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90_HB0888
215 ILCS 5/356t new
215 ILCS 5/370s new
215 ILCS 5/511.114 new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
215 ILCS 130/3009 from Ch. 73, par. 1503-9
215 ILCS 165/10 from Ch. 32, par. 604
Amends the Illinois Insurance Code, Health Maintenance
Organization Act, Limited Health Service Organization Act,
and Voluntary Health Services Plans Act. Requires coverage
under those Acts to include diabetes self-management training
and education. Effective immediately.
LRB9004054JSgc
LRB9004054JSgc
1 AN ACT concerning health coverage for treatment of
2 diabetes, amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Insurance Code is amended by
6 adding Sections 356t, 370s, and 511.114 as follows:
7 (215 ILCS 5/356t new)
8 Sec. 356t. Diabetes self-management training and
9 education.
10 (a) An individual or group policy of accident and health
11 insurance and a managed care plan, as defined in Section 356r
12 of this Code, that is amended, delivered, issued, or renewed
13 after the effective date of this amendatory Act of 1997 shall
14 provide coverage for outpatient self-management training and
15 education, equipment, and supplies for the treatment of
16 insulin-dependent diabetes, insulin-using diabetes,
17 gestational diabetes, and non-insulin using diabetes.
18 (b) As used in this Section, "diabetes self-management
19 training" means instruction in an inpatient or outpatient
20 setting which enables diabetic patients to understand the
21 diabetic management process and daily management of diabetic
22 therapy as a means of avoiding frequent hospitalizations and
23 complications. Diabetic self-management training shall
24 comply with the standards developed by the Department of
25 Public Health in consultation with a national diabetes
26 association affiliated with this State.
27 (c) Diabetes self-management training shall be provided
28 by a certified, registered, or licensed health care
29 professional with expertise in diabetes management. Medical
30 nutritional therapy, however, may be provided only by a
31 licensee under the Dietetic and Nutrition Services Practice
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1 Act. The Department of Public Health shall establish minimum
2 requirements for demonstrating expertise in diabetes
3 management in consultation with a national diabetes
4 association affiliated with this State.
5 (d) Coverage under this Section for diabetes
6 self-management training, including medical nutrition
7 therapy, shall be limited to the following:
8 (1) visits medically necessary upon the diagnosis
9 of diabetes by a physician;
10 (2) a physician diagnosis that represents a
11 significant change in the patient's symptoms or condition
12 requiring medically necessary changes in the patient's
13 self-management; and
14 (3) visits when reeducation or refresher training
15 is medically necessary.
16 Diabetes self-management training may be provided as part
17 of an office visit, group setting, or in-home visit.
18 Coverage under this Section shall be subject to the same
19 deductible and coinsurance provisions that apply to other
20 coverage under the policy.
21 (e) Other coverage under a policy or plan may not be
22 reduced or eliminated because of the requirements of this
23 Section. The Department shall issue rules necessary to
24 enforce the provisions of this Section.
25 (215 ILCS 5/370s new)
26 Sec. 370s. Diabetes management training. All insurers
27 and administrators are subject to Section 356t of this Code.
28 (215 ILCS 5/511.114 new)
29 Sec. 511.114. Diabetes management training. All
30 administrators are subject to Section 356t of this Code.
31 Section 10. The Health Maintenance Organization Act is
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1 amended by changing Section 5-3 as follows:
2 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
3 Sec. 5-3. Insurance Code provisions.
4 (a) Health Maintenance Organizations shall be subject to
5 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
6 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
7 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356t, 367i, 401,
8 401.1, 402, 403, 403A, 408, 408.2, and 412, paragraph (c) of
9 subsection (2) of Section 367, and Articles VIII 1/2, XII,
10 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
11 Code.
12 (b) For purposes of the Illinois Insurance Code, except
13 for Articles XIII and XIII 1/2, Health Maintenance
14 Organizations in the following categories are deemed to be
15 "domestic companies":
16 (1) a corporation authorized under the Medical
17 Service Plan Act, the Dental Service Plan Act, the Vision
18 Service Plan Act, the Pharmaceutical Service Plan Act,
19 the Voluntary Health Services Plan Act, or the Nonprofit
20 Health Care Service Plan Act;
21 (2) a corporation organized under the laws of this
22 State; or
23 (3) a corporation organized under the laws of
24 another state, 30% or more of the enrollees of which are
25 residents of this State, except a corporation subject to
26 substantially the same requirements in its state of
27 organization as is a "domestic company" under Article
28 VIII 1/2 of the Illinois Insurance Code.
29 (c) In considering the merger, consolidation, or other
30 acquisition of control of a Health Maintenance Organization
31 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
32 (1) the Director shall give primary consideration
33 to the continuation of benefits to enrollees and the
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1 financial conditions of the acquired Health Maintenance
2 Organization after the merger, consolidation, or other
3 acquisition of control takes effect;
4 (2)(i) the criteria specified in subsection (1)(b)
5 of Section 131.8 of the Illinois Insurance Code shall not
6 apply and (ii) the Director, in making his determination
7 with respect to the merger, consolidation, or other
8 acquisition of control, need not take into account the
9 effect on competition of the merger, consolidation, or
10 other acquisition of control;
11 (3) the Director shall have the power to require
12 the following information:
13 (A) certification by an independent actuary of
14 the adequacy of the reserves of the Health
15 Maintenance Organization sought to be acquired;
16 (B) pro forma financial statements reflecting
17 the combined balance sheets of the acquiring company
18 and the Health Maintenance Organization sought to be
19 acquired as of the end of the preceding year and as
20 of a date 90 days prior to the acquisition, as well
21 as pro forma financial statements reflecting
22 projected combined operation for a period of 2
23 years;
24 (C) a pro forma business plan detailing an
25 acquiring party's plans with respect to the
26 operation of the Health Maintenance Organization
27 sought to be acquired for a period of not less than
28 3 years; and
29 (D) such other information as the Director
30 shall require.
31 (d) The provisions of Article VIII 1/2 of the Illinois
32 Insurance Code and this Section 5-3 shall apply to the sale
33 by any health maintenance organization of greater than 10% of
34 its enrollee population (including without limitation the
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1 health maintenance organization's right, title, and interest
2 in and to its health care certificates).
3 (e) In considering any management contract or service
4 agreement subject to Section 141.1 of the Illinois Insurance
5 Code, the Director (i) shall, in addition to the criteria
6 specified in Section 141.2 of the Illinois Insurance Code,
7 take into account the effect of the management contract or
8 service agreement on the continuation of benefits to
9 enrollees and the financial condition of the health
10 maintenance organization to be managed or serviced, and (ii)
11 need not take into account the effect of the management
12 contract or service agreement on competition.
13 (f) Except for small employer groups as defined in the
14 Small Employer Rating, Renewability and Portability Health
15 Insurance Act and except for medicare supplement policies as
16 defined in Section 363 of the Illinois Insurance Code, a
17 Health Maintenance Organization may by contract agree with a
18 group or other enrollment unit to effect refunds or charge
19 additional premiums under the following terms and conditions:
20 (i) the amount of, and other terms and conditions
21 with respect to, the refund or additional premium are set
22 forth in the group or enrollment unit contract agreed in
23 advance of the period for which a refund is to be paid or
24 additional premium is to be charged (which period shall
25 not be less than one year); and
26 (ii) the amount of the refund or additional premium
27 shall not exceed 20% of the Health Maintenance
28 Organization's profitable or unprofitable experience with
29 respect to the group or other enrollment unit for the
30 period (and, for purposes of a refund or additional
31 premium, the profitable or unprofitable experience shall
32 be calculated taking into account a pro rata share of the
33 Health Maintenance Organization's administrative and
34 marketing expenses, but shall not include any refund to
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1 be made or additional premium to be paid pursuant to this
2 subsection (f)). The Health Maintenance Organization and
3 the group or enrollment unit may agree that the
4 profitable or unprofitable experience may be calculated
5 taking into account the refund period and the immediately
6 preceding 2 plan years.
7 The Health Maintenance Organization shall include a
8 statement in the evidence of coverage issued to each enrollee
9 describing the possibility of a refund or additional premium,
10 and upon request of any group or enrollment unit, provide to
11 the group or enrollment unit a description of the method used
12 to calculate (1) the Health Maintenance Organization's
13 profitable experience with respect to the group or enrollment
14 unit and the resulting refund to the group or enrollment unit
15 or (2) the Health Maintenance Organization's unprofitable
16 experience with respect to the group or enrollment unit and
17 the resulting additional premium to be paid by the group or
18 enrollment unit.
19 In no event shall the Illinois Health Maintenance
20 Organization Guaranty Association be liable to pay any
21 contractual obligation of an insolvent organization to pay
22 any refund authorized under this Section.
23 (Source: P.A. 88-313; 89-90, eff. 6-30-95.)
24 Section 15. The Limited Health Service Organization Act
25 is amended by changing Section 3009 as follows:
26 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
27 Sec. 3009. Point-of-service limited health service
28 contracts.
29 (a) An LHSO that offers a POS contract:
30 (1) shall include as in-plan covered services all
31 services required by law to be provided by an LHSO;
32 (2) shall provide incentives, which shall include
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1 financial incentives, for enrollees to use in-plan
2 covered services;
3 (3) shall not offer services out-of-plan without
4 providing those services on an in-plan basis;
5 (4) may limit or exclude specific types of services
6 from coverage when obtained out-of-plan;
7 (5) may include annual out-of-pocket limits and
8 lifetime maximum benefits allowances for out-of-plan
9 services that are separate from any limits or allowances
10 applied to in-plan services;
11 (6) shall include an annual maximum benefit
12 allowance not to exceed $2,500 per year that is separate
13 from any limits or allowances applied to in-plan
14 services;
15 (7) may limit the groups to which a POS product is
16 offered, however, if a POS product is offered to a group,
17 then it must be offered to all eligible members of that
18 group, when an LHSO provider is available;
19 (8) shall not consider emergency services,
20 authorized referral services, or non-routine services
21 obtained out of the service area to be POS services; and
22 (9) may treat as out-of-plan services those
23 services that an enrollee obtains from a participating
24 provider, but for which the proper authorization was not
25 given by the LHSO.
26 (b) An LHSO offering a POS contract shall be subject to
27 the following limitations:
28 (1) The LHSO shall not expend in any calendar
29 quarter more than 20% of its total limited health
30 services expenditures for all its members for out-of-plan
31 covered services.
32 (2) If the amount specified in paragraph (1) is
33 exceeded by 2% in a quarter, the LHSO shall effect
34 compliance with paragraph (1) by the end of the following
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1 quarter.
2 (3) If compliance with the amount specified in
3 paragraph (1) is not demonstrated in the LHSO's next
4 quarterly report, the LHSO may not offer the POS contract
5 to new groups or include the POS option in the renewal of
6 an existing group until compliance with the amount
7 specified in paragraph (1) is demonstrated or otherwise
8 allowed by the Director.
9 (4) Any LHSO failing, without just cause, to comply
10 with the provisions of this subsection shall be required,
11 after notice and hearing, to pay a penalty of $250 for
12 each day out of compliance, to be recovered by the
13 Director of Insurance. Any penalty recovered shall be
14 paid into the General Revenue Fund. The Director may
15 reduce the penalty if the LHSO demonstrates to the
16 Director that the imposition of the penalty would
17 constitute a financial hardship to the LHSO.
18 (c) Any LHSO that offers a POS product shall:
19 (1) File a quarterly financial statement detailing
20 compliance with the requirements of subsection (b).
21 (2) Track out-of-plan POS utilization separately
22 from in-plan or non-POS out-of-plan emergency care,
23 referral care, and urgent care out of the service area
24 utilization.
25 (3) Record out-of-plan utilization in a manner that
26 will permit such utilization and cost reporting as the
27 Director may, by regulation, require.
28 (4) Demonstrate to the Director's satisfaction that
29 the LHSO has the fiscal, administrative, and marketing
30 capacity to control its POS enrollment, utilization, and
31 costs so as not to jeopardize the financial security of
32 the LHSO.
33 (5) Maintain the deposit required by subsection (b)
34 of Section 2006 in addition to any other deposit required
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1 under this Act.
2 (d) An LHSO shall not issue a POS contract until it has
3 filed and had approved by the Director a plan to comply with
4 the provisions of this Section. The compliance plan shall at
5 a minimum include provisions demonstrating that the LHSO will
6 do all of the following:
7 (1) Design the benefit levels and conditions of
8 coverage for in-plan covered services and out-of-plan
9 covered services as required by this Article.
10 (2) Provide or arrange for the provision of
11 adequate systems to:
12 (A) process and pay claims for all out-of-plan
13 covered services;
14 (B) meet the requirements for a POS contract
15 set forth in this Section and any additional
16 requirements that may be set forth by the Director;
17 and
18 (C) generate accurate data and financial and
19 regulatory reports on a timely basis so that the
20 Department can evaluate the LHSO's experience with
21 the POS contract and monitor compliance with POS
22 contract provisions.
23 (3) Comply initially and on an ongoing basis with
24 the requirements of subsections (b) and (c).
25 (e) A limited health service organization that offers a
26 POS contract must comply with Section 356t of the Illinois
27 Insurance Code.
28 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.)
29 Section 20. The Voluntary Health Services Plans Act is
30 amended by changing Section 10 as follows:
31 (215 ILCS 165/10) (from Ch. 32, par. 604)
32 Sec. 10. Application of Insurance Code provisions.
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1 Health services plan corporations and all persons interested
2 therein or dealing therewith shall be subject to the
3 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
4 143, 143c, 149, 354, 355.2, 356r, 356t, 367.2, 401, 401.1,
5 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
6 (15) of Section 367 of the Illinois Insurance Code.
7 (Source: P.A. 89-514, eff. 7-17-96.)
8 Section 99. Effective date. This Act takes effect upon
9 becoming law.