deductibles, and co-insurance
18requirements for serious mental illness as are provided for
19other illnesses and diseases. This subsection does not apply to
20any group policy of accident and health insurance or health
21care plan for any plan year of a small employer as defined in
22Section 5 of the Illinois Health Insurance Portability and
23Accountability Act coverage provided to employees by employers
24who have 50 or fewer employees.
25    (2) "Serious mental illness" means the following
26psychiatric illnesses as defined in the most current edition of

 

 

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1the Diagnostic and Statistical Manual (DSM) published by the
2American Psychiatric Association:
3        (A) schizophrenia;
4        (B) paranoid and other psychotic disorders;
5        (C) bipolar disorders (hypomanic, manic, depressive,
6    and mixed);
7        (D) major depressive disorders (single episode or
8    recurrent);
9        (E) schizoaffective disorders (bipolar or depressive);
10        (F) pervasive developmental disorders;
11        (G) obsessive-compulsive disorders;
12        (H) depression in childhood and adolescence;
13        (I) panic disorder;
14        (J) post-traumatic stress disorders (acute, chronic,
15    or with delayed onset); and
16        (K) anorexia nervosa and bulimia nervosa.
17    (2.5) "Substance use disorder" means the following mental
18disorders as defined in the most current edition of the
19Diagnostic and Statistical Manual (DSM) published by the
20American Psychiatric Association:
21        (A) substance abuse disorders;
22        (B) substance dependence disorders; and
23        (C) substance induced disorders.
24    (3) Unless otherwise prohibited by federal law and
25consistent with the parity requirements of Section 370c.1 of
26this Code, Upon request of the reimbursing insurer, a provider

 

 

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1of treatment of serious mental illness or substance use
2disorder shall furnish medical records or other necessary data
3that substantiate that initial or continued treatment is at all
4times medically necessary. An insurer shall provide a mechanism
5for the timely review by a provider holding the same license
6and practicing in the same specialty as the patient's provider,
7who is unaffiliated with the insurer, jointly selected by the
8patient (or the patient's next of kin or legal representative
9if the patient is unable to act for himself or herself), the
10patient's provider, and the insurer in the event of a dispute
11between the insurer and patient's provider regarding the
12medical necessity of a treatment proposed by a patient's
13provider. If the reviewing provider determines the treatment to
14be medically necessary, the insurer shall provide
15reimbursement for the treatment. Future contractual or
16employment actions by the insurer regarding the patient's
17provider may not be based on the provider's participation in
18this procedure. Nothing prevents the insured from agreeing in
19writing to continue treatment at his or her expense. When
20making a determination of the medical necessity for a treatment
21modality for serious serous mental illness or substance use
22disorder, an insurer must make the determination in a manner
23that is consistent with the manner used to make that
24determination with respect to other diseases or illnesses
25covered under the policy, including an appeals process. Medical
26necessity determinations for substance use disorders shall be

 

 

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1made in accordance with appropriate patient placement criteria
2established by the American Society of Addiction Medicine.
3    (4) A group health benefit plan amended, delivered, issued,
4or renewed on or after the effective date of this amendatory
5Act of the 97th General Assembly:
6        (A) shall provide coverage based upon medical
7    necessity for the following treatment of mental illness and
8    substance use disorders consistent with the parity
9    requirements of Section 370c.1 of this Code; provided,
10    however, that in each calendar year coverage shall not be
11    less than the following:
12            (i) 45 days of inpatient treatment; and
13            (ii) beginning on June 26, 2006 (the effective date
14        of Public Act 94-921), 60 visits for outpatient
15        treatment including group and individual outpatient
16        treatment; and
17            (iii) for plans or policies delivered, issued for
18        delivery, renewed, or modified after January 1, 2007
19        (the effective date of Public Act 94-906), 20
20        additional outpatient visits for speech therapy for
21        treatment of pervasive developmental disorders that
22        will be in addition to speech therapy provided pursuant
23        to item (ii) of this subparagraph (A); and
24        (B) may not include a lifetime limit on the number of
25    days of inpatient treatment or the number of outpatient
26    visits covered under the plan. ; and

 

 

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1        (C) (Blank). shall include the same amount limits,
2    deductibles, copayments, and coinsurance factors for
3    serious mental illness as for physical illness.
4    (5) An issuer of a group health benefit plan may not count
5toward the number of outpatient visits required to be covered
6under this Section an outpatient visit for the purpose of
7medication management and shall cover the outpatient visits
8under the same terms and conditions as it covers outpatient
9visits for the treatment of physical illness.
10    (6) An issuer of a group health benefit plan may provide or
11offer coverage required under this Section through a managed
12care plan.
13    (7) (Blank). This Section shall not be interpreted to
14require a group health benefit plan to provide coverage for
15treatment of:
16        (A) an addiction to a controlled substance or cannabis
17    that is used in violation of law; or
18        (B) mental illness resulting from the use of a
19    controlled substance or cannabis in violation of law.
20    (8) (Blank).
21    (9) With respect to substance use disorders, coverage for
22inpatient treatment shall include coverage for treatment in a
23residential treatment center licensed by the Department of
24Public Health or the Department of Human Services, Division of
25Alcoholism and Substance Abuse.
26    (c) This Section shall not be interpreted to require

 

 

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1coverage for speech therapy or other habilitative services for
2those individuals covered under Section 356z.15 of this Code.
3(Source: P.A. 95-331, eff. 8-21-07; 95-972, eff. 9-22-08;
495-973, eff. 1-1-09; 95-1049, eff. 1-1-10; 96-328, eff.
58-11-09; 96-1000, eff. 7-2-10.)
 
6    (215 ILCS 5/370c.1 new)
7    Sec. 370c.1. Mental health parity.
8    (a) On and after the effective date of this amendatory Act
9of the 97th General Assembly, every insurer that amends,
10delivers, issues, or renews a group policy of accident and
11health insurance in this State providing coverage for hospital
12or medical treatment and for the treatment of mental,
13emotional, nervous, or substance use disorders or conditions
14shall ensure that:
15        (1) the financial requirements applicable to such
16    mental, emotional, nervous, or substance use disorder or
17    condition benefits are no more restrictive than the
18    predominant financial requirements applied to
19    substantially all hospital and medical benefits covered by
20    the policy and that there are no separate cost-sharing
21    requirements that are applicable only with respect to
22    mental, emotional, nervous, or substance use disorder or
23    condition benefits; and
24        (2) the treatment limitations applicable to such
25    mental, emotional, nervous, or substance use disorder or

 

 

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1    condition benefits are no more restrictive than the
2    predominant treatment limitations applied to substantially
3    all hospital and medical benefits covered by the policy and
4    that there are no separate treatment limitations that are
5    applicable only with respect to mental, emotional,
6    nervous, or substance use disorder or condition benefits.
7    (b) The following provisions shall apply concerning
8aggregate lifetime limits:
9        (1) In the case of a group policy of accident and
10    health insurance amended, delivered, issued, or renewed in
11    this State on or after the effective date of this
12    amendatory Act of the 97th General Assembly that provides
13    coverage for hospital or medical treatment and for the
14    treatment of mental, emotional, nervous, or substance use
15    disorders or conditions the following provisions shall
16    apply:
17            (A) if the policy does not include an aggregate
18        lifetime limit on substantially all hospital and
19        medical benefits, then the policy may not impose any
20        aggregate lifetime limit on mental, emotional,
21        nervous, or substance use disorder or condition
22        benefits; or
23            (B) if the policy includes an aggregate lifetime
24        limit on substantially all hospital and medical
25        benefits (in this subsection referred to as the
26        "applicable lifetime limit"), then the policy shall

 

 

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1        either:
2                (i) apply the applicable lifetime limit both
3            to the hospital and medical benefits to which it
4            otherwise would apply and to mental, emotional,
5            nervous, or substance use disorder or condition
6            benefits and not distinguish in the application of
7            the limit between the hospital and medical
8            benefits and mental, emotional, nervous, or
9            substance use disorder or condition benefits; or
10                (ii) not include any aggregate lifetime limit
11            on mental, emotional, nervous, or substance use
12            disorder or condition benefits that is less than
13            the applicable lifetime limit.
14        (2) In the case of a policy that is not described in
15    paragraph (1) of subsection (b) of this Section and that
16    includes no or different aggregate lifetime limits on
17    different categories of hospital and medical benefits, the
18    Director shall establish rules under which subparagraph
19    (B) of paragraph (1) of subsection (b) of this Section is
20    applied to such policy with respect to mental, emotional,
21    nervous, or substance use disorder or condition benefits by
22    substituting for the applicable lifetime limit an average
23    aggregate lifetime limit that is computed taking into
24    account the weighted average of the aggregate lifetime
25    limits applicable to such categories.
26    (c) The following provisions shall apply concerning annual

 

 

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1limits:
2        (1) In the case of a group policy of accident and
3    health insurance amended, delivered, issued, or renewed in
4    this State on or after the effective date of this
5    amendatory Act of the 97th General Assembly that provides
6    coverage for hospital or medical treatment and for the
7    treatment of mental, emotional, nervous, or substance use
8    disorders or conditions the following provisions shall
9    apply:
10            (A) if the policy does not include an annual limit
11        on substantially all hospital and medical benefits,
12        then the policy may not impose any annual limits on
13        mental, emotional, nervous, or substance use disorder
14        or condition benefits; or
15            (B) if the policy includes an annual limit on
16        substantially all hospital and medical benefits (in
17        this subsection referred to as the "applicable annual
18        limit"), then the policy shall either:
19                (i) apply the applicable annual limit both to
20            the hospital and medical benefits to which it
21            otherwise would apply and to mental, emotional,
22            nervous, or substance use disorder or condition
23            benefits and not distinguish in the application of
24            the limit between the hospital and medical
25            benefits and mental, emotional, nervous, or
26            substance use disorder or condition benefits; or

 

 

HB1530 Engrossed- 22 -LRB097 09356 RPM 49491 b

1                (ii) not include any annual limit on mental,
2            emotional, nervous, or substance use disorder or
3            condition benefits that is less than the
4            applicable annual limit.
5        (2) In the case of a policy that is not described in
6    paragraph (1) of subsection (c) of this Section and that
7    includes no or different annual limits on different
8    categories of hospital and medical benefits, the Director
9    shall establish rules under which subparagraph (B) of
10    paragraph (1) of subsection (c) of this Section is applied
11    to such policy with respect to mental, emotional, nervous,
12    or substance use disorder or condition benefits by
13    substituting for the applicable annual limit an average
14    annual limit that is computed taking into account the
15    weighted average of the annual limits applicable to such
16    categories.
17    (d) This Section shall be interpreted in a manner
18consistent with the interim final regulations promulgated by
19the U.S. Department of Health and Human Services at 75 FR 5410,
20including the prohibition against applying a cumulative
21financial requirement or cumulative quantitative treatment
22limitation for mental, emotional, nervous, or substance use
23disorder benefits that accumulates separately from any
24cumulative financial requirement or cumulative quantitative
25treatment limitation established for hospital and medical
26benefits in the same classification.

 

 

HB1530 Engrossed- 23 -LRB097 09356 RPM 49491 b

1    (e) The provisions of subsections (b) and (c) of this
2Section shall not be interpreted to allow the use of lifetime
3or annual limits otherwise prohibited by State or federal law.
4    (f) As used in this Section:
5    "Financial requirement" includes deductibles, copayments,
6coinsurance, and out-of-pocket maximums, but does not include
7an aggregate lifetime limit or an annual limit subject to
8subsections (b) and (c).
9    "Treatment limitation" includes limits on benefits based
10on the frequency of treatment, number of visits, days of
11coverage, days in a waiting period, or other similar limits on
12the scope or duration of treatment. "Treatment limitation"
13includes both quantitative treatment limitations, which are
14expressed numerically (such as 50 outpatient visits per year),
15and nonquantitative treatment limitations, which otherwise
16limit the scope or duration of treatment. A permanent exclusion
17of all benefits for a particular condition or disorder shall
18not be considered a treatment limitation.
 
19    Section 10. The Health Maintenance Organization Act is
20amended by changing Section 5-3 as follows:
 
21    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
22    Sec. 5-3. Insurance Code provisions.
23    (a) Health Maintenance Organizations shall be subject to
24the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,

 

 

HB1530 Engrossed- 24 -LRB097 09356 RPM 49491 b

1141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
2154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
3356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
4356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
5356z.18, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
6368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2,
7409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
8Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
9XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
10    (b) For purposes of the Illinois Insurance Code, except for
11Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
12Maintenance Organizations in the following categories are
13deemed to be "domestic companies":
14        (1) a corporation authorized under the Dental Service
15    Plan Act or the Voluntary Health Services Plans Act;
16        (2) a corporation organized under the laws of this
17    State; or
18        (3) a corporation organized under the laws of another
19    state, 30% or more of the enrollees of which are residents
20    of this State, except a corporation subject to
21    substantially the same requirements in its state of
22    organization as is a "domestic company" under Article VIII
23    1/2 of the Illinois Insurance Code.
24    (c) In considering the merger, consolidation, or other
25acquisition of control of a Health Maintenance Organization
26pursuant to Article VIII 1/2 of the Illinois Insurance Code,

 

 

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

 

 

HB1530 Engrossed- 26 -LRB097 09356 RPM 49491 b

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

 

 

HB1530 Engrossed- 27 -LRB097 09356 RPM 49491 b

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

 

 

HB1530 Engrossed- 28 -LRB097 09356 RPM 49491 b

1the group or enrollment unit a description of the method used
2to calculate (1) the Health Maintenance Organization's
3profitable experience with respect to the group or enrollment
4unit and the resulting refund to the group or enrollment unit
5or (2) the Health Maintenance Organization's unprofitable
6experience with respect to the group or enrollment unit and the
7resulting additional premium to be paid by the group or
8enrollment unit.
9    In no event shall the Illinois Health Maintenance
10Organization Guaranty Association be liable to pay any
11contractual obligation of an insolvent organization to pay any
12refund authorized under this Section.
13    (g) Rulemaking authority to implement Public Act 95-1045,
14if any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
2095-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
2195-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
221-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff.
236-1-10; 96-1000, eff. 7-2-10.)
 
24    Section 99. Effective date. This Act takes effect upon
25becoming law.