Full Text of SB0101 95th General Assembly
SB0101ham002 95TH GENERAL ASSEMBLY
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Rep. Elaine Nekritz
Filed: 5/31/2008
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LRB095 03635 DRJ 51832 a |
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| AMENDMENT TO SENATE BILL 101
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| AMENDMENT NO. ______. Amend Senate Bill 101, AS AMENDED, by | 3 |
| replacing everything after the enacting clause with the | 4 |
| following:
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| "Section 5. The State Employees Group Insurance Act of 1971 | 6 |
| 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 | 9 |
| Code
requirements. The program of health
benefits shall provide | 10 |
| the post-mastectomy care benefits required to be covered
by a | 11 |
| policy of accident and health insurance under Section 356t of | 12 |
| the Illinois
Insurance Code. The program of health benefits | 13 |
| shall provide the coverage
required under Sections 356g.5,
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| 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, | 15 |
| and 356z.11 and 356z.9 of the
Illinois Insurance Code.
The |
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| program of health benefits must comply with Section 155.37 of | 2 |
| the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 4 |
| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 10. The Counties Code is amended by changing | 6 |
| Section 5-1069.3 as follows: | 7 |
| (55 ILCS 5/5-1069.3)
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| Sec. 5-1069.3. Required health benefits. If a county, | 9 |
| including a home
rule
county, is a self-insurer for purposes of | 10 |
| providing health insurance coverage
for its employees, the | 11 |
| coverage shall include coverage for the post-mastectomy
care | 12 |
| benefits required to be covered by a policy of accident and | 13 |
| health
insurance under Section 356t and the coverage required | 14 |
| under Sections 356g.5, 356u,
356w, 356x, 356z.6, and 356z.9, | 15 |
| 356z.10, and 356z.11 and 356z.9 of
the Illinois Insurance Code. | 16 |
| The requirement that health benefits be covered
as provided in | 17 |
| this Section is an
exclusive power and function of the State | 18 |
| and is a denial and limitation under
Article VII, Section 6, | 19 |
| subsection (h) of the Illinois Constitution. A home
rule county | 20 |
| to which this Section applies must comply with every provision | 21 |
| of
this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 23 |
| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 15. The Illinois Municipal Code is amended by | 2 |
| changing Section 10-4-2.3 as follows: | 3 |
| (65 ILCS 5/10-4-2.3)
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| Sec. 10-4-2.3. Required health benefits. If a | 5 |
| municipality, including a
home rule municipality, is a | 6 |
| self-insurer for purposes of providing health
insurance | 7 |
| coverage for its employees, the coverage shall include coverage | 8 |
| for
the post-mastectomy care benefits required to be covered by | 9 |
| a policy of
accident and health insurance under Section 356t | 10 |
| and the coverage required
under Sections 356g.5, 356u, 356w, | 11 |
| 356x, 356z.6, and 356z.9, 356z.10, and 356z.11 and 356z.9 of | 12 |
| the Illinois
Insurance
Code. The requirement that health
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| benefits be covered as provided in this is an exclusive power | 14 |
| and function of
the State and is a denial and limitation under | 15 |
| Article VII, Section 6,
subsection (h) of the Illinois | 16 |
| Constitution. A home rule municipality to which
this Section | 17 |
| applies must comply with every provision of this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 19 |
| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 20. The School Code is amended by changing Section | 21 |
| 10-22.3f as follows: | 22 |
| (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 | 2 |
| post-mastectomy care benefits required to be
covered by a | 3 |
| policy of accident and health insurance under Section 356t and | 4 |
| the
coverage required under Sections 356g.5, 356u, 356w, 356x,
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| 356z.6, and 356z.9 , and 356z.11 of
the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 7 |
| revised 12-4-07.)
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| Section 25. The Illinois Insurance Code is amended by | 9 |
| adding Sections 356z.11 and 370c as follows: | 10 |
| (215 ILCS 5/356z.11 new) | 11 |
| Sec. 356z.11. Habilitative services for children. | 12 |
| (a) As used in this Section, "habilitative services" means | 13 |
| occupational therapy, physical therapy, speech therapy, and | 14 |
| other services prescribed by the insured's treating physician | 15 |
| pursuant to a treatment plan to enhance the ability of a child | 16 |
| to function with a congenital, genetic, or early acquired | 17 |
| disorder. A congenital or genetic disorder includes, but is not | 18 |
| limited to, hereditary disorders. An early acquired disorder | 19 |
| refers to a disorder resulting from illness, trauma, injury, or | 20 |
| some other event or condition suffered by a child prior to that | 21 |
| child developing functional life skills such as, but not | 22 |
| limited to, walking, talking, or self-help skills. Congenital, | 23 |
| genetic, and early acquired disorders may include, but are not | 24 |
| limited to, autism or an autism spectrum disorder, cerebral |
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| palsy, and other disorders resulting from early childhood | 2 |
| illness, trauma, or injury. | 3 |
| (b) A group or individual policy of accident and health | 4 |
| insurance or managed care plan amended, delivered, issued, or | 5 |
| renewed after the effective date of this amendatory Act of the | 6 |
| 95th General Assembly must provide coverage for habilitative | 7 |
| services for children under 19 years of age with a congenital, | 8 |
| genetic, or early acquired disorder so long as all of the | 9 |
| following conditions are met: | 10 |
| (1) A physician licensed to practice medicine in all | 11 |
| its branches has diagnosed the child's congenital, | 12 |
| genetic, or early acquired disorder. | 13 |
| (2) The treatment is administered by a licensed | 14 |
| speech-language pathologist, licensed audiologist, | 15 |
| licensed occupational therapist, licensed physical | 16 |
| therapist, licensed physician, licensed nurse, licensed | 17 |
| optometrist, licensed nutritionist, licensed social | 18 |
| worker, or licensed psychologist upon the referral of a | 19 |
| physician licensed to practice medicine in all its | 20 |
| branches. | 21 |
| (3) The initial or continued treatment must be | 22 |
| medically necessary and therapeutic and not experimental | 23 |
| or investigational. | 24 |
| (c) The coverage required by this Section shall be subject | 25 |
| to other general exclusions and limitations of the policy, | 26 |
| including coordination of benefits, participating provider |
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| requirements, restrictions on services provided by family or | 2 |
| household members, utilization review of health care services, | 3 |
| including review of medical necessity, case management, | 4 |
| experimental, and investigational treatments, and other | 5 |
| managed care provisions. | 6 |
| (d) Coverage under this Section does not apply to those | 7 |
| services that are solely educational in nature or otherwise | 8 |
| paid under State or federal law for purely educational | 9 |
| services. Nothing in this subsection (d) relieves an insurer or | 10 |
| similar third party from an otherwise valid obligation to | 11 |
| provide or to pay for services provided to a child with a | 12 |
| disability. | 13 |
| (e) Coverage under this Section for children under age 19 | 14 |
| shall not apply to treatment of mental or emotional disorders | 15 |
| or illnesses as covered under Section 370 of this Code as well | 16 |
| as any other benefit based upon a specific diagnosis that may | 17 |
| be otherwise required by law. | 18 |
| (f) The provisions of this Section do not apply to | 19 |
| short-term travel, accident-only, limited, or specific disease | 20 |
| policies. | 21 |
| (g) Any denial of care for habilitative services shall be | 22 |
| subject to appeal and external independent review procedures as | 23 |
| provided by Section 45 of the Managed Care Reform and Patient | 24 |
| Rights Act. | 25 |
| (h) Upon request of the reimbursing insurer, the provider | 26 |
| under whose supervision the habilitative services are being |
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| provided shall furnish medical records, clinical notes, or | 2 |
| other necessary data to allow the insurer to substantiate that | 3 |
| initial or continued medical treatment is medically necessary | 4 |
| and that the patient's condition is clinically improving. When | 5 |
| the treating provider anticipates that continued treatment is | 6 |
| or will be required to permit the patient to achieve | 7 |
| demonstrable progress, the insurer may request that the | 8 |
| provider furnish a treatment plan consisting of diagnosis, | 9 |
| proposed treatment by type, frequency, anticipated duration of | 10 |
| treatment, the anticipated goals of treatment, and how | 11 |
| frequently the treatment plan will be updated. | 12 |
| (i) The Department may not adopt rules to amend the | 13 |
| provisions of the amendatory Act of the 95th General Assembly.
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| (215 ILCS 5/370c) (from Ch. 73, par. 982c)
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| Sec. 370c. Mental and emotional disorders.
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| (a) (1) On and after the effective date of this Section,
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| every insurer which delivers, issues for delivery or renews or | 18 |
| modifies
group A&H policies providing coverage for hospital or | 19 |
| medical treatment or
services for illness on an | 20 |
| expense-incurred basis shall offer to the
applicant or group | 21 |
| policyholder subject to the insurers standards of
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| insurability, coverage for reasonable and necessary treatment | 23 |
| and services
for mental, emotional or nervous disorders or | 24 |
| conditions, other than serious
mental illnesses as defined in | 25 |
| item (2) of subsection (b), up to the limits
provided in the |
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| policy for other disorders or conditions, except (i) the
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| insured may be required to pay up to 50% of expenses incurred | 3 |
| as a result
of the treatment or services, and (ii) the annual | 4 |
| benefit limit may be
limited to the lesser of $10,000 or 25% of | 5 |
| the lifetime policy limit.
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| (2) Each insured that is covered for mental, emotional or | 7 |
| nervous
disorders or conditions shall be free to select the | 8 |
| physician licensed to
practice medicine in all its branches, | 9 |
| licensed clinical psychologist,
licensed clinical social | 10 |
| worker, or licensed clinical professional counselor of
his | 11 |
| choice to treat such disorders, and
the insurer shall pay the | 12 |
| covered charges of such physician licensed to
practice medicine | 13 |
| in all its branches, licensed clinical psychologist,
licensed | 14 |
| clinical social worker, or licensed clinical professional | 15 |
| counselor up
to the limits of coverage, provided (i)
the | 16 |
| disorder or condition treated is covered by the policy, and | 17 |
| (ii) the
physician, licensed psychologist, licensed clinical | 18 |
| social worker, or licensed
clinical professional counselor is
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| authorized to provide said services under the statutes of this | 20 |
| State and in
accordance with accepted principles of his | 21 |
| profession.
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| (3) Insofar as this Section applies solely to licensed | 23 |
| clinical social
workers and licensed clinical professional | 24 |
| counselors, those persons who may
provide services to | 25 |
| individuals shall do so
after the licensed clinical social | 26 |
| worker or licensed clinical professional
counselor has |
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| informed the patient of the
desirability of the patient | 2 |
| conferring with the patient's primary care
physician and the | 3 |
| licensed clinical social worker or licensed clinical
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| professional counselor has
provided written
notification to | 5 |
| the patient's primary care physician, if any, that services
are | 6 |
| being provided to the patient. That notification may, however, | 7 |
| be
waived by the patient on a written form. Those forms shall | 8 |
| be retained by
the licensed clinical social worker or licensed | 9 |
| clinical professional counselor
for a period of not less than 5 | 10 |
| years.
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| (b) (1) An insurer that provides coverage for hospital or | 12 |
| medical
expenses under a group policy of accident and health | 13 |
| insurance or
health care plan amended, delivered, issued, or | 14 |
| renewed after the effective
date of this amendatory Act of the | 15 |
| 92nd General Assembly shall provide coverage
under the policy | 16 |
| for treatment of serious mental illness under the same terms
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| and conditions as coverage for hospital or medical expenses | 18 |
| related to other
illnesses and diseases. The coverage required | 19 |
| under this Section must provide
for same durational limits, | 20 |
| amount limits, deductibles, and co-insurance
requirements for | 21 |
| serious mental illness as are provided for other illnesses
and | 22 |
| diseases. This subsection does not apply to coverage provided | 23 |
| to
employees by employers who have 50 or fewer employees.
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| (2) "Serious mental illness" means the following | 25 |
| psychiatric illnesses as
defined in the most current edition of | 26 |
| the Diagnostic and Statistical Manual
(DSM) published by the |
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| American Psychiatric Association:
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| (A) schizophrenia;
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| (B) paranoid and other psychotic disorders;
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| (C) bipolar disorders (hypomanic, manic, depressive, | 5 |
| and mixed);
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| (D) major depressive disorders (single episode or | 7 |
| recurrent);
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| (E) schizoaffective disorders (bipolar or depressive);
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| (F) pervasive developmental disorders;
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| (G) obsessive-compulsive disorders;
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| (H) depression in childhood and adolescence;
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| (I) panic disorder; and | 13 |
| (J) post-traumatic stress disorders (acute, chronic, | 14 |
| or with delayed onset).
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| (3) Upon request of the reimbursing insurer, a provider of | 16 |
| treatment of
serious mental illness shall furnish medical | 17 |
| records or other necessary data
that substantiate that initial | 18 |
| or continued treatment is at all times medically
necessary. An | 19 |
| insurer shall provide a mechanism for the timely review by a
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| provider holding the same license and practicing in the same | 21 |
| specialty as the
patient's provider, who is unaffiliated with | 22 |
| the insurer, jointly selected by
the patient (or the patient's | 23 |
| next of kin or legal representative if the
patient is unable to | 24 |
| act for himself or herself), the patient's provider, and
the | 25 |
| insurer in the event of a dispute between the insurer and | 26 |
| patient's
provider regarding the medical necessity of a |
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| treatment proposed by a patient's
provider. If the reviewing | 2 |
| provider determines the treatment to be medically
necessary, | 3 |
| the insurer shall provide reimbursement for the treatment. | 4 |
| Future
contractual or employment actions by the insurer | 5 |
| regarding the patient's
provider may not be based on the | 6 |
| provider's participation in this procedure.
Nothing prevents
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| the insured from agreeing in writing to continue treatment at | 8 |
| his or her
expense. When making a determination of the medical | 9 |
| necessity for a treatment
modality for serous mental illness, | 10 |
| an insurer must make the determination in a
manner that is | 11 |
| consistent with the manner used to make that determination with
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| respect to other diseases or illnesses covered under the | 13 |
| policy, including an
appeals process.
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| (4) A group health benefit plan:
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| (A) shall provide coverage based upon medical | 16 |
| necessity for the following
treatment of mental illness in | 17 |
| each calendar year:
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| (i) 45 days of inpatient treatment; and
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| (ii) beginning on June 26, 2006 (the effective date | 20 |
| of Public Act 94-921), 60 visits for outpatient | 21 |
| treatment including group and individual
outpatient | 22 |
| treatment; and | 23 |
| (iii) for plans or policies delivered, issued for | 24 |
| delivery, renewed, or modified after January 1, 2007 | 25 |
| (the effective date of Public Act 94-906),
20 | 26 |
| additional outpatient visits for speech therapy for |
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| treatment of pervasive developmental disorders that | 2 |
| will be in addition to speech therapy provided pursuant | 3 |
| to item (ii) of this subparagraph (A);
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| (B) may not include a lifetime limit on the number of | 5 |
| days of inpatient
treatment or the number of outpatient | 6 |
| visits covered under the plan; and
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| (C) shall include the same amount limits, deductibles, | 8 |
| copayments, and
coinsurance factors for serious mental | 9 |
| illness as for physical illness.
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| (5) An issuer of a group health benefit plan may not count | 11 |
| toward the number
of outpatient visits required to be covered | 12 |
| under this Section an outpatient
visit for the purpose of | 13 |
| medication management and shall cover the outpatient
visits | 14 |
| under the same terms and conditions as it covers outpatient | 15 |
| visits for
the treatment of physical illness.
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| (6) An issuer of a group health benefit
plan may provide or | 17 |
| offer coverage required under this Section through a
managed | 18 |
| care plan.
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| (7) This Section shall not be interpreted to require a | 20 |
| group health benefit
plan to provide coverage for treatment of:
| 21 |
| (A) an addiction to a controlled substance or cannabis | 22 |
| that is used in
violation of law; or
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| (B) mental illness resulting from the use of a | 24 |
| controlled substance or
cannabis in violation of law.
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| (8)
(Blank).
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| (c) This Section shall not be interpreted to require |
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| coverage for speech therapy or other habilitative services for | 2 |
| those individuals covered under Section 356z.11 of this Code. | 3 |
| (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; | 4 |
| 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff. | 5 |
| 8-21-07.)
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| Section 30. The Health Maintenance Organization Act is | 7 |
| 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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| Sec. 5-3. Insurance Code provisions.
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| (a) Health Maintenance Organizations
shall be subject to | 11 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 12 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 13 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | 14 |
| 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | 15 |
| 356z.11 356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | 16 |
| 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, | 17 |
| 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section | 18 |
| 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, | 19 |
| XXV, and XXVI of the Illinois Insurance Code.
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| (b) For purposes of the Illinois Insurance Code, except for | 21 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 22 |
| Maintenance Organizations in
the following categories are | 23 |
| deemed to be "domestic companies":
| 24 |
| (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 | 3 |
| State; or
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| (3) a corporation organized under the laws of another | 5 |
| state, 30% or more
of the enrollees of which are residents | 6 |
| of this State, except a
corporation subject to | 7 |
| substantially the same requirements in its state of
| 8 |
| organization as is a "domestic company" under Article VIII | 9 |
| 1/2 of the
Illinois Insurance Code.
| 10 |
| (c) In considering the merger, consolidation, or other | 11 |
| acquisition of
control of a Health Maintenance Organization | 12 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 13 |
| (1) the Director shall give primary consideration to | 14 |
| the continuation of
benefits to enrollees and the financial | 15 |
| conditions of the acquired Health
Maintenance Organization | 16 |
| after the merger, consolidation, or other
acquisition of | 17 |
| control takes effect;
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| (2)(i) the criteria specified in subsection (1)(b) of | 19 |
| Section 131.8 of
the Illinois Insurance Code shall not | 20 |
| apply and (ii) the Director, in making
his determination | 21 |
| with respect to the merger, consolidation, or other
| 22 |
| acquisition of control, need not take into account the | 23 |
| effect on
competition of the merger, consolidation, or | 24 |
| other acquisition of control;
| 25 |
| (3) the Director shall have the power to require the | 26 |
| following
information:
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| (A) certification by an independent actuary of the | 2 |
| adequacy
of the reserves of the Health Maintenance | 3 |
| Organization sought to be acquired;
| 4 |
| (B) pro forma financial statements reflecting the | 5 |
| combined balance
sheets of the acquiring company and | 6 |
| the Health Maintenance Organization sought
to be | 7 |
| acquired as of the end of the preceding year and as of | 8 |
| a date 90 days
prior to the acquisition, as well as pro | 9 |
| forma financial statements
reflecting projected | 10 |
| combined operation for a period of 2 years;
| 11 |
| (C) a pro forma business plan detailing an | 12 |
| acquiring party's plans with
respect to the operation | 13 |
| of the Health Maintenance Organization sought to
be | 14 |
| acquired for a period of not less than 3 years; and
| 15 |
| (D) such other information as the Director shall | 16 |
| require.
| 17 |
| (d) The provisions of Article VIII 1/2 of the Illinois | 18 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 19 |
| any health maintenance
organization of greater than 10% of its
| 20 |
| enrollee population (including without limitation the health | 21 |
| maintenance
organization's right, title, and interest in and to | 22 |
| its health care
certificates).
| 23 |
| (e) In considering any management contract or service | 24 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 25 |
| Code, the Director (i) shall, in
addition to the criteria | 26 |
| 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 | 2 |
| agreement on the continuation of benefits to enrollees and the
| 3 |
| financial condition of the health maintenance organization to | 4 |
| be managed or
serviced, and (ii) need not take into account the | 5 |
| effect of the management
contract or service agreement on | 6 |
| competition.
| 7 |
| (f) Except for small employer groups as defined in the | 8 |
| Small Employer
Rating, Renewability and Portability Health | 9 |
| Insurance Act and except for
medicare supplement policies as | 10 |
| defined in Section 363 of the Illinois
Insurance Code, a Health | 11 |
| Maintenance Organization may by contract agree with a
group or | 12 |
| other enrollment unit to effect refunds or charge additional | 13 |
| premiums
under the following terms and conditions:
| 14 |
| (i) the amount of, and other terms and conditions with | 15 |
| respect to, the
refund or additional premium are set forth | 16 |
| in the group or enrollment unit
contract agreed in advance | 17 |
| of the period for which a refund is to be paid or
| 18 |
| additional premium is to be charged (which period shall not | 19 |
| be less than one
year); and
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| (ii) the amount of the refund or additional premium | 21 |
| shall not exceed 20%
of the Health Maintenance | 22 |
| Organization's profitable or unprofitable experience
with | 23 |
| respect to the group or other enrollment unit for the | 24 |
| period (and, for
purposes of a refund or additional | 25 |
| premium, the profitable or unprofitable
experience shall | 26 |
| be calculated taking into account a pro rata share of the
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| Health Maintenance Organization's administrative and | 2 |
| marketing expenses, but
shall not include any refund to be | 3 |
| made or additional premium to be paid
pursuant to this | 4 |
| subsection (f)). The Health Maintenance Organization and | 5 |
| the
group or enrollment unit may agree that the profitable | 6 |
| or unprofitable
experience may be calculated taking into | 7 |
| account the refund period and the
immediately preceding 2 | 8 |
| plan years.
| 9 |
| The Health Maintenance Organization shall include a | 10 |
| statement in the
evidence of coverage issued to each enrollee | 11 |
| describing the possibility of a
refund or additional premium, | 12 |
| and upon request of any group or enrollment unit,
provide to | 13 |
| the group or enrollment unit a description of the method used | 14 |
| to
calculate (1) the Health Maintenance Organization's | 15 |
| profitable experience with
respect to the group or enrollment | 16 |
| unit and the resulting refund to the group
or enrollment unit | 17 |
| or (2) the Health Maintenance Organization's unprofitable
| 18 |
| experience with respect to the group or enrollment unit and the | 19 |
| resulting
additional premium to be paid by the group or | 20 |
| enrollment unit.
| 21 |
| In no event shall the Illinois Health Maintenance | 22 |
| Organization
Guaranty Association be liable to pay any | 23 |
| contractual obligation of an
insolvent organization to pay any | 24 |
| refund authorized under this Section.
| 25 |
| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | 26 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
|
|
|
|
09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
|
| 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 40. The Illinois Public Aid Code is amended by | 17 |
| changing Section 5-2 as follows:
| 18 |
| (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
| 19 |
| Sec. 5-2. Classes of Persons Eligible. Medical assistance | 20 |
| under this
Article shall be available to any of the following | 21 |
| classes of persons in
respect to whom a plan for coverage has | 22 |
| been submitted to the Governor
by the Illinois Department and |
|
|
|
09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
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| 1 |
| approved by him:
| 2 |
| 1. Recipients of basic maintenance grants under | 3 |
| Articles III and IV.
| 4 |
| 2. Persons otherwise eligible for basic maintenance | 5 |
| under Articles
III and IV but who fail to qualify | 6 |
| thereunder on the basis of need, and
who have insufficient | 7 |
| income and resources to meet the costs of
necessary medical | 8 |
| care, including but not limited to the following:
| 9 |
| (a) All persons otherwise eligible for basic | 10 |
| maintenance under Article
III but who fail to qualify | 11 |
| under that Article on the basis of need and who
meet | 12 |
| either of the following requirements:
| 13 |
| (i) their income, as determined by the | 14 |
| Illinois Department in
accordance with any federal | 15 |
| requirements, is equal to or less than 70% in
| 16 |
| fiscal year 2001, equal to or less than 85% in | 17 |
| fiscal year 2002 and until
a date to be determined | 18 |
| by the Department by rule, and equal to or less
| 19 |
| than 100% beginning on the date determined by the | 20 |
| Department by rule, of the nonfarm income official | 21 |
| poverty
line, as defined by the federal Office of | 22 |
| Management and Budget and revised
annually in | 23 |
| accordance with Section 673(2) of the Omnibus | 24 |
| Budget Reconciliation
Act of 1981, applicable to | 25 |
| families of the same size; or
| 26 |
| (ii) their income, after the deduction of |
|
|
|
09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
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| 1 |
| costs incurred for medical
care and for other types | 2 |
| of remedial care, is equal to or less than 70% in
| 3 |
| fiscal year 2001, equal to or less than 85% in | 4 |
| fiscal year 2002 and until
a date to be determined | 5 |
| by the Department by rule, and equal to or less
| 6 |
| than 100% beginning on the date determined by the | 7 |
| Department by rule, of the nonfarm income official | 8 |
| poverty
line, as defined in item (i) of this | 9 |
| subparagraph (a).
| 10 |
| (b) All persons who would be determined eligible | 11 |
| for such basic
maintenance under Article IV by | 12 |
| disregarding the maximum earned income
permitted by | 13 |
| federal law.
| 14 |
| 3. Persons who would otherwise qualify for Aid to the | 15 |
| Medically
Indigent under Article VII.
| 16 |
| 4. Persons not eligible under any of the preceding | 17 |
| paragraphs who fall
sick, are injured, or die, not having | 18 |
| sufficient money, property or other
resources to meet the | 19 |
| costs of necessary medical care or funeral and burial
| 20 |
| expenses.
| 21 |
| 5.(a) Women during pregnancy, after the fact
of | 22 |
| pregnancy has been determined by medical diagnosis, and | 23 |
| during the
60-day period beginning on the last day of the | 24 |
| pregnancy, together with
their infants and children born | 25 |
| after September 30, 1983,
whose income and
resources are | 26 |
| insufficient to meet the costs of necessary medical care to
|
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09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
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| 1 |
| the maximum extent possible under Title XIX of the
Federal | 2 |
| Social Security Act.
| 3 |
| (b) The Illinois Department and the Governor shall | 4 |
| provide a plan for
coverage of the persons eligible under | 5 |
| paragraph 5(a) by April 1, 1990. Such
plan shall provide | 6 |
| ambulatory prenatal care to pregnant women during a
| 7 |
| presumptive eligibility period and establish an income | 8 |
| eligibility standard
that is equal to 133%
of the nonfarm | 9 |
| income official poverty line, as defined by
the federal | 10 |
| Office of Management and Budget and revised annually in
| 11 |
| accordance with Section 673(2) of the Omnibus Budget | 12 |
| Reconciliation Act of
1981, applicable to families of the | 13 |
| same size, provided that costs incurred
for medical care | 14 |
| are not taken into account in determining such income
| 15 |
| eligibility.
| 16 |
| (c) The Illinois Department may conduct a | 17 |
| demonstration in at least one
county that will provide | 18 |
| medical assistance to pregnant women, together
with their | 19 |
| infants and children up to one year of age,
where the | 20 |
| income
eligibility standard is set up to 185% of the | 21 |
| nonfarm income official
poverty line, as defined by the | 22 |
| federal Office of Management and Budget.
The Illinois | 23 |
| Department shall seek and obtain necessary authorization
| 24 |
| provided under federal law to implement such a | 25 |
| demonstration. Such
demonstration may establish resource | 26 |
| standards that are not more
restrictive than those |
|
|
|
09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
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| 1 |
| established under Article IV of this Code.
| 2 |
| 6. Persons under the age of 18 who fail to qualify as | 3 |
| dependent under
Article IV and who have insufficient income | 4 |
| and resources to meet the costs
of necessary medical care | 5 |
| to the maximum extent permitted under Title XIX
of the | 6 |
| Federal Social Security Act.
| 7 |
| 7. Persons who are under 21 years of age and would
| 8 |
| qualify as
disabled as defined under the Federal | 9 |
| Supplemental Security Income Program,
provided medical | 10 |
| service for such persons would be eligible for Federal
| 11 |
| Financial Participation, and provided the Illinois | 12 |
| Department determines that:
| 13 |
| (a) the person requires a level of care provided by | 14 |
| a hospital, skilled
nursing facility, or intermediate | 15 |
| care facility, as determined by a physician
licensed to | 16 |
| practice medicine in all its branches;
| 17 |
| (b) it is appropriate to provide such care outside | 18 |
| of an institution, as
determined by a physician | 19 |
| licensed to practice medicine in all its branches;
| 20 |
| (c) the estimated amount which would be expended | 21 |
| for care outside the
institution is not greater than | 22 |
| the estimated amount which would be
expended in an | 23 |
| institution.
| 24 |
| 8. Persons who become ineligible for basic maintenance | 25 |
| assistance
under Article IV of this Code in programs | 26 |
| administered by the Illinois
Department due to employment |
|
|
|
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LRB095 03635 DRJ 51832 a |
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| 1 |
| earnings and persons in
assistance units comprised of | 2 |
| adults and children who become ineligible for
basic | 3 |
| maintenance assistance under Article VI of this Code due to
| 4 |
| employment earnings. The plan for coverage for this class | 5 |
| of persons shall:
| 6 |
| (a) extend the medical assistance coverage for up | 7 |
| to 12 months following
termination of basic | 8 |
| maintenance assistance; and
| 9 |
| (b) offer persons who have initially received 6 | 10 |
| months of the
coverage provided in paragraph (a) above, | 11 |
| the option of receiving an
additional 6 months of | 12 |
| coverage, subject to the following:
| 13 |
| (i) such coverage shall be pursuant to | 14 |
| provisions of the federal
Social Security Act;
| 15 |
| (ii) such coverage shall include all services | 16 |
| covered while the person
was eligible for basic | 17 |
| maintenance assistance;
| 18 |
| (iii) no premium shall be charged for such | 19 |
| coverage; and
| 20 |
| (iv) such coverage shall be suspended in the | 21 |
| event of a person's
failure without good cause to | 22 |
| file in a timely fashion reports required for
this | 23 |
| coverage under the Social Security Act and | 24 |
| coverage shall be reinstated
upon the filing of | 25 |
| such reports if the person remains otherwise | 26 |
| eligible.
|
|
|
|
09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
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| 1 |
| 9. Persons with acquired immunodeficiency syndrome | 2 |
| (AIDS) or with
AIDS-related conditions with respect to whom | 3 |
| there has been a determination
that but for home or | 4 |
| community-based services such individuals would
require | 5 |
| the level of care provided in an inpatient hospital, | 6 |
| skilled
nursing facility or intermediate care facility the | 7 |
| cost of which is
reimbursed under this Article. Assistance | 8 |
| shall be provided to such
persons to the maximum extent | 9 |
| permitted under Title
XIX of the Federal Social Security | 10 |
| Act.
| 11 |
| 10. Participants in the long-term care insurance | 12 |
| partnership program
established under the Illinois | 13 |
| Long-Term Care Partnership Program Act
Partnership for | 14 |
| Long-Term Care Act who meet the
qualifications for | 15 |
| protection of resources described in Section 15
25 of that
| 16 |
| Act.
| 17 |
| 11. Persons with disabilities who are employed and | 18 |
| eligible for Medicaid,
pursuant to Section | 19 |
| 1902(a)(10)(A)(ii)(xv) of the Social Security Act, as
| 20 |
| provided by the Illinois Department by rule. In | 21 |
| establishing eligibility standards under this paragraph | 22 |
| 11, the Department shall, subject to federal approval: | 23 |
| (a) set the income eligibility standard at not | 24 |
| lower than 350% of the federal poverty level; | 25 |
| (b) exempt retirement accounts that the person | 26 |
| cannot access without penalty before the age
of 59 1/2, |
|
|
|
09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
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| 1 |
| and medical savings accounts established pursuant to | 2 |
| 26 U.S.C. 220; | 3 |
| (c) allow non-exempt assets up to $25,000 as to | 4 |
| those assets accumulated during periods of eligibility | 5 |
| under this paragraph 11; and
| 6 |
| (d) continue to apply subparagraphs (b) and (c) in | 7 |
| determining the eligibility of the person under this | 8 |
| Article even if the person loses eligibility under this | 9 |
| paragraph 11.
| 10 |
| 12. Subject to federal approval, persons who are | 11 |
| eligible for medical
assistance coverage under applicable | 12 |
| provisions of the federal Social Security
Act and the | 13 |
| federal Breast and Cervical Cancer Prevention and | 14 |
| Treatment Act of
2000. Those eligible persons are defined | 15 |
| to include, but not be limited to,
the following persons:
| 16 |
| (1) persons who have been screened for breast or | 17 |
| cervical cancer under
the U.S. Centers for Disease | 18 |
| Control and Prevention Breast and Cervical Cancer
| 19 |
| Program established under Title XV of the federal | 20 |
| Public Health Services Act in
accordance with the | 21 |
| requirements of Section 1504 of that Act as | 22 |
| administered by
the Illinois Department of Public | 23 |
| Health; and
| 24 |
| (2) persons whose screenings under the above | 25 |
| program were funded in whole
or in part by funds | 26 |
| appropriated to the Illinois Department of Public |
|
|
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09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
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| 1 |
| Health
for breast or cervical cancer screening.
| 2 |
| "Medical assistance" under this paragraph 12 shall be | 3 |
| identical to the benefits
provided under the State's | 4 |
| approved plan under Title XIX of the Social Security
Act. | 5 |
| The Department must request federal approval of the | 6 |
| coverage under this
paragraph 12 within 30 days after the | 7 |
| effective date of this amendatory Act of
the 92nd General | 8 |
| Assembly.
| 9 |
| 13. Subject to appropriation and to federal approval, | 10 |
| persons living with HIV/AIDS who are not otherwise eligible | 11 |
| under this Article and who qualify for services covered | 12 |
| under Section 5-5.04 as provided by the Illinois Department | 13 |
| by rule.
| 14 |
| 14. Subject to the availability of funds for this | 15 |
| purpose, the Department may provide coverage under this | 16 |
| Article to persons who reside in Illinois who are not | 17 |
| eligible under any of the preceding paragraphs and who meet | 18 |
| the income guidelines of paragraph 2(a) of this Section and | 19 |
| (i) have an application for asylum pending before the | 20 |
| federal Department of Homeland Security or on appeal before | 21 |
| a court of competent jurisdiction and are represented | 22 |
| either by counsel or by an advocate accredited by the | 23 |
| federal Department of Homeland Security and employed by a | 24 |
| not-for-profit organization in regard to that application | 25 |
| or appeal, or (ii) are receiving services through a | 26 |
| federally funded torture treatment center. Medical |
|
|
|
09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
|
| 1 |
| coverage under this paragraph 14 may be provided for up to | 2 |
| 24 continuous months from the initial eligibility date so | 3 |
| long as an individual continues to satisfy the criteria of | 4 |
| this paragraph 14. If an individual has an appeal pending | 5 |
| regarding an application for asylum before the Department | 6 |
| of Homeland Security, eligibility under this paragraph 14 | 7 |
| may be extended until a final decision is rendered on the | 8 |
| appeal. The Department may adopt rules governing the | 9 |
| implementation of this paragraph 14.
| 10 |
| 15. Subject to federal approval, persons with | 11 |
| medically improved disability who are employed or eligible | 12 |
| for Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) | 13 |
| of the Social Security Act that meet applicable eligibility | 14 |
| standards established in paragraph 11. The Department may | 15 |
| not otherwise adopt any rule to implement this paragraph. | 16 |
| The Illinois Department and the Governor shall provide a | 17 |
| plan for
coverage of the persons eligible under paragraph 7 as | 18 |
| soon as possible after
July 1, 1984.
| 19 |
| The eligibility of any such person for medical assistance | 20 |
| under this
Article is not affected by the payment of any grant | 21 |
| under the Senior
Citizens and Disabled Persons Property Tax | 22 |
| Relief and Pharmaceutical
Assistance Act or any distributions | 23 |
| or items of income described under
subparagraph (X) of
| 24 |
| paragraph (2) of subsection (a) of Section 203 of the Illinois | 25 |
| Income Tax
Act. The Department shall by rule establish the | 26 |
| amounts of
assets to be disregarded in determining eligibility |
|
|
|
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LRB095 03635 DRJ 51832 a |
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| 1 |
| for medical assistance,
which shall at a minimum equal the | 2 |
| amounts to be disregarded under the
Federal Supplemental | 3 |
| Security Income Program. The amount of assets of a
single | 4 |
| person to be disregarded
shall not be less than $2,000, and the | 5 |
| amount of assets of a married couple
to be disregarded shall | 6 |
| not be less than $3,000.
| 7 |
| To the extent permitted under federal law, any person found | 8 |
| guilty of a
second violation of Article VIIIA
shall be | 9 |
| ineligible for medical assistance under this Article, as | 10 |
| provided
in Section 8A-8.
| 11 |
| The eligibility of any person for medical assistance under | 12 |
| this Article
shall not be affected by the receipt by the person | 13 |
| of donations or benefits
from fundraisers held for the person | 14 |
| in cases of serious illness,
as long as neither the person nor | 15 |
| members of the person's family
have actual control over the | 16 |
| donations or benefits or the disbursement
of the donations or | 17 |
| benefits.
| 18 |
| (Source: P.A. 94-629, eff. 1-1-06; 94-1043, eff. 7-24-06; | 19 |
| 95-546, eff. 8-29-07; revised 1-22-08.)
| 20 |
| Section 90. The State Mandates Act is amended by adding | 21 |
| Section 8.32 as follows: | 22 |
| (30 ILCS 805/8.32 new) | 23 |
| Sec. 8.32. Exempt mandate. Notwithstanding Sections 6 and 8 | 24 |
| of this Act, no reimbursement by the State is required for the |
|
|
|
09500SB0101ham002 |
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LRB095 03635 DRJ 51832 a |
|
| 1 |
| implementation of any mandate created by this amendatory Act of | 2 |
| the 95th General Assembly. | 3 |
| Section 99. Effective date. This Act takes effect upon | 4 |
| becoming law.".
|
|