Full Text of SB0934 095th General Assembly
SB0934enr 95TH GENERAL ASSEMBLY
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| AN ACT concerning health.
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| Be it enacted by the People of the State of Illinois,
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| 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 356g.5,
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| 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, and 356z.10 , | 14 |
| and 356z.14
of the
Illinois Insurance Code.
The program of | 15 |
| health benefits must comply with Section 155.37 of the
Illinois | 16 |
| 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; 95-876, eff. 8-21-08.)
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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 356g.5, 356u,
356w, 356x, 356z.6, 356z.9, and | 8 |
| 356z.10 , and 356z.14
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; 95-876, eff. 8-21-08.)
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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 356g.5, 356u, 356w, | 3 |
| 356x, 356z.6, 356z.9, and 356z.10 , and 356z.14
of the Illinois
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| Insurance
Code. The requirement that health
benefits be covered | 5 |
| as provided in this is an exclusive power and function of
the | 6 |
| State and is a denial and limitation under Article VII, Section | 7 |
| 6,
subsection (h) of the Illinois Constitution. A home rule | 8 |
| municipality to which
this Section applies must comply with | 9 |
| 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; 95-876, eff. 8-21-08.)
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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 356g.5, 356u, 356w, 356x,
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| 356z.6, and 356z.9 , and 356z.14 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 |
| 95-876, eff. 8-21-08.)
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| Section 25. The Illinois Insurance Code is amended by |
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| adding Section 356z.14 as follows: | 2 |
| (215 ILCS 5/356z.14 new) | 3 |
| Sec. 356z.14. Autism spectrum disorders. | 4 |
| (a) A group or individual policy of accident and health | 5 |
| insurance or managed care plan amended, delivered, issued, or | 6 |
| renewed after the effective date of this amendatory Act of the | 7 |
| 95th General Assembly must provide individuals under 21 years | 8 |
| of age coverage for the diagnosis of autism spectrum disorders | 9 |
| and for the treatment of autism spectrum disorders to the | 10 |
| extent that the diagnosis and treatment of autism spectrum | 11 |
| disorders are not already covered by the policy of accident and | 12 |
| health insurance or managed care plan. | 13 |
| (b) Coverage provided under this Section shall be subject | 14 |
| to a maximum benefit of $36,000 per year, but shall not be | 15 |
| subject to any limits on the number of visits to a service | 16 |
| provider. After December 30, 2009, the Director of the Division | 17 |
| of Insurance shall, on an annual basis, adjust the maximum | 18 |
| benefit for inflation using the Medical Care Component of the | 19 |
| United States Department of Labor Consumer Price Index for All | 20 |
| Urban Consumers. Payments made by an insurer on behalf of a | 21 |
| covered individual for any care, treatment, intervention, | 22 |
| service, or item, the provision of which was for the treatment | 23 |
| of a health condition not diagnosed as an autism spectrum | 24 |
| disorder, shall not be applied toward any maximum benefit | 25 |
| established under this subsection. |
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| (c) Coverage under this Section shall be subject to | 2 |
| copayment, deductible, and coinsurance provisions of a policy | 3 |
| of accident and health insurance or managed care plan to the | 4 |
| extent that other medical services covered by the policy of | 5 |
| accident and health insurance or managed care plan are subject | 6 |
| to these provisions. | 7 |
| (d) This Section shall not be construed as limiting | 8 |
| benefits that are otherwise available to an individual under a | 9 |
| policy of accident and health insurance or managed care plan | 10 |
| and benefits provided under this Section may not be subject to | 11 |
| dollar limits, deductibles, copayments, or coinsurance | 12 |
| provisions that are less favorable to the insured than the | 13 |
| dollar limits, deductibles, or coinsurance provisions that | 14 |
| apply to physical illness generally. | 15 |
| (e) An insurer may not deny or refuse to provide otherwise | 16 |
| covered services, or refuse to renew, refuse to reissue, or | 17 |
| otherwise terminate or restrict coverage under an individual | 18 |
| contract to provide services to an individual because the | 19 |
| individual or their dependent is diagnosed with an autism | 20 |
| spectrum disorder or due to the individual utilizing benefits | 21 |
| in this Section. | 22 |
| (f) Upon request of the reimbursing insurer, a provider of | 23 |
| treatment for autism spectrum disorders shall furnish medical | 24 |
| records, clinical notes, or other necessary data that | 25 |
| substantiate that initial or continued medical treatment is | 26 |
| medically necessary and is resulting in improved clinical |
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| status. When treatment is anticipated to require continued | 2 |
| services to achieve demonstrable progress, the insurer may | 3 |
| request a treatment plan consisting of diagnosis, proposed | 4 |
| treatment by type, frequency, anticipated duration of | 5 |
| treatment, the anticipated outcomes stated as goals, and the | 6 |
| frequency by which the treatment plan will be updated. | 7 |
| (g) When making a determination of medical necessity for a | 8 |
| treatment modality for autism spectrum disorders, an insurer | 9 |
| must make the determination in a manner that is consistent with | 10 |
| the manner used to make that determination with respect to | 11 |
| other diseases or illnesses covered under the policy, including | 12 |
| an appeals process. During the appeals process, any challenge | 13 |
| to medical necessity must be viewed as reasonable only if the | 14 |
| review includes a physician with expertise in the most current | 15 |
| and effective treatment modalities for autism spectrum | 16 |
| disorders. | 17 |
| (h) Coverage for medically necessary early intervention | 18 |
| services must be delivered by certified early intervention | 19 |
| specialists, as defined in 89 Ill. Admin. Code 500 and any | 20 |
| subsequent amendments thereto. | 21 |
| (i) As used in this Section: | 22 |
| "Autism spectrum disorders" means pervasive developmental | 23 |
| disorders as defined in the most recent edition of the | 24 |
| Diagnostic and Statistical Manual of Mental Disorders, | 25 |
| including autism, Asperger's disorder, and pervasive | 26 |
| developmental disorder not otherwise specified. |
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| "Diagnosis of autism spectrum disorders" means one or more | 2 |
| tests, evaluations, or assessments to diagnose whether an | 3 |
| individual has autism spectrum disorder that is prescribed, | 4 |
| performed, or ordered by (A) a physician licensed to practice | 5 |
| medicine in all its branches or (B) a licensed clinical | 6 |
| psychologist with expertise in diagnosing autism spectrum | 7 |
| disorders. | 8 |
| "Medically necessary" means any care, treatment, | 9 |
| intervention, service or item which will or is reasonably | 10 |
| expected to do any of the following: (i) prevent the onset of | 11 |
| an illness, condition, injury, disease or disability; (ii) | 12 |
| reduce or ameliorate the physical, mental or developmental | 13 |
| effects of an illness, condition, injury, disease or | 14 |
| disability; or (iii) assist to achieve or maintain maximum | 15 |
| functional activity in performing daily activities. | 16 |
| "Treatment for autism spectrum disorders" shall include | 17 |
| the following care prescribed, provided, or ordered for an | 18 |
| individual diagnosed with an autism spectrum disorder by (A) a | 19 |
| physician licensed to practice medicine in all its branches or | 20 |
| (B) a certified, registered, or licensed health care | 21 |
| professional with expertise in treating effects of autism | 22 |
| spectrum disorders when the care is determined to be medically | 23 |
| necessary and ordered by a physician licensed to practice | 24 |
| medicine in all its branches: | 25 |
| (1) Psychiatric care, meaning direct, consultative, or | 26 |
| diagnostic services provided by a licensed psychiatrist. |
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| (2) Psychological care, meaning direct or consultative | 2 |
| services provided by a licensed psychologist. | 3 |
| (3) Habilitative or rehabilitative care, meaning | 4 |
| professional, counseling, and guidance services and | 5 |
| treatment programs, including applied behavior analysis, | 6 |
| that are intended to develop, maintain, and restore the | 7 |
| functioning of an individual. As used in this subsection | 8 |
| (i), "applied behavior analysis" means the design, | 9 |
| implementation, and evaluation of environmental | 10 |
| modifications using behavioral stimuli and consequences to | 11 |
| produce socially significant improvement in human | 12 |
| behavior, including the use of direct observation, | 13 |
| measurement, and functional analysis of the relations | 14 |
| between environment and behavior. | 15 |
| (4) Therapeutic care, including behavioral, speech, | 16 |
| occupational, and physical therapies that provide | 17 |
| treatment in the following areas: (i) self care and | 18 |
| feeding, (ii) pragmatic, receptive, and expressive | 19 |
| language, (iii) cognitive functioning, (iv) applied | 20 |
| behavior analysis, intervention, and modification, (v) | 21 |
| motor planning, and (vi) sensory processing. | 22 |
| (j) Rulemaking authority to implement this amendatory Act | 23 |
| of the 95th General Assembly, if any, is conditioned on the | 24 |
| rules being adopted in accordance with all provisions of the | 25 |
| Illinois Administrative Procedure Act and all rules and | 26 |
| procedures of the Joint Committee on Administrative Rules; any |
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| purported rule not so adopted, for whatever reason, is | 2 |
| unauthorized. | 3 |
| Section 30. The Health Maintenance Organization Act is | 4 |
| 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 | 8 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 9 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 10 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | 11 |
| 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | 12 |
| 356z.14, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | 13 |
| 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | 14 |
| 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | 15 |
| and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | 16 |
| and XXVI of the Illinois Insurance Code.
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| (b) For purposes of the Illinois Insurance Code, except for | 18 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 19 |
| Maintenance Organizations in
the following categories are | 20 |
| deemed to be "domestic companies":
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| (1) a corporation authorized under the
Dental Service | 22 |
| Plan Act or the Voluntary Health Services Plans Act;
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| (2) a corporation organized under the laws of this | 24 |
| State; or
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| (3) a corporation organized under the laws of another | 2 |
| state, 30% or more
of the enrollees of which are residents | 3 |
| of this State, except a
corporation subject to | 4 |
| substantially the same requirements in its state of
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| organization as is a "domestic company" under Article VIII | 6 |
| 1/2 of the
Illinois Insurance Code.
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| (c) In considering the merger, consolidation, or other | 8 |
| acquisition of
control of a Health Maintenance Organization | 9 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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| (1) the Director shall give primary consideration to | 11 |
| the continuation of
benefits to enrollees and the financial | 12 |
| conditions of the acquired Health
Maintenance Organization | 13 |
| after the merger, consolidation, or other
acquisition of | 14 |
| control takes effect;
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| (2)(i) the criteria specified in subsection (1)(b) of | 16 |
| Section 131.8 of
the Illinois Insurance Code shall not | 17 |
| apply and (ii) the Director, in making
his determination | 18 |
| with respect to the merger, consolidation, or other
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| acquisition of control, need not take into account the | 20 |
| effect on
competition of the merger, consolidation, or | 21 |
| other acquisition of control;
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| (3) the Director shall have the power to require the | 23 |
| following
information:
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| (A) certification by an independent actuary of the | 25 |
| adequacy
of the reserves of the Health Maintenance | 26 |
| Organization sought to be acquired;
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| (B) pro forma financial statements reflecting the | 2 |
| combined balance
sheets of the acquiring company and | 3 |
| the Health Maintenance Organization sought
to be | 4 |
| acquired as of the end of the preceding year and as of | 5 |
| a date 90 days
prior to the acquisition, as well as pro | 6 |
| forma financial statements
reflecting projected | 7 |
| combined operation for a period of 2 years;
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| (C) a pro forma business plan detailing an | 9 |
| acquiring party's plans with
respect to the operation | 10 |
| of the Health Maintenance Organization sought to
be | 11 |
| acquired for a period of not less than 3 years; and
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| (D) such other information as the Director shall | 13 |
| require.
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| (d) The provisions of Article VIII 1/2 of the Illinois | 15 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 16 |
| any health maintenance
organization of greater than 10% of its
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| enrollee population (including without limitation the health | 18 |
| maintenance
organization's right, title, and interest in and to | 19 |
| its health care
certificates).
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| (e) In considering any management contract or service | 21 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 22 |
| Code, the Director (i) shall, in
addition to the criteria | 23 |
| specified in Section 141.2 of the Illinois
Insurance Code, take | 24 |
| into account the effect of the management contract or
service | 25 |
| agreement on the continuation of benefits to enrollees and the
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| financial condition of the health maintenance organization to |
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| be managed or
serviced, and (ii) need not take into account the | 2 |
| effect of the management
contract or service agreement on | 3 |
| competition.
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| (f) Except for small employer groups as defined in the | 5 |
| Small Employer
Rating, Renewability and Portability Health | 6 |
| Insurance Act and except for
medicare supplement policies as | 7 |
| defined in Section 363 of the Illinois
Insurance Code, a Health | 8 |
| Maintenance Organization may by contract agree with a
group or | 9 |
| other enrollment unit to effect refunds or charge additional | 10 |
| premiums
under the following terms and conditions:
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| (i) the amount of, and other terms and conditions with | 12 |
| respect to, the
refund or additional premium are set forth | 13 |
| in the group or enrollment unit
contract agreed in advance | 14 |
| of the period for which a refund is to be paid or
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| additional premium is to be charged (which period shall not | 16 |
| be less than one
year); and
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| (ii) the amount of the refund or additional premium | 18 |
| shall not exceed 20%
of the Health Maintenance | 19 |
| Organization's profitable or unprofitable experience
with | 20 |
| respect to the group or other enrollment unit for the | 21 |
| period (and, for
purposes of a refund or additional | 22 |
| premium, the profitable or unprofitable
experience shall | 23 |
| be calculated taking into account a pro rata share of the
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| Health Maintenance Organization's administrative and | 25 |
| marketing expenses, but
shall not include any refund to be | 26 |
| made or additional premium to be paid
pursuant to this |
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| subsection (f)). The Health Maintenance Organization and | 2 |
| the
group or enrollment unit may agree that the profitable | 3 |
| or unprofitable
experience may be calculated taking into | 4 |
| account the refund period and the
immediately preceding 2 | 5 |
| plan years.
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| The Health Maintenance Organization shall include a | 7 |
| statement in the
evidence of coverage issued to each enrollee | 8 |
| describing the possibility of a
refund or additional premium, | 9 |
| and upon request of any group or enrollment unit,
provide to | 10 |
| the group or enrollment unit a description of the method used | 11 |
| to
calculate (1) the Health Maintenance Organization's | 12 |
| profitable experience with
respect to the group or enrollment | 13 |
| unit and the resulting refund to the group
or enrollment unit | 14 |
| or (2) the Health Maintenance Organization's unprofitable
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| experience with respect to the group or enrollment unit and the | 16 |
| resulting
additional premium to be paid by the group or | 17 |
| enrollment unit.
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| In no event shall the Illinois Health Maintenance | 19 |
| Organization
Guaranty Association be liable to pay any | 20 |
| contractual obligation of an
insolvent organization to pay any | 21 |
| refund authorized under this Section.
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| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | 23 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | 24 |
| 8-21-08.)
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| Section 35. The Voluntary Health Services Plans Act is |
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| 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 | 4 |
| services
plan corporations and all persons interested therein | 5 |
| or dealing therewith
shall be subject to the provisions of | 6 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | 7 |
| 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, | 8 |
| 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, | 9 |
| 356z.9,
356z.10, 356z.14, 364.01, 367.2, 368a, 401, 401.1,
402,
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| 403, 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of | 11 |
| 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; | 13 |
| 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | 14 |
| 8-28-07; 95-876, eff. 8-21-08.)
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| Section 99. Effective date. This Act takes effect upon | 16 |
| becoming law.
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