Full Text of SB0874 95th General Assembly
SB0874eng 95TH GENERAL ASSEMBLY
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SB0874 Engrossed |
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| AN ACT concerning regulation.
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| Be it enacted by the People of the State of Illinois, | 3 |
| represented in the General Assembly:
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| Section 5. The State Employees Group Insurance Act of 1971 | 5 |
| 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 | 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 356f.1, | 13 |
| 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, | 14 |
| and 356z.10 356z.9 of the
Illinois Insurance Code.
The program | 15 |
| of health benefits must comply with Section 155.37 of the
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| Illinois Insurance Code.
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| (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.)
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| 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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| 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 356f.1, 356g.5, 356u,
356w, 356x, 356z.6, and | 8 |
| 356z.9, and 356z.10 356z.9 of
the Illinois Insurance Code. The | 9 |
| requirement that health benefits be covered
as provided in this | 10 |
| Section is an
exclusive power and function of the State and is | 11 |
| 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.
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| (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.)
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| 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)
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| 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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| a policy of
accident and health insurance under Section 356t | 2 |
| and the coverage required
under Sections 356f.1, 356g.5, 356u, | 3 |
| 356w, 356x, 356z.6, and 356z.9, and 356z.10 356z.9 of the | 4 |
| Illinois
Insurance
Code. The requirement that health
benefits | 5 |
| be covered as provided in this is an exclusive power and | 6 |
| 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.
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| (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.)
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| Section 20. The School Code is amended by changing Section | 13 |
| 10-22.3f as follows: | 14 |
| (105 ILCS 5/10-22.3f)
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| 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 356f.1, 356g.5, 356u, | 20 |
| 356w, 356x,
356z.6, and 356z.9 of
the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 22 |
| revised 12-4-07.)
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| Section 25. The Illinois Insurance Code is amended by |
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| adding Section 356f.1 as follows: | 2 |
| (215 ILCS 5/356f.1 new) | 3 |
| Sec. 356f.1. External review appeals process. | 4 |
| (a) A policy of accident or health insurance or managed | 5 |
| care plan shall maintain an external review appeals process for | 6 |
| member or member representative requests to reverse or modify | 7 |
| adverse determinations made by the insurer or managed care | 8 |
| plan. For the purposes of this Section, "adverse determination" | 9 |
| means a determination by a health insurer, managed care plan, | 10 |
| or its designee utilization review organization that an | 11 |
| admission, course of treatment, continued stay, or other health | 12 |
| care service that is not excluded explicitly by applicable | 13 |
| benefit language, including determinations that a health | 14 |
| service is experimental or investigational, does not meet the | 15 |
| insurer's or managed care plan's requirements for medical | 16 |
| necessity, appropriateness, health care setting, level of | 17 |
| care, or effectiveness and the requested payment for the | 18 |
| service is therefore denied, reduced, or terminated. | 19 |
| (b) An insurer or managed care plan shall comply with | 20 |
| subsection (a) of this Section by providing an external review | 21 |
| appeals program that meets or exceeds the Health Utilization | 22 |
| Management independent review process standards established by | 23 |
| URAC, whether or not the appeal relates to adverse | 24 |
| determinations related to utilization management review. | 25 |
| (c) An insurer or managed care plan may comply with this |
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| Section by: | 2 |
| (1) registering its utilization review program, | 3 |
| including appeals, with the Division of Insurance, as | 4 |
| provided in Section 85 of the Managed Care and Patients | 5 |
| Rights Act, and certifying compliance with the external | 6 |
| review standards of the Health Utilization Management | 7 |
| Standards of URAC sufficient to achieve accreditation from | 8 |
| URAC, doing business as the American Accreditation | 9 |
| Healthcare Commission, Inc.; or | 10 |
| (2) submitting evidence of accreditation by the | 11 |
| American Accreditation Healthcare Commission (URAC) for | 12 |
| its Health Utilization Management Standards. | 13 |
| Nothing in this Act shall be construed to require an | 14 |
| insurer or managed care plan or its subcontractors to become | 15 |
| American Accreditation Healthcare Commission (URAC) | 16 |
| accredited. | 17 |
| (d) The Director of the Division of Insurance, in | 18 |
| consultation with the Director of the Department of Public | 19 |
| Health, may certify alternative external review standards of | 20 |
| national accreditation organizations or entities in order for | 21 |
| insurers or managed care plans to comply with this Section. Any | 22 |
| alternative external review standards shall meet or exceed | 23 |
| those standards required under subsection (b) of this Section. | 24 |
| (e) This Section does not apply to: | 25 |
| (1) persons providing utilization review program | 26 |
| services only to the federal government; |
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| (2) self-insured health plans under the
federal | 2 |
| Employee Retirement Income Security Act of 1974; however, | 3 |
| this Section does apply to persons
conducting a utilization | 4 |
| review program on behalf of these health plans; | 5 |
| (3) hospitals and medical groups performing
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| utilization review activities for internal purposes unless | 7 |
| the utilization review program is conducted for another | 8 |
| person; or | 9 |
| (4) workers' compensation, short-term travel, | 10 |
| accident-only, limited, or specific disease policies. | 11 |
| Nothing in this Act prohibits an insurer or managed care | 12 |
| plan or other entity from contractually requiring an entity | 13 |
| designated in item (3) of this subsection (e) to adhere to the | 14 |
| utilization review program requirements of this Act. | 15 |
| (f) If the Division of Insurance finds that an external | 16 |
| review program is not in compliance with this Section, the | 17 |
| Director shall issue a corrective action plan and allow a | 18 |
| reasonable amount of time for compliance with the insurer or | 19 |
| managed care plan. Before issuing a cease and desist order | 20 |
| under this Section, the Director shall provide the insurer or | 21 |
| managed care plan with a written notice of the reasons for the | 22 |
| order and allow a reasonable amount of time to supply | 23 |
| additional information demonstrating compliance with | 24 |
| requirements of this Section and to request a hearing. The | 25 |
| hearing notice shall be sent by certified mail, return receipt | 26 |
| requested and the hearing shall be conducted in accordance with |
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| the Illinois Administrative Procedure Act. | 2 |
| If the insurer's or managed care plan's external review | 3 |
| program does not come into compliance with this Section, the | 4 |
| Director may issue a cease and desist order. | 5 |
| (g) A utilization review program subject to a corrective | 6 |
| action may continue to conduct business until a final decision | 7 |
| has been issued by the Director. | 8 |
| Section 30. The Limited Health Service Organization Act is | 9 |
| amended by changing Section 4003 as follows:
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| (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
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| Sec. 4003. Illinois Insurance Code provisions. Limited | 12 |
| health service
organizations shall be subject to the provisions | 13 |
| of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | 14 |
| 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | 15 |
| 155.04, 155.37, 355.2, 356f.1, 356v, 356z.10 356z.9 , 368a, 401, | 16 |
| 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and | 17 |
| Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and | 18 |
| XXVI of the Illinois Insurance Code. For purposes of the
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| Illinois Insurance Code, except for Sections 444 and 444.1 and | 20 |
| Articles XIII
and XIII 1/2, limited health service | 21 |
| organizations in the following categories
are deemed to be | 22 |
| domestic companies:
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| (1) a corporation under the laws of this State; or
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| (2) a corporation organized under the laws of another |
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| state, 30% of more
of the enrollees of which are residents | 2 |
| of this State, except a corporation
subject to | 3 |
| substantially the same requirements in its state of | 4 |
| organization as
is a domestic company under Article VIII | 5 |
| 1/2 of the Illinois Insurance Code.
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| (Source: P.A. 95-520, eff. 8-28-07; revised 12-5-07.)
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| Section 35. The Voluntary Health Services Plans Act is | 8 |
| amended by changing Section 10 as follows:
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| (215 ILCS 165/10) (from Ch. 32, par. 604)
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| Sec. 10. Application of Insurance Code provisions. Health | 11 |
| services
plan corporations and all persons interested therein | 12 |
| or dealing therewith
shall be subject to the provisions of | 13 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | 14 |
| 149, 155.37, 354, 355.2, 356f.1, 356g.5, 356r, 356t, 356u, | 15 |
| 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | 16 |
| 356z.8, 356z.9,
356z.10 356z.9 , 364.01, 367.2, 368a, 401, | 17 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | 18 |
| and (15) of Section 367 of the Illinois
Insurance Code.
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| (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | 20 |
| 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | 21 |
| 8-28-07; revised 12-5-07.)
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