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Public Act 095-1045 |
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AN ACT concerning regulation.
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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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Article 1. Legislative Intent | ||||
Section 1-1. Legislative intent. The General Assembly | ||||
finds that the mortality associated with breast cancer for | ||||
minority women in Illinois is significantly higher compared to | ||||
non-minority women. This disparity has grown over the last 2 | ||||
decades and is unacceptable. A recent New England Journal of | ||||
Medicine article found that even modest cost-sharing deters | ||||
women from getting a mammogram. The reduction was most | ||||
pronounced for those with lower income and less education. Many | ||||
other studies have found that women with lower family income | ||||
and those relying on public programs for healthcare access | ||||
mammography at a lower rate. It is, therefore, the intent of | ||||
this legislation to decrease health disparities as they relate | ||||
to breast cancer and to improve access for all women to quality | ||||
breast cancer screening and treatment where necessary. | ||||
Article 5. Improving State Healthcare Programs | ||||
With Respect To | ||||
Mammography And Breast Cancer Treatment |
Section 5-5. The Illinois Public Aid Code is amended by | ||
changing Section 5-5 as follows: | ||
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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Sec. 5-5. Medical services. The Illinois Department, by | ||
rule, shall
determine the quantity and quality of and the rate | ||
of reimbursement for the
medical assistance for which
payment | ||
will be authorized, and the medical services to be provided,
| ||
which may include all or part of the following: (1) inpatient | ||
hospital
services; (2) outpatient hospital services; (3) other | ||
laboratory and
X-ray services; (4) skilled nursing home | ||
services; (5) physicians'
services whether furnished in the | ||
office, the patient's home, a
hospital, a skilled nursing home, | ||
or elsewhere; (6) medical care, or any
other type of remedial | ||
care furnished by licensed practitioners; (7)
home health care | ||
services; (8) private duty nursing service; (9) clinic
| ||
services; (10) dental services, including prevention and | ||
treatment of periodontal disease and dental caries disease for | ||
pregnant women; (11) physical therapy and related
services; | ||
(12) prescribed drugs, dentures, and prosthetic devices; and
| ||
eyeglasses prescribed by a physician skilled in the diseases of | ||
the eye,
or by an optometrist, whichever the person may select; | ||
(13) other
diagnostic, screening, preventive, and | ||
rehabilitative services; (14)
transportation and such other | ||
expenses as may be necessary; (15) medical
treatment of sexual | ||
assault survivors, as defined in
Section 1a of the Sexual |
Assault Survivors Emergency Treatment Act, for
injuries | ||
sustained as a result of the sexual assault, including
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examinations and laboratory tests to discover evidence which | ||
may be used in
criminal proceedings arising from the sexual | ||
assault; (16) the
diagnosis and treatment of sickle cell | ||
anemia; and (17)
any other medical care, and any other type of | ||
remedial care recognized
under the laws of this State, but not | ||
including abortions, or induced
miscarriages or premature | ||
births, unless, in the opinion of a physician,
such procedures | ||
are necessary for the preservation of the life of the
woman | ||
seeking such treatment, or except an induced premature birth
| ||
intended to produce a live viable child and such procedure is | ||
necessary
for the health of the mother or her unborn child. The | ||
Illinois Department,
by rule, shall prohibit any physician from | ||
providing medical assistance
to anyone eligible therefor under | ||
this Code where such physician has been
found guilty of | ||
performing an abortion procedure in a wilful and wanton
manner | ||
upon a woman who was not pregnant at the time such abortion
| ||
procedure was performed. The term "any other type of remedial | ||
care" shall
include nursing care and nursing home service for | ||
persons who rely on
treatment by spiritual means alone through | ||
prayer for healing.
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Notwithstanding any other provision of this Section, a | ||
comprehensive
tobacco use cessation program that includes | ||
purchasing prescription drugs or
prescription medical devices | ||
approved by the Food and Drug administration shall
be covered |
under the medical assistance
program under this Article for | ||
persons who are otherwise eligible for
assistance under this | ||
Article.
| ||
Notwithstanding any other provision of this Code, the | ||
Illinois
Department may not require, as a condition of payment | ||
for any laboratory
test authorized under this Article, that a | ||
physician's handwritten signature
appear on the laboratory | ||
test order form. The Illinois Department may,
however, impose | ||
other appropriate requirements regarding laboratory test
order | ||
documentation.
| ||
The Department of Healthcare and Family Services shall | ||
provide the following services to
persons
eligible for | ||
assistance under this Article who are participating in
| ||
education, training or employment programs operated by the | ||
Department of Human
Services as successor to the Department of | ||
Public Aid:
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(1) dental services, which shall include but not be | ||
limited to
prosthodontics; and
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(2) eyeglasses prescribed by a physician skilled in the | ||
diseases of the
eye, or by an optometrist, whichever the | ||
person may select.
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The Illinois Department, by rule, may distinguish and | ||
classify the
medical services to be provided only in accordance | ||
with the classes of
persons designated in Section 5-2.
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The Department of Healthcare and Family Services must | ||
provide coverage and reimbursement for amino acid-based |
elemental formulas, regardless of delivery method, for the | ||
diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||
short bowel syndrome when the prescribing physician has issued | ||
a written order stating that the amino acid-based elemental | ||
formula is medically necessary.
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The Illinois Department shall authorize the provision of, | ||
and shall
authorize payment for, screening by low-dose | ||
mammography for the presence of
occult breast cancer for women | ||
35 years of age or older who are eligible
for medical | ||
assistance under this Article, as follows: | ||
(A) A a baseline
mammogram for women 35 to 39 years of | ||
age . and an
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(B) An annual mammogram for women 40 years of age or | ||
older. | ||
(C) A mammogram at the age and intervals considered | ||
medically necessary by the woman's health care provider for | ||
women under 40 years of age and having a family history of | ||
breast cancer, prior personal history of breast cancer, | ||
positive genetic testing, or other risk factors. | ||
(D) A comprehensive ultrasound screening of an entire | ||
breast or breasts if a mammogram demonstrates | ||
heterogeneous or dense breast tissue, when medically | ||
necessary as determined by a physician licensed to practice | ||
medicine in all of its branches. | ||
All screenings
shall
include a physical breast exam, | ||
instruction on self-examination and
information regarding the |
frequency of self-examination and its value as a
preventative | ||
tool. For purposes of As used in this Section, "low-dose | ||
mammography" means
the x-ray examination of the breast using | ||
equipment dedicated specifically
for mammography, including | ||
the x-ray tube, filter, compression device,
and image receptor, | ||
and cassettes, with an average radiation exposure delivery
of | ||
less than one rad per breast for mid-breast, with 2 views of an | ||
average size for each breast. The term also includes digital | ||
mammography.
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On and after July 1, 2008, screening and diagnostic | ||
mammography shall be reimbursed at the same rate as the | ||
Medicare program's rates, including the increased | ||
reimbursement for digital mammography. | ||
The Department shall convene an expert panel including | ||
representatives of hospitals, free-standing mammography | ||
facilities, and doctors, including radiologists, to establish | ||
quality standards. Based on these quality standards, the | ||
Department shall provide for bonus payments to mammography | ||
facilities meeting the standards for screening and diagnosis. | ||
The bonus payments shall be at least 15% higher than the | ||
Medicare rates for mammography. | ||
Subject to federal approval, the Department shall | ||
establish a rate methodology for mammography at federally | ||
qualified health centers and other encounter-rate clinics. | ||
These clinics or centers may also collaborate with other | ||
hospital-based mammography facilities. |
The Department shall establish a methodology to remind | ||
women who are age-appropriate for screening mammography, but | ||
who have not received a mammogram within the previous 18 | ||
months, of the importance and benefit of screening mammography. | ||
The Department shall establish a performance goal for | ||
primary care providers with respect to their female patients | ||
over age 40 receiving an annual mammogram. This performance | ||
goal shall be used to provide additional reimbursement in the | ||
form of a quality performance bonus to primary care providers | ||
who meet that goal. | ||
The Department shall devise a means of case-managing or | ||
patient navigation for beneficiaries diagnosed with breast | ||
cancer. This program shall initially operate as a pilot program | ||
in areas of the State with the highest incidence of mortality | ||
related to breast cancer. At least one pilot program site shall | ||
be in the metropolitan Chicago area and at least one site shall | ||
be outside the metropolitan Chicago area. An evaluation of the | ||
pilot program shall be carried out measuring health outcomes | ||
and cost of care for those served by the pilot program compared | ||
to similarly situated patients who are not served by the pilot | ||
program. | ||
Any medical or health care provider shall immediately | ||
recommend, to
any pregnant woman who is being provided prenatal | ||
services and is suspected
of drug abuse or is addicted as | ||
defined in the Alcoholism and Other Drug Abuse
and Dependency | ||
Act, referral to a local substance abuse treatment provider
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licensed by the Department of Human Services or to a licensed
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hospital which provides substance abuse treatment services. | ||
The Department of Healthcare and Family Services
shall assure | ||
coverage for the cost of treatment of the drug abuse or
| ||
addiction for pregnant recipients in accordance with the | ||
Illinois Medicaid
Program in conjunction with the Department of | ||
Human Services.
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All medical providers providing medical assistance to | ||
pregnant women
under this Code shall receive information from | ||
the Department on the
availability of services under the Drug | ||
Free Families with a Future or any
comparable program providing | ||
case management services for addicted women,
including | ||
information on appropriate referrals for other social services
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that may be needed by addicted women in addition to treatment | ||
for addiction.
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The Illinois Department, in cooperation with the | ||
Departments of Human
Services (as successor to the Department | ||
of Alcoholism and Substance
Abuse) and Public Health, through a | ||
public awareness campaign, may
provide information concerning | ||
treatment for alcoholism and drug abuse and
addiction, prenatal | ||
health care, and other pertinent programs directed at
reducing | ||
the number of drug-affected infants born to recipients of | ||
medical
assistance.
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Neither the Department of Healthcare and Family Services | ||
nor the Department of Human
Services shall sanction the | ||
recipient solely on the basis of
her substance abuse.
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The Illinois Department shall establish such regulations | ||
governing
the dispensing of health services under this Article | ||
as it shall deem
appropriate. The Department
should
seek the | ||
advice of formal professional advisory committees appointed by
| ||
the Director of the Illinois Department for the purpose of | ||
providing regular
advice on policy and administrative matters, | ||
information dissemination and
educational activities for | ||
medical and health care providers, and
consistency in | ||
procedures to the Illinois Department.
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The Illinois Department may develop and contract with | ||
Partnerships of
medical providers to arrange medical services | ||
for persons eligible under
Section 5-2 of this Code. | ||
Implementation of this Section may be by
demonstration projects | ||
in certain geographic areas. The Partnership shall
be | ||
represented by a sponsor organization. The Department, by rule, | ||
shall
develop qualifications for sponsors of Partnerships. | ||
Nothing in this
Section shall be construed to require that the | ||
sponsor organization be a
medical organization.
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The sponsor must negotiate formal written contracts with | ||
medical
providers for physician services, inpatient and | ||
outpatient hospital care,
home health services, treatment for | ||
alcoholism and substance abuse, and
other services determined | ||
necessary by the Illinois Department by rule for
delivery by | ||
Partnerships. Physician services must include prenatal and
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obstetrical care. The Illinois Department shall reimburse | ||
medical services
delivered by Partnership providers to clients |
in target areas according to
provisions of this Article and the | ||
Illinois Health Finance Reform Act,
except that:
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(1) Physicians participating in a Partnership and | ||
providing certain
services, which shall be determined by | ||
the Illinois Department, to persons
in areas covered by the | ||
Partnership may receive an additional surcharge
for such | ||
services.
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(2) The Department may elect to consider and negotiate | ||
financial
incentives to encourage the development of | ||
Partnerships and the efficient
delivery of medical care.
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(3) Persons receiving medical services through | ||
Partnerships may receive
medical and case management | ||
services above the level usually offered
through the | ||
medical assistance program.
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Medical providers shall be required to meet certain | ||
qualifications to
participate in Partnerships to ensure the | ||
delivery of high quality medical
services. These | ||
qualifications shall be determined by rule of the Illinois
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Department and may be higher than qualifications for | ||
participation in the
medical assistance program. Partnership | ||
sponsors may prescribe reasonable
additional qualifications | ||
for participation by medical providers, only with
the prior | ||
written approval of the Illinois Department.
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Nothing in this Section shall limit the free choice of | ||
practitioners,
hospitals, and other providers of medical | ||
services by clients.
In order to ensure patient freedom of |
choice, the Illinois Department shall
immediately promulgate | ||
all rules and take all other necessary actions so that
provided | ||
services may be accessed from therapeutically certified | ||
optometrists
to the full extent of the Illinois Optometric | ||
Practice Act of 1987 without
discriminating between service | ||
providers.
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The Department shall apply for a waiver from the United | ||
States Health
Care Financing Administration to allow for the | ||
implementation of
Partnerships under this Section.
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The Illinois Department shall require health care | ||
providers to maintain
records that document the medical care | ||
and services provided to recipients
of Medical Assistance under | ||
this Article. The Illinois Department shall
require health care | ||
providers to make available, when authorized by the
patient, in | ||
writing, the medical records in a timely fashion to other
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health care providers who are treating or serving persons | ||
eligible for
Medical Assistance under this Article. All | ||
dispensers of medical services
shall be required to maintain | ||
and retain business and professional records
sufficient to | ||
fully and accurately document the nature, scope, details and
| ||
receipt of the health care provided to persons eligible for | ||
medical
assistance under this Code, in accordance with | ||
regulations promulgated by
the Illinois Department. The rules | ||
and regulations shall require that proof
of the receipt of | ||
prescription drugs, dentures, prosthetic devices and
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eyeglasses by eligible persons under this Section accompany |
each claim
for reimbursement submitted by the dispenser of such | ||
medical services.
No such claims for reimbursement shall be | ||
approved for payment by the Illinois
Department without such | ||
proof of receipt, unless the Illinois Department
shall have put | ||
into effect and shall be operating a system of post-payment
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audit and review which shall, on a sampling basis, be deemed | ||
adequate by
the Illinois Department to assure that such drugs, | ||
dentures, prosthetic
devices and eyeglasses for which payment | ||
is being made are actually being
received by eligible | ||
recipients. Within 90 days after the effective date of
this | ||
amendatory Act of 1984, the Illinois Department shall establish | ||
a
current list of acquisition costs for all prosthetic devices | ||
and any
other items recognized as medical equipment and | ||
supplies reimbursable under
this Article and shall update such | ||
list on a quarterly basis, except that
the acquisition costs of | ||
all prescription drugs shall be updated no
less frequently than | ||
every 30 days as required by Section 5-5.12.
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The rules and regulations of the Illinois Department shall | ||
require
that a written statement including the required opinion | ||
of a physician
shall accompany any claim for reimbursement for | ||
abortions, or induced
miscarriages or premature births. This | ||
statement shall indicate what
procedures were used in providing | ||
such medical services.
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The Illinois Department shall require all dispensers of | ||
medical
services, other than an individual practitioner or | ||
group of practitioners,
desiring to participate in the Medical |
Assistance program
established under this Article to disclose | ||
all financial, beneficial,
ownership, equity, surety or other | ||
interests in any and all firms,
corporations, partnerships, | ||
associations, business enterprises, joint
ventures, agencies, | ||
institutions or other legal entities providing any
form of | ||
health care services in this State under this Article.
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The Illinois Department may require that all dispensers of | ||
medical
services desiring to participate in the medical | ||
assistance program
established under this Article disclose, | ||
under such terms and conditions as
the Illinois Department may | ||
by rule establish, all inquiries from clients
and attorneys | ||
regarding medical bills paid by the Illinois Department, which
| ||
inquiries could indicate potential existence of claims or liens | ||
for the
Illinois Department.
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Enrollment of a vendor that provides non-emergency medical | ||
transportation,
defined by the Department by rule,
shall be
| ||
conditional for 180 days. During that time, the Department of | ||
Healthcare and Family Services may
terminate the vendor's | ||
eligibility to participate in the medical assistance
program | ||
without cause. That termination of eligibility is not subject | ||
to the
Department's hearing process.
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The Illinois Department shall establish policies, | ||
procedures,
standards and criteria by rule for the acquisition, | ||
repair and replacement
of orthotic and prosthetic devices and | ||
durable medical equipment. Such
rules shall provide, but not be | ||
limited to, the following services: (1)
immediate repair or |
replacement of such devices by recipients without
medical | ||
authorization; and (2) rental, lease, purchase or | ||
lease-purchase of
durable medical equipment in a | ||
cost-effective manner, taking into
consideration the | ||
recipient's medical prognosis, the extent of the
recipient's | ||
needs, and the requirements and costs for maintaining such
| ||
equipment. Such rules shall enable a recipient to temporarily | ||
acquire and
use alternative or substitute devices or equipment | ||
pending repairs or
replacements of any device or equipment | ||
previously authorized for such
recipient by the Department.
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The Department shall execute, relative to the nursing home | ||
prescreening
project, written inter-agency agreements with the | ||
Department of Human
Services and the Department on Aging, to | ||
effect the following: (i) intake
procedures and common | ||
eligibility criteria for those persons who are receiving
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non-institutional services; and (ii) the establishment and | ||
development of
non-institutional services in areas of the State | ||
where they are not currently
available or are undeveloped.
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The Illinois Department shall develop and operate, in | ||
cooperation
with other State Departments and agencies and in | ||
compliance with
applicable federal laws and regulations, | ||
appropriate and effective
systems of health care evaluation and | ||
programs for monitoring of
utilization of health care services | ||
and facilities, as it affects
persons eligible for medical | ||
assistance under this Code.
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The Illinois Department shall report annually to the |
General Assembly,
no later than the second Friday in April of | ||
1979 and each year
thereafter, in regard to:
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(a) actual statistics and trends in utilization of | ||
medical services by
public aid recipients;
| ||
(b) actual statistics and trends in the provision of | ||
the various medical
services by medical vendors;
| ||
(c) current rate structures and proposed changes in | ||
those rate structures
for the various medical vendors; and
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(d) efforts at utilization review and control by the | ||
Illinois Department.
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The period covered by each report shall be the 3 years | ||
ending on the June
30 prior to the report. The report shall | ||
include suggested legislation
for consideration by the General | ||
Assembly. The filing of one copy of the
report with the | ||
Speaker, one copy with the Minority Leader and one copy
with | ||
the Clerk of the House of Representatives, one copy with the | ||
President,
one copy with the Minority Leader and one copy with | ||
the Secretary of the
Senate, one copy with the Legislative | ||
Research Unit, and such additional
copies
with the State | ||
Government Report Distribution Center for the General
Assembly | ||
as is required under paragraph (t) of Section 7 of the State
| ||
Library Act shall be deemed sufficient to comply with this | ||
Section.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois |
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)
| ||
Article 10. Breast Cancer Patients' | ||
Access To Pain Relief | ||
Section 10-5. The Illinois Insurance Code is amended by | ||
adding Section 356g.5-1 as follows: | ||
(215 ILCS 5/356g.5-1 new) | ||
Sec. 356g.5-1. Breast cancer pain medication and therapy. A | ||
group or individual policy of accident and health insurance or | ||
managed care plan that is amended, delivered, issued, or | ||
renewed after the effective date of this amendatory Act of the | ||
95th General Assembly must provide coverage for all medically | ||
necessary pain medication and pain therapy related to the | ||
treatment of breast cancer on the same terms and conditions | ||
that are generally applicable to coverage for other conditions. | ||
For purposes of this Section, "pain therapy" means pain therapy | ||
that is medically based and includes reasonably defined goals, | ||
including, but not limited to, stabilizing or reducing pain, | ||
with periodic evaluations of the efficacy of the pain therapy | ||
against these goals. The provisions of this Section do not | ||
apply to short-term travel, accident-only, limited, or |
specified-disease policies, or to policies or contracts | ||
designed for issuance to persons eligible for coverage under | ||
Title XVIII of the Social Security Act, known as Medicare, or | ||
any other similar coverage under State or federal governmental | ||
plans. | ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
Section 10-10. The State Employees Group Insurance Act of | ||
1971 is amended by changing Section 6.11 as follows:
| ||
(5 ILCS 375/6.11)
| ||
(Text of Section before amendment by P.A. 95-958 ) | ||
Sec. 6.11. Required health benefits; Illinois Insurance | ||
Code
requirements. The program of health
benefits shall provide | ||
the post-mastectomy care benefits required to be covered
by a | ||
policy of accident and health insurance under Section 356t of | ||
the Illinois
Insurance Code. The program of health benefits | ||
shall provide the coverage
required under Sections 356g.5,
| ||
356g.5-1, 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, | ||
356z.10, and 356z.13
356z.11
of the
Illinois Insurance Code.
| ||
The program of health benefits must comply with Section 155.37 |
of the
Illinois Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||
1-1-09; revised 10-15-08.)
| ||
(Text of Section after amendment by P.A. 95-958 )
| ||
Sec. 6.11. Required health benefits; Illinois Insurance | ||
Code
requirements. The program of health
benefits shall provide | ||
the post-mastectomy care benefits required to be covered
by a | ||
policy of accident and health insurance under Section 356t of | ||
the Illinois
Insurance Code. The program of health benefits | ||
shall provide the coverage
required under Sections 356g.5,
| ||
356g.5-1, 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, | ||
356z.10, 356z.11, and 356z.12 , and 356z.13
356z.11 of the
| ||
Illinois Insurance Code.
The program of health benefits must | ||
comply with Section 155.37 of the
Illinois Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of |
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||
6-1-09; 95-978, eff. 1-1-09; revised 10-15-08.) | ||
Section 10-15. The Counties Code is amended by changing | ||
Section 5-1069.3 as follows: | ||
(55 ILCS 5/5-1069.3)
| ||
(Text of Section before amendment by P.A. 95-958 )
| ||
Sec. 5-1069.3. Required health benefits. If a county, | ||
including a home
rule
county, is a self-insurer for purposes of | ||
providing health insurance coverage
for its employees, the | ||
coverage shall include coverage for the post-mastectomy
care | ||
benefits required to be covered by a policy of accident and | ||
health
insurance under Section 356t and the coverage required | ||
under Sections 356g.5, 356g.5-1, 356u,
356w, 356x, 356z.6, | ||
356z.9, 356z.10, and
356z.13
356z.11 of
the Illinois Insurance | ||
Code. The requirement that health benefits be covered
as | ||
provided in this Section is an
exclusive power and function of | ||
the State and is a denial and limitation under
Article VII, | ||
Section 6, subsection (h) of the Illinois Constitution. A home
| ||
rule county to which this Section applies must comply with | ||
every provision of
this Section.
| ||
Rulemaking authority to implement this amendatory Act of |
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||
1-1-09; revised 10-15-08.)
| ||
(Text of Section after amendment by P.A. 95-958 ) | ||
Sec. 5-1069.3. Required health benefits. If a county, | ||
including a home
rule
county, is a self-insurer for purposes of | ||
providing health insurance coverage
for its employees, the | ||
coverage shall include coverage for the post-mastectomy
care | ||
benefits required to be covered by a policy of accident and | ||
health
insurance under Section 356t and the coverage required | ||
under Sections 356g.5, 356g.5-1, 356u,
356w, 356x, 356z.6, | ||
356z.9, 356z.10, 356z.11, and 356z.12 , and 356z.13
356z.11 of
| ||
the Illinois Insurance Code. The requirement that health | ||
benefits be covered
as provided in this Section is an
exclusive | ||
power and function of the State and is a denial and limitation | ||
under
Article VII, Section 6, subsection (h) of the Illinois | ||
Constitution. A home
rule county to which this Section applies | ||
must comply with every provision of
this Section.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules |
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||
6-1-09; 95-978, eff. 1-1-09; revised 10-15-08.) | ||
Section 10-20. The Illinois Municipal Code is amended by | ||
changing Section 10-4-2.3 as follows: | ||
(65 ILCS 5/10-4-2.3)
| ||
(Text of Section before amendment by P.A. 95-958 )
| ||
Sec. 10-4-2.3. Required health benefits. If a | ||
municipality, including a
home rule municipality, is a | ||
self-insurer for purposes of providing health
insurance | ||
coverage for its employees, the coverage shall include coverage | ||
for
the post-mastectomy care benefits required to be covered by | ||
a policy of
accident and health insurance under Section 356t | ||
and the coverage required
under Sections 356g.5, 356g.5-1, | ||
356u, 356w, 356x, 356z.6, 356z.9, 356z.10, and
356z.13
356z.11 | ||
of the Illinois
Insurance
Code. The requirement that health
| ||
benefits be covered as provided in this is an exclusive power | ||
and function of
the State and is a denial and limitation under | ||
Article VII, Section 6,
subsection (h) of the Illinois | ||
Constitution. A home rule municipality to which
this Section |
applies must comply with every provision of this Section.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||
1-1-09; revised 10-15-08.)
| ||
(Text of Section after amendment by P.A. 95-958 ) | ||
Sec. 10-4-2.3. Required health benefits. If a | ||
municipality, including a
home rule municipality, is a | ||
self-insurer for purposes of providing health
insurance | ||
coverage for its employees, the coverage shall include coverage | ||
for
the post-mastectomy care benefits required to be covered by | ||
a policy of
accident and health insurance under Section 356t | ||
and the coverage required
under Sections 356g.5, 356g.5-1, | ||
356u, 356w, 356x, 356z.6, 356z.9, 356z.10, 356z.11, and | ||
356z.12 , and 356z.13
356z.11 of the Illinois
Insurance
Code. | ||
The requirement that health
benefits be covered as provided in | ||
this is an exclusive power and function of
the State and is a | ||
denial and limitation under Article VII, Section 6,
subsection | ||
(h) of the Illinois Constitution. A home rule municipality to | ||
which
this Section applies must comply with every provision of |
this Section.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||
6-1-09; 95-978, eff. 1-1-09; revised 10-15-08.) | ||
Section 10-25. The School Code is amended by changing | ||
Section 10-22.3f as follows: | ||
(105 ILCS 5/10-22.3f)
| ||
(Text of Section before amendment by P.A. 95-958 )
| ||
Sec. 10-22.3f. Required health benefits. Insurance | ||
protection and
benefits
for employees shall provide the | ||
post-mastectomy care benefits required to be
covered by a | ||
policy of accident and health insurance under Section 356t and | ||
the
coverage required under Sections 356g.5, 356g.5-1, 356u, | ||
356w, 356x,
356z.6, 356z.9, and 356z.13
356z.11 of
the
Illinois | ||
Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois |
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-876, eff. 8-21-08; 95-978, eff. 1-1-09; revised 10-15-08.)
| ||
(Text of Section after amendment by P.A. 95-958 ) | ||
Sec. 10-22.3f. Required health benefits. Insurance | ||
protection and
benefits
for employees shall provide the | ||
post-mastectomy care benefits required to be
covered by a | ||
policy of accident and health insurance under Section 356t and | ||
the
coverage required under Sections 356g.5, 356g.5-1, 356u, | ||
356w, 356x,
356z.6, 356z.9, 356z.11, and 356z.12, and 356z.13
| ||
356z.11 of
the
Illinois Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||
revised 10-15-08.) | ||
Section 10-30. The Health Maintenance Organization Act is | ||
amended by changing Section 5-3 as follows:
|
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||
(Text of Section before amendment by P.A. 95-958 )
| ||
Sec. 5-3. Insurance Code provisions.
| ||
(a) Health Maintenance Organizations
shall be subject to | ||
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||
154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||
356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||
356z.10, 356z.13
356z.11 ,
364.01, 367.2, 367.2-5, 367i, 368a, | ||
368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, | ||
408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | ||
(2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | ||
XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| ||
(b) For purposes of the Illinois Insurance Code, except for | ||
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||
Maintenance Organizations in
the following categories are | ||
deemed to be "domestic companies":
| ||
(1) a corporation authorized under the
Dental Service | ||
Plan Act or the Voluntary Health Services Plans Act;
| ||
(2) a corporation organized under the laws of this | ||
State; or
| ||
(3) a corporation organized under the laws of another | ||
state, 30% or more
of the enrollees of which are residents | ||
of this State, except a
corporation subject to | ||
substantially the same requirements in its state of
|
organization as is a "domestic company" under Article VIII | ||
1/2 of the
Illinois Insurance Code.
| ||
(c) In considering the merger, consolidation, or other | ||
acquisition of
control of a Health Maintenance Organization | ||
pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||
(1) the Director shall give primary consideration to | ||
the continuation of
benefits to enrollees and the financial | ||
conditions of the acquired Health
Maintenance Organization | ||
after the merger, consolidation, or other
acquisition of | ||
control takes effect;
| ||
(2)(i) the criteria specified in subsection (1)(b) of | ||
Section 131.8 of
the Illinois Insurance Code shall not | ||
apply and (ii) the Director, in making
his determination | ||
with respect to the merger, consolidation, or other
| ||
acquisition of control, need not take into account the | ||
effect on
competition of the merger, consolidation, or | ||
other acquisition of control;
| ||
(3) the Director shall have the power to require the | ||
following
information:
| ||
(A) certification by an independent actuary of the | ||
adequacy
of the reserves of the Health Maintenance | ||
Organization sought to be acquired;
| ||
(B) pro forma financial statements reflecting the | ||
combined balance
sheets of the acquiring company and | ||
the Health Maintenance Organization sought
to be | ||
acquired as of the end of the preceding year and as of |
a date 90 days
prior to the acquisition, as well as pro | ||
forma financial statements
reflecting projected | ||
combined operation for a period of 2 years;
| ||
(C) a pro forma business plan detailing an | ||
acquiring party's plans with
respect to the operation | ||
of the Health Maintenance Organization sought to
be | ||
acquired for a period of not less than 3 years; and
| ||
(D) such other information as the Director shall | ||
require.
| ||
(d) The provisions of Article VIII 1/2 of the Illinois | ||
Insurance Code
and this Section 5-3 shall apply to the sale by | ||
any health maintenance
organization of greater than 10% of its
| ||
enrollee population (including without limitation the health | ||
maintenance
organization's right, title, and interest in and to | ||
its health care
certificates).
| ||
(e) In considering any management contract or service | ||
agreement subject
to Section 141.1 of the Illinois Insurance | ||
Code, the Director (i) shall, in
addition to the criteria | ||
specified in Section 141.2 of the Illinois
Insurance Code, take | ||
into account the effect of the management contract or
service | ||
agreement on the continuation of benefits to enrollees and the
| ||
financial condition of the health maintenance organization to | ||
be managed or
serviced, and (ii) need not take into account the | ||
effect of the management
contract or service agreement on | ||
competition.
| ||
(f) Except for small employer groups as defined in the |
Small Employer
Rating, Renewability and Portability Health | ||
Insurance Act and except for
medicare supplement policies as | ||
defined in Section 363 of the Illinois
Insurance Code, a Health | ||
Maintenance Organization may by contract agree with a
group or | ||
other enrollment unit to effect refunds or charge additional | ||
premiums
under the following terms and conditions:
| ||
(i) the amount of, and other terms and conditions with | ||
respect to, the
refund or additional premium are set forth | ||
in the group or enrollment unit
contract agreed in advance | ||
of the period for which a refund is to be paid or
| ||
additional premium is to be charged (which period shall not | ||
be less than one
year); and
| ||
(ii) the amount of the refund or additional premium | ||
shall not exceed 20%
of the Health Maintenance | ||
Organization's profitable or unprofitable experience
with | ||
respect to the group or other enrollment unit for the | ||
period (and, for
purposes of a refund or additional | ||
premium, the profitable or unprofitable
experience shall | ||
be calculated taking into account a pro rata share of the
| ||
Health Maintenance Organization's administrative and | ||
marketing expenses, but
shall not include any refund to be | ||
made or additional premium to be paid
pursuant to this | ||
subsection (f)). The Health Maintenance Organization and | ||
the
group or enrollment unit may agree that the profitable | ||
or unprofitable
experience may be calculated taking into | ||
account the refund period and the
immediately preceding 2 |
plan years.
| ||
The Health Maintenance Organization shall include a | ||
statement in the
evidence of coverage issued to each enrollee | ||
describing the possibility of a
refund or additional premium, | ||
and upon request of any group or enrollment unit,
provide to | ||
the group or enrollment unit a description of the method used | ||
to
calculate (1) the Health Maintenance Organization's | ||
profitable experience with
respect to the group or enrollment | ||
unit and the resulting refund to the group
or enrollment unit | ||
or (2) the Health Maintenance Organization's unprofitable
| ||
experience with respect to the group or enrollment unit and the | ||
resulting
additional premium to be paid by the group or | ||
enrollment unit.
| ||
In no event shall the Illinois Health Maintenance | ||
Organization
Guaranty Association be liable to pay any | ||
contractual obligation of an
insolvent organization to pay any | ||
refund authorized under this Section.
| ||
(g) Rulemaking authority to implement this amendatory Act | ||
of the 95th General Assembly, if any, is conditioned on the | ||
rules being adopted in accordance with all provisions of the | ||
Illinois Administrative Procedure Act and all rules and | ||
procedures of the Joint Committee on Administrative Rules; any | ||
purported rule not so adopted, for whatever reason, is | ||
unauthorized. | ||
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
8-21-08; 95-978, eff. 1-1-09; revised 10-15-08.)
| ||
(Text of Section after amendment by P.A. 95-958 ) | ||
Sec. 5-3. Insurance Code provisions.
| ||
(a) Health Maintenance Organizations
shall be subject to | ||
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||
154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||
356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||
356z.10, 356z.11, 356z.12 , 356z.13
356z.11 , 364.01, 367.2, | ||
367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, | ||
402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph | ||
(c) of subsection (2) of Section 367, and Articles IIA, VIII | ||
1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the | ||
Illinois Insurance Code.
| ||
(b) For purposes of the Illinois Insurance Code, except for | ||
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||
Maintenance Organizations in
the following categories are | ||
deemed to be "domestic companies":
| ||
(1) a corporation authorized under the
Dental Service | ||
Plan Act or the Voluntary Health Services Plans Act;
| ||
(2) a corporation organized under the laws of this | ||
State; or
| ||
(3) a corporation organized under the laws of another | ||
state, 30% or more
of the enrollees of which are residents | ||
of this State, except a
corporation subject to |
substantially the same requirements in its state of
| ||
organization as is a "domestic company" under Article VIII | ||
1/2 of the
Illinois Insurance Code.
| ||
(c) In considering the merger, consolidation, or other | ||
acquisition of
control of a Health Maintenance Organization | ||
pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||
(1) the Director shall give primary consideration to | ||
the continuation of
benefits to enrollees and the financial | ||
conditions of the acquired Health
Maintenance Organization | ||
after the merger, consolidation, or other
acquisition of | ||
control takes effect;
| ||
(2)(i) the criteria specified in subsection (1)(b) of | ||
Section 131.8 of
the Illinois Insurance Code shall not | ||
apply and (ii) the Director, in making
his determination | ||
with respect to the merger, consolidation, or other
| ||
acquisition of control, need not take into account the | ||
effect on
competition of the merger, consolidation, or | ||
other acquisition of control;
| ||
(3) the Director shall have the power to require the | ||
following
information:
| ||
(A) certification by an independent actuary of the | ||
adequacy
of the reserves of the Health Maintenance | ||
Organization sought to be acquired;
| ||
(B) pro forma financial statements reflecting the | ||
combined balance
sheets of the acquiring company and | ||
the Health Maintenance Organization sought
to be |
acquired as of the end of the preceding year and as of | ||
a date 90 days
prior to the acquisition, as well as pro | ||
forma financial statements
reflecting projected | ||
combined operation for a period of 2 years;
| ||
(C) a pro forma business plan detailing an | ||
acquiring party's plans with
respect to the operation | ||
of the Health Maintenance Organization sought to
be | ||
acquired for a period of not less than 3 years; and
| ||
(D) such other information as the Director shall | ||
require.
| ||
(d) The provisions of Article VIII 1/2 of the Illinois | ||
Insurance Code
and this Section 5-3 shall apply to the sale by | ||
any health maintenance
organization of greater than 10% of its
| ||
enrollee population (including without limitation the health | ||
maintenance
organization's right, title, and interest in and to | ||
its health care
certificates).
| ||
(e) In considering any management contract or service | ||
agreement subject
to Section 141.1 of the Illinois Insurance | ||
Code, the Director (i) shall, in
addition to the criteria | ||
specified in Section 141.2 of the Illinois
Insurance Code, take | ||
into account the effect of the management contract or
service | ||
agreement on the continuation of benefits to enrollees and the
| ||
financial condition of the health maintenance organization to | ||
be managed or
serviced, and (ii) need not take into account the | ||
effect of the management
contract or service agreement on | ||
competition.
|
(f) Except for small employer groups as defined in the | ||
Small Employer
Rating, Renewability and Portability Health | ||
Insurance Act and except for
medicare supplement policies as | ||
defined in Section 363 of the Illinois
Insurance Code, a Health | ||
Maintenance Organization may by contract agree with a
group or | ||
other enrollment unit to effect refunds or charge additional | ||
premiums
under the following terms and conditions:
| ||
(i) the amount of, and other terms and conditions with | ||
respect to, the
refund or additional premium are set forth | ||
in the group or enrollment unit
contract agreed in advance | ||
of the period for which a refund is to be paid or
| ||
additional premium is to be charged (which period shall not | ||
be less than one
year); and
| ||
(ii) the amount of the refund or additional premium | ||
shall not exceed 20%
of the Health Maintenance | ||
Organization's profitable or unprofitable experience
with | ||
respect to the group or other enrollment unit for the | ||
period (and, for
purposes of a refund or additional | ||
premium, the profitable or unprofitable
experience shall | ||
be calculated taking into account a pro rata share of the
| ||
Health Maintenance Organization's administrative and | ||
marketing expenses, but
shall not include any refund to be | ||
made or additional premium to be paid
pursuant to this | ||
subsection (f)). The Health Maintenance Organization and | ||
the
group or enrollment unit may agree that the profitable | ||
or unprofitable
experience may be calculated taking into |
account the refund period and the
immediately preceding 2 | ||
plan years.
| ||
The Health Maintenance Organization shall include a | ||
statement in the
evidence of coverage issued to each enrollee | ||
describing the possibility of a
refund or additional premium, | ||
and upon request of any group or enrollment unit,
provide to | ||
the group or enrollment unit a description of the method used | ||
to
calculate (1) the Health Maintenance Organization's | ||
profitable experience with
respect to the group or enrollment | ||
unit and the resulting refund to the group
or enrollment unit | ||
or (2) the Health Maintenance Organization's unprofitable
| ||
experience with respect to the group or enrollment unit and the | ||
resulting
additional premium to be paid by the group or | ||
enrollment unit.
| ||
In no event shall the Illinois Health Maintenance | ||
Organization
Guaranty Association be liable to pay any | ||
contractual obligation of an
insolvent organization to pay any | ||
refund authorized under this Section.
| ||
(g) Rulemaking authority to implement this amendatory Act | ||
of the 95th General Assembly, if any, is conditioned on the | ||
rules being adopted in accordance with all provisions of the | ||
Illinois Administrative Procedure Act and all rules and | ||
procedures of the Joint Committee on Administrative Rules; any | ||
purported rule not so adopted, for whatever reason, is | ||
unauthorized. | ||
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; |
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||
8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; revised | ||
10-15-08.) | ||
Section 10-35. The Voluntary Health Services Plans Act is | ||
amended by changing Section 10 as follows:
| ||
(215 ILCS 165/10) (from Ch. 32, par. 604)
| ||
(Text of Section before amendment by P.A. 95-958 )
| ||
Sec. 10. Application of Insurance Code provisions. Health | ||
services
plan corporations and all persons interested therein | ||
or dealing therewith
shall be subject to the provisions of | ||
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||
149, 155.37, 354, 355.2, 356g.5, 356g.5-1, 356r, 356t, 356u, | ||
356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||
356z.8, 356z.9,
356z.10, 356z.13
356z.11 ,
364.01, 367.2, 368a, | ||
401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs | ||
(7) and (15) of Section 367 of the Illinois
Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. |
8-28-07; 95-876, eff. 8-21-08; 95-978, eff. 1-1-09; revised | ||
10-15-08.)
| ||
(Text of Section after amendment by P.A. 95-958 ) | ||
Sec. 10. Application of Insurance Code provisions. Health | ||
services
plan corporations and all persons interested therein | ||
or dealing therewith
shall be subject to the provisions of | ||
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||
149, 155.37, 354, 355.2, 356g.5, 356g.5-1, 356r, 356t, 356u, | ||
356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||
356z.8, 356z.9,
356z.10, 356z.11, 356z.12 , 356z.13
356z.11 , | ||
364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, | ||
and 412, and paragraphs (7) and (15) of Section 367 of the | ||
Illinois
Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||
8-28-07; 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, | ||
eff. 1-1-09; revised 10-15-08.) | ||
Article 15. Reducing Financial Barriers To Mammography |
Section 15-5. The Illinois Insurance Code is amended by | ||
changing Section 356g as follows:
| ||
(215 ILCS 5/356g) (from Ch. 73, par. 968g)
| ||
Sec. 356g. Mammograms; mastectomies.
| ||
(a) Every insurer shall provide in each group or individual
| ||
policy, contract, or certificate of insurance issued or renewed | ||
for persons
who are residents of this State, coverage for | ||
screening by low-dose
mammography for all women 35 years of age | ||
or older for the presence of
occult breast cancer within the | ||
provisions of the policy, contract, or
certificate. The | ||
coverage shall be as follows:
| ||
(1) A baseline mammogram for women 35 to 39 years of | ||
age.
| ||
(2) An annual mammogram for women 40 years of age or | ||
older.
| ||
(3) A mammogram at the age and intervals considered | ||
medically necessary by the woman's health care provider for | ||
women under 40 years of age and having a family history of | ||
breast cancer, prior personal history of breast cancer, | ||
positive genetic testing, or other risk factors.
| ||
(4) A comprehensive ultrasound screening of an entire | ||
breast or breasts if a mammogram demonstrates | ||
heterogeneous or dense breast tissue, when medically | ||
necessary as determined by a physician licensed to practice |
medicine in all of its branches.
| ||
These benefits shall be at least as favorable as for other | ||
radiological
examinations and subject to the same dollar | ||
limits, deductibles, and
co-insurance factors. For purposes of | ||
this Section, "low-dose mammography"
means the x-ray | ||
examination of the breast using equipment dedicated
| ||
specifically for mammography, including the x-ray tube, | ||
filter, compression
device, and image receptor, with radiation | ||
exposure delivery of less than
1 rad per breast for 2 views of | ||
an average size breast. The term also includes digital | ||
mammography.
| ||
(a-5) Coverage as described by subsection (a) shall be | ||
provided at no cost to the insured and shall not be applied to | ||
an annual or lifetime maximum benefit. | ||
(a-10) When health care services are available through | ||
contracted providers and a person does not comply with plan | ||
provisions specific to the use of contracted providers, the | ||
requirements of subsection (a-5) are not applicable. When a | ||
person does not comply with plan provisions specific to the use | ||
of contracted providers, plan provisions specific to the use of | ||
non-contracted providers must be applied without distinction | ||
for coverage required by this Section and shall be at least as | ||
favorable as for other radiological examinations covered by the | ||
policy or contract. | ||
(b) No policy of accident or health insurance that provides | ||
for
the surgical procedure known as a mastectomy shall be |
issued, amended,
delivered, or renewed in this State unless
| ||
that coverage also provides for prosthetic devices
or | ||
reconstructive surgery
incident to the mastectomy.
Coverage | ||
for breast reconstruction in connection with a mastectomy shall
| ||
include:
| ||
(1) reconstruction of the breast upon which the | ||
mastectomy has been
performed;
| ||
(2) surgery and reconstruction of the other breast to | ||
produce a
symmetrical appearance; and
| ||
(3) prostheses and treatment for physical | ||
complications at all stages of
mastectomy, including | ||
lymphedemas.
| ||
Care shall be determined in consultation with the attending | ||
physician and the
patient.
The offered coverage for prosthetic | ||
devices and
reconstructive surgery shall be subject to the | ||
deductible and coinsurance
conditions applied to the | ||
mastectomy, and all other terms and conditions
applicable to | ||
other benefits. When a mastectomy is performed and there is
no | ||
evidence of malignancy then the offered coverage may be limited | ||
to the
provision of prosthetic devices and reconstructive | ||
surgery to within 2
years after the date of the mastectomy. As | ||
used in this Section,
"mastectomy" means the removal of all or | ||
part of the breast for medically
necessary reasons, as | ||
determined by a licensed physician.
| ||
Written notice of the availability of coverage under this | ||
Section shall be
delivered to the insured upon enrollment and |
annually thereafter. An insurer
may not deny to an insured | ||
eligibility, or continued eligibility, to enroll or
to renew | ||
coverage under the terms of the plan solely for the purpose of
| ||
avoiding the requirements of this Section. An insurer may not | ||
penalize or
reduce or
limit the reimbursement of an attending | ||
provider or provide incentives
(monetary or otherwise) to an | ||
attending provider to induce the provider to
provide care to an | ||
insured in a manner inconsistent with this Section.
| ||
(c) Rulemaking authority to implement this amendatory Act | ||
of the 95th General Assembly, if any, is conditioned on the | ||
rules being adopted in accordance with all provisions of the | ||
Illinois Administrative Procedure Act and all rules and | ||
procedures of the Joint Committee on Administrative Rules; any | ||
purported rule not so adopted, for whatever reason, is | ||
unauthorized. | ||
(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
| ||
Section 15-10. The State Employees Group Insurance Act of | ||
1971 is amended by changing Section 6.11 as follows:
| ||
(5 ILCS 375/6.11)
| ||
(Text of Section before amendment by P.A. 95-958 ) | ||
Sec. 6.11. Required health benefits; Illinois Insurance | ||
Code
requirements. The program of health
benefits shall provide | ||
the post-mastectomy care benefits required to be covered
by a | ||
policy of accident and health insurance under Section 356t of |
the Illinois
Insurance Code. The program of health benefits | ||
shall provide the coverage
required under Sections 356g, | ||
356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, | ||
356z.10, and 356z.13
356z.11
of the
Illinois Insurance Code.
| ||
The program of health benefits must comply with Section 155.37 | ||
of the
Illinois Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||
1-1-09; revised 10-15-08.)
| ||
(Text of Section after amendment by P.A. 95-958 )
| ||
Sec. 6.11. Required health benefits; Illinois Insurance | ||
Code
requirements. The program of health
benefits shall provide | ||
the post-mastectomy care benefits required to be covered
by a | ||
policy of accident and health insurance under Section 356t of | ||
the Illinois
Insurance Code. The program of health benefits | ||
shall provide the coverage
required under Sections 356g, | ||
356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, | ||
356z.10, 356z.11, and 356z.12 , and 356z.13
356z.11 of the
| ||
Illinois Insurance Code.
The program of health benefits must |
comply with Section 155.37 of the
Illinois Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||
6-1-09; 95-978, eff. 1-1-09; revised 10-15-08.) | ||
Section 15-15. The Counties Code is amended by changing | ||
Sections 5-1069 and 5-1069.3 as follows:
| ||
(55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
| ||
Sec. 5-1069. Group life, health, accident, hospital, and | ||
medical
insurance.
| ||
(a) The county board of any county may arrange to provide, | ||
for
the benefit of employees of the county, group life, health, | ||
accident, hospital,
and medical insurance, or any one or any | ||
combination of those types of
insurance, or the county board | ||
may self-insure, for the benefit of its
employees, all or a | ||
portion of the employees' group life, health, accident,
| ||
hospital, and medical insurance, or any one or any combination | ||
of those
types of insurance, including a combination of | ||
self-insurance and other
types of insurance authorized by this |
Section, provided that the county
board complies with all other | ||
requirements of this Section. The insurance
may include | ||
provision for employees who rely on treatment by prayer or
| ||
spiritual means alone for healing in accordance with the tenets | ||
and
practice of a well recognized religious denomination. The | ||
county board may
provide for payment by the county of a portion | ||
or all of the premium or
charge for the insurance with the | ||
employee paying the balance of the
premium or charge, if any. | ||
If the county board undertakes a plan under
which the county | ||
pays only a portion of the premium or charge, the county
board | ||
shall provide for withholding and deducting from the | ||
compensation of
those employees who consent to join the plan | ||
the balance of the premium or
charge for the insurance.
| ||
(b) If the county board does not provide for self-insurance | ||
or for a plan
under which the county pays a portion or all of | ||
the premium or charge for a
group insurance plan, the county | ||
board may provide for withholding and
deducting from the | ||
compensation of those employees who consent thereto the
total | ||
premium or charge for any group life, health, accident, | ||
hospital, and
medical insurance.
| ||
(c) The county board may exercise the powers granted in | ||
this Section only if
it provides for self-insurance or, where | ||
it makes arrangements to provide
group insurance through an | ||
insurance carrier, if the kinds of group
insurance are obtained | ||
from an insurance company authorized to do business
in the | ||
State of Illinois. The county board may enact an ordinance
|
prescribing the method of operation of the insurance program.
| ||
(d) If a county, including a home rule county, is a | ||
self-insurer for
purposes of providing health insurance | ||
coverage for its employees, the
insurance coverage shall | ||
include screening by low-dose mammography for all
women 35 | ||
years of age or older for the presence of occult breast cancer
| ||
unless the county elects to provide mammograms itself under | ||
Section
5-1069.1. The coverage shall be as follows:
| ||
(1) A baseline mammogram for women 35 to 39 years of | ||
age.
| ||
(2) An annual mammogram for women 40 years of age or | ||
older.
| ||
(3) A mammogram at the age and intervals considered | ||
medically necessary by the woman's health care provider for | ||
women under 40 years of age and having a family history of | ||
breast cancer, prior personal history of breast cancer, | ||
positive genetic testing, or other risk factors. | ||
(4) A comprehensive ultrasound screening of an entire | ||
breast or breasts if a mammogram demonstrates | ||
heterogeneous or dense breast tissue, when medically | ||
necessary as determined by a physician licensed to practice | ||
medicine in all of its branches. | ||
Those benefits shall be at least as favorable as for other | ||
radiological
examinations and subject to the same dollar | ||
limits, deductibles, and
co-insurance factors. For purposes of | ||
this subsection, "low-dose mammography"
means the x-ray |
examination of the breast using equipment dedicated
| ||
specifically for mammography, including the x-ray tube, | ||
filter, compression
device, screens, and image receptor | ||
receptors , with an average radiation exposure
delivery of less | ||
than one rad per breast for mid-breast, with 2 views of an | ||
average size for each breast. The term also includes digital | ||
mammography. | ||
(d-5) Coverage as described by subsection (d) shall be | ||
provided at no cost to the insured and shall not be applied to | ||
an annual or lifetime maximum benefit. | ||
(d-10) When health care services are available through | ||
contracted providers and a person does not comply with plan | ||
provisions specific to the use of contracted providers, the | ||
requirements of subsection (d-5) are not applicable. When a | ||
person does not comply with plan provisions specific to the use | ||
of contracted providers, plan provisions specific to the use of | ||
non-contracted providers must be applied without distinction | ||
for coverage required by this Section and shall be at least as | ||
favorable as for other radiological examinations covered by the | ||
policy or contract. | ||
(d-15) If a county, including a home rule county, is a | ||
self-insurer for purposes of providing health insurance | ||
coverage for its employees, the insurance coverage shall | ||
include mastectomy coverage, which includes coverage for | ||
prosthetic devices or reconstructive surgery incident to the | ||
mastectomy. Coverage for breast reconstruction in connection |
with a mastectomy shall include: | ||
(1) reconstruction of the breast upon which the | ||
mastectomy has been performed; | ||
(2) surgery and reconstruction of the other breast to | ||
produce a symmetrical appearance; and | ||
(3) prostheses and treatment for physical | ||
complications at all stages of mastectomy, including | ||
lymphedemas. | ||
Care shall be determined in consultation with the attending | ||
physician and the patient. The offered coverage for prosthetic | ||
devices and reconstructive surgery shall be subject to the | ||
deductible and coinsurance conditions applied to the | ||
mastectomy, and all other terms and conditions applicable to | ||
other benefits. When a mastectomy is performed and there is no | ||
evidence of malignancy then the offered coverage may be limited | ||
to the provision of prosthetic devices and reconstructive | ||
surgery to within 2 years after the date of the mastectomy. As | ||
used in this Section, "mastectomy" means the removal of all or | ||
part of the breast for medically necessary reasons, as | ||
determined by a licensed physician. | ||
A county, including a home rule county, that is a | ||
self-insurer for purposes of providing health insurance | ||
coverage for its employees, may not penalize or reduce or limit | ||
the reimbursement of an attending provider or provide | ||
incentives (monetary or otherwise) to an attending provider to | ||
induce the provider to provide care to an insured in a manner |
inconsistent with this Section. | ||
(d-20) The
requirement that mammograms be included in | ||
health insurance coverage as
provided in subsections this | ||
subsection (d) through (d-15) is an exclusive power and | ||
function of the
State and is a denial and limitation under | ||
Article VII, Section 6,
subsection (h) of the Illinois | ||
Constitution of home rule county powers. A
home rule county to | ||
which subsections (d) through (d-15) apply this subsection | ||
applies must comply with every
provision of those subsections | ||
this subsection .
| ||
(e) The term "employees" as used in this Section includes | ||
elected or
appointed officials but does not include temporary | ||
employees.
| ||
(f) The county board may, by ordinance, arrange to provide | ||
group life,
health, accident, hospital, and medical insurance, | ||
or any one or a combination
of those types of insurance, under | ||
this Section to retired former employees and
retired former | ||
elected or appointed officials of the county.
| ||
(g) Rulemaking authority to implement this amendatory Act | ||
of the 95th General Assembly, if any, is conditioned on the | ||
rules being adopted in accordance with all provisions of the | ||
Illinois Administrative Procedure Act and all rules and | ||
procedures of the Joint Committee on Administrative Rules; any | ||
purported rule not so adopted, for whatever reason, is | ||
unauthorized. | ||
(Source: P.A. 90-7, eff. 6-10-97; 91-217, eff. 1-1-00.)
|
(55 ILCS 5/5-1069.3)
| ||
(Text of Section before amendment by P.A. 95-958 )
| ||
Sec. 5-1069.3. Required health benefits. If a county, | ||
including a home
rule
county, is a self-insurer for purposes of | ||
providing health insurance coverage
for its employees, the | ||
coverage shall include coverage for the post-mastectomy
care | ||
benefits required to be covered by a policy of accident and | ||
health
insurance under Section 356t and the coverage required | ||
under Sections 356g, 356g.5, 356u,
356w, 356x, 356z.6, 356z.9, | ||
356z.10, and
356z.13
356z.11 of
the Illinois Insurance Code. | ||
The requirement that health benefits be covered
as provided in | ||
this Section is an
exclusive power and function of the State | ||
and is a denial and limitation under
Article VII, Section 6, | ||
subsection (h) of the Illinois Constitution. A home
rule county | ||
to which this Section applies must comply with every provision | ||
of
this Section.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||
1-1-09; revised 10-15-08.)
|
(Text of Section after amendment by P.A. 95-958 ) | ||
Sec. 5-1069.3. Required health benefits. If a county, | ||
including a home
rule
county, is a self-insurer for purposes of | ||
providing health insurance coverage
for its employees, the | ||
coverage shall include coverage for the post-mastectomy
care | ||
benefits required to be covered by a policy of accident and | ||
health
insurance under Section 356t and the coverage required | ||
under Sections 356g, 356g.5, 356u,
356w, 356x, 356z.6, 356z.9, | ||
356z.10, 356z.11, and 356z.12 , and 356z.13
356z.11 of
the | ||
Illinois Insurance Code. The requirement that health benefits | ||
be covered
as provided in this Section is an
exclusive power | ||
and function of the State and is a denial and limitation under
| ||
Article VII, Section 6, subsection (h) of the Illinois | ||
Constitution. A home
rule county to which this Section applies | ||
must comply with every provision of
this Section.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||
6-1-09; 95-978, eff. 1-1-09; revised 10-15-08.) |
Section 15-20. The Illinois Municipal Code is amended by | ||
changing Sections 10-4-2 and 10-4-2.3 as follows:
| ||
(65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
| ||
Sec. 10-4-2. Group insurance.
| ||
(a) The corporate authorities of any municipality may | ||
arrange
to provide, for the benefit of employees of the | ||
municipality, group life,
health, accident, hospital, and | ||
medical insurance, or any one or any
combination of those types | ||
of insurance, and may arrange to provide that
insurance for the | ||
benefit of the spouses or dependents of those employees.
The | ||
insurance may include provision for employees or other insured | ||
persons
who rely on treatment by prayer or spiritual means | ||
alone for healing in
accordance with the tenets and practice of | ||
a well recognized religious
denomination. The corporate | ||
authorities may provide for payment by the
municipality of a | ||
portion of the premium or charge for the insurance with
the | ||
employee paying the balance of the premium or charge. If the | ||
corporate
authorities undertake a plan under which the | ||
municipality pays a portion of
the premium or charge, the | ||
corporate authorities shall provide for
withholding and | ||
deducting from the compensation of those municipal
employees | ||
who consent to join the plan the balance of the premium or | ||
charge
for the insurance.
| ||
(b) If the corporate authorities do not provide for a plan | ||
under which
the municipality pays a portion of the premium or |
charge for a group
insurance plan, the corporate authorities | ||
may provide for withholding
and deducting from the compensation | ||
of those employees who consent thereto
the premium or charge | ||
for any group life, health, accident, hospital, and
medical | ||
insurance.
| ||
(c) The corporate authorities may exercise the powers | ||
granted in this
Section only if the kinds of group insurance | ||
are obtained from an
insurance company authorized to do | ||
business
in the State of Illinois,
or are obtained through an
| ||
intergovernmental joint self-insurance pool as authorized | ||
under the
Intergovernmental Cooperation Act.
The
corporate | ||
authorities may enact an ordinance prescribing the method of
| ||
operation of the insurance program.
| ||
(d) If a municipality, including a home rule municipality, | ||
is a
self-insurer for purposes of providing health insurance | ||
coverage for its
employees, the insurance coverage shall | ||
include screening by low-dose
mammography for all women 35 | ||
years of age or older for the presence of
occult breast cancer | ||
unless the municipality elects to provide mammograms
itself | ||
under Section 10-4-2.1. The coverage shall be as follows:
| ||
(1) A baseline mammogram for women 35 to 39 years of | ||
age.
| ||
(2) An annual mammogram for women 40 years of age or | ||
older.
| ||
(3) A mammogram at the age and intervals considered | ||
medically necessary by the woman's health care provider for |
women under 40 years of age and having a family history of | ||
breast cancer, prior personal history of breast cancer, | ||
positive genetic testing, or other risk factors. | ||
(4) A comprehensive ultrasound screening of an entire | ||
breast or breasts if a mammogram demonstrates | ||
heterogeneous or dense breast tissue, when medically | ||
necessary as determined by a physician licensed to practice | ||
medicine in all of its branches. | ||
Those benefits shall be at least as favorable as for other | ||
radiological
examinations and subject to the same dollar | ||
limits, deductibles, and
co-insurance factors. For purposes of | ||
this subsection, "low-dose mammography"
means the x-ray | ||
examination of the breast using equipment dedicated
| ||
specifically for mammography, including the x-ray tube, | ||
filter, compression
device, screens, and image receptor | ||
receptors , with an average radiation exposure
delivery of less | ||
than one rad per breast for mid-breast, with 2 views of an | ||
average size for each breast. The term also includes digital | ||
mammography. | ||
(d-5) Coverage as described by subsection (d) shall be | ||
provided at no cost to the insured and shall not be applied to | ||
an annual or lifetime maximum benefit. | ||
(d-10) When health care services are available through | ||
contracted providers and a person does not comply with plan | ||
provisions specific to the use of contracted providers, the | ||
requirements of subsection (d-5) are not applicable. When a |
person does not comply with plan provisions specific to the use | ||
of contracted providers, plan provisions specific to the use of | ||
non-contracted providers must be applied without distinction | ||
for coverage required by this Section and shall be at least as | ||
favorable as for other radiological examinations covered by the | ||
policy or contract. | ||
(d-15) If a municipality, including a home rule | ||
municipality, is a self-insurer for purposes of providing | ||
health insurance coverage for its employees, the insurance | ||
coverage shall include mastectomy coverage, which includes | ||
coverage for prosthetic devices or reconstructive surgery | ||
incident to the mastectomy. Coverage for breast reconstruction | ||
in connection with a mastectomy shall include: | ||
(1) reconstruction of the breast upon which the | ||
mastectomy has been performed; | ||
(2) surgery and reconstruction of the other breast to | ||
produce a symmetrical appearance; and | ||
(3) prostheses and treatment for physical | ||
complications at all stages of mastectomy, including | ||
lymphedemas. | ||
Care shall be determined in consultation with the attending | ||
physician and the patient. The offered coverage for prosthetic | ||
devices and reconstructive surgery shall be subject to the | ||
deductible and coinsurance conditions applied to the | ||
mastectomy, and all other terms and conditions applicable to | ||
other benefits. When a mastectomy is performed and there is no |
evidence of malignancy then the offered coverage may be limited | ||
to the provision of prosthetic devices and reconstructive | ||
surgery to within 2 years after the date of the mastectomy. As | ||
used in this Section, "mastectomy" means the removal of all or | ||
part of the breast for medically necessary reasons, as | ||
determined by a licensed physician. | ||
A municipality, including a home rule municipality, that is | ||
a self-insurer for purposes of providing health insurance | ||
coverage for its employees, may not penalize or reduce or limit | ||
the reimbursement of an attending provider or provide | ||
incentives (monetary or otherwise) to an attending provider to | ||
induce the provider to provide care to an insured in a manner | ||
inconsistent with this Section. | ||
(d-20) The
requirement that mammograms be included in | ||
health insurance coverage as
provided in subsections this | ||
subsection (d) through (d-15) is an exclusive power and | ||
function of the
State and is a denial and limitation under | ||
Article VII, Section 6,
subsection (h) of the Illinois | ||
Constitution of home rule municipality
powers. A home rule | ||
municipality to which subsections (d) through (d-15) apply this | ||
subsection applies must
comply with every provision of through | ||
subsections this subsection .
| ||
(e) Rulemaking authority to implement this amendatory Act | ||
of the 95th General Assembly, if any, is conditioned on the | ||
rules being adopted in accordance with all provisions of the | ||
Illinois Administrative Procedure Act and all rules and |
procedures of the Joint Committee on Administrative Rules; any | ||
purported rule not so adopted, for whatever reason, is | ||
unauthorized. | ||
(Source: P.A. 90-7, eff. 6-10-97; 91-160, eff. 1-1-00.)
| ||
(65 ILCS 5/10-4-2.3)
| ||
(Text of Section before amendment by P.A. 95-958 )
| ||
Sec. 10-4-2.3. Required health benefits. If a | ||
municipality, including a
home rule municipality, is a | ||
self-insurer for purposes of providing health
insurance | ||
coverage for its employees, the coverage shall include coverage | ||
for
the post-mastectomy care benefits required to be covered by | ||
a policy of
accident and health insurance under Section 356t | ||
and the coverage required
under Sections 356g, 356g.5, 356u, | ||
356w, 356x, 356z.6, 356z.9, 356z.10, and
356z.13
356z.11 of the | ||
Illinois
Insurance
Code. The requirement that health
benefits | ||
be covered as provided in this is an exclusive power and | ||
function of
the State and is a denial and limitation under | ||
Article VII, Section 6,
subsection (h) of the Illinois | ||
Constitution. A home rule municipality to which
this Section | ||
applies must comply with every provision of this Section.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule |
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||
1-1-09; revised 10-15-08.)
| ||
(Text of Section after amendment by P.A. 95-958 ) | ||
Sec. 10-4-2.3. Required health benefits. If a | ||
municipality, including a
home rule municipality, is a | ||
self-insurer for purposes of providing health
insurance | ||
coverage for its employees, the coverage shall include coverage | ||
for
the post-mastectomy care benefits required to be covered by | ||
a policy of
accident and health insurance under Section 356t | ||
and the coverage required
under Sections 356g, 356g.5, 356u, | ||
356w, 356x, 356z.6, 356z.9, 356z.10, 356z.11, and 356z.12 , and | ||
356z.13
356z.11 of the Illinois
Insurance
Code. The requirement | ||
that health
benefits be covered as provided in this is an | ||
exclusive power and function of
the State and is a denial and | ||
limitation under Article VII, Section 6,
subsection (h) of the | ||
Illinois Constitution. A home rule municipality to which
this | ||
Section applies must comply with every provision of this | ||
Section.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule |
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||
6-1-09; 95-978, eff. 1-1-09; revised 10-15-08.) | ||
Section 15-25. The School Code is amended by changing | ||
Section 10-22.3f as follows: | ||
(105 ILCS 5/10-22.3f)
| ||
(Text of Section before amendment by P.A. 95-958 )
| ||
Sec. 10-22.3f. Required health benefits. Insurance | ||
protection and
benefits
for employees shall provide the | ||
post-mastectomy care benefits required to be
covered by a | ||
policy of accident and health insurance under Section 356t and | ||
the
coverage required under Sections 356g, 356g.5, 356u, 356w, | ||
356x,
356z.6, 356z.9, and 356z.13
356z.11 of
the
Illinois | ||
Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-876, eff. 8-21-08; 95-978, eff. 1-1-09; revised 10-15-08.)
|
(Text of Section after amendment by P.A. 95-958 ) | ||
Sec. 10-22.3f. Required health benefits. Insurance | ||
protection and
benefits
for employees shall provide the | ||
post-mastectomy care benefits required to be
covered by a | ||
policy of accident and health insurance under Section 356t and | ||
the
coverage required under Sections 356g, 356g.5, 356u, 356w, | ||
356x,
356z.6, 356z.9, 356z.11, and 356z.12, and 356z.13
356z.11 | ||
of
the
Illinois Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||
revised 10-15-08.) | ||
Section 15-30. The Health Maintenance Organization Act is | ||
amended by changing Section 4-6.1 as follows:
| ||
(215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
| ||
Sec. 4-6.1. Mammograms; mastectomies.
| ||
(a) Every contract or evidence of coverage
issued by a | ||
Health Maintenance Organization for persons who are residents | ||
of
this State shall contain coverage for screening by low-dose |
mammography
for all women 35 years of age or older for the | ||
presence of occult breast
cancer. The coverage shall be as | ||
follows:
| ||
(1) A baseline mammogram for women 35 to 39 years of | ||
age.
| ||
(2) An annual mammogram for women 40 years of age or | ||
older.
| ||
(3) A mammogram at the age and intervals considered | ||
medically necessary by the woman's health care provider for | ||
women under 40 years of age and having a family history of | ||
breast cancer, prior personal history of breast cancer, | ||
positive genetic testing, or other risk factors. | ||
(4) A comprehensive ultrasound screening of an entire | ||
breast or breasts if a mammogram demonstrates | ||
heterogeneous or dense breast tissue, when medically | ||
necessary as determined by a physician licensed to practice | ||
medicine in all of its branches.
| ||
These benefits shall be at least as favorable as for other | ||
radiological
examinations and subject to the same dollar | ||
limits, deductibles, and
co-insurance factors. For purposes of | ||
this Section, "low-dose mammography"
means the x-ray | ||
examination of the breast using equipment dedicated
| ||
specifically for mammography, including the x-ray tube, | ||
filter, compression
device, and image receptor, with radiation | ||
exposure delivery of less than 1
rad per breast for 2 views of | ||
an average size breast. The term also includes digital |
mammography.
| ||
(a-5) Coverage as described in subsection (a) shall be | ||
provided at no cost to the enrollee and shall not be applied to | ||
an annual or lifetime maximum benefit. | ||
(b) No contract or evidence of coverage issued by a health | ||
maintenance
organization that provides for the
surgical | ||
procedure known as a mastectomy shall be issued, amended, | ||
delivered,
or renewed in this State on or after the effective | ||
date of this amendatory Act
of the 92nd General Assembly unless | ||
that coverage also provides for prosthetic
devices or | ||
reconstructive surgery incident to the mastectomy, providing | ||
that
the mastectomy is performed after the effective date of | ||
this amendatory Act.
Coverage for breast reconstruction in | ||
connection
with a mastectomy shall
include:
| ||
(1) reconstruction of the breast upon which the | ||
mastectomy has been
performed;
| ||
(2) surgery and reconstruction of the other breast to | ||
produce a
symmetrical appearance; and
| ||
(3) prostheses and treatment for physical | ||
complications at all stages of
mastectomy, including | ||
lymphedemas.
| ||
Care shall be determined in consultation with the attending | ||
physician and the
patient.
The offered coverage for prosthetic | ||
devices and
reconstructive surgery shall be subject to the | ||
deductible and coinsurance
conditions applied to the | ||
mastectomy and all other terms and conditions
applicable to |
other benefits. When a mastectomy is performed and there is
no | ||
evidence of malignancy, then the offered coverage may be | ||
limited to the
provision of prosthetic devices and | ||
reconstructive surgery to within 2
years after the date of the | ||
mastectomy. As used in this Section,
"mastectomy" means the | ||
removal of all or part of the breast for medically
necessary | ||
reasons, as determined by a licensed physician.
| ||
Written notice of the availability of coverage under this | ||
Section shall be
delivered to the enrollee upon enrollment and | ||
annually thereafter. A
health maintenance organization may not | ||
deny to an enrollee eligibility, or
continued eligibility, to | ||
enroll or
to renew coverage under the terms of the plan solely | ||
for the purpose of
avoiding the requirements of this Section. A | ||
health maintenance organization
may not penalize or
reduce or
| ||
limit the reimbursement of an attending provider or provide | ||
incentives
(monetary or otherwise) to an attending provider to | ||
induce the provider to
provide care to an insured in a manner | ||
inconsistent with this Section.
| ||
(c) Rulemaking authority to implement this amendatory Act | ||
of the 95th General Assembly, if any, is conditioned on the | ||
rules being adopted in accordance with all provisions of the | ||
Illinois Administrative Procedure Act and all rules and | ||
procedures of the Joint Committee on Administrative Rules; any | ||
purported rule not so adopted, for whatever reason, is | ||
unauthorized. | ||
(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
|
Section 15-35. The Voluntary Health Services Plans Act is | ||
amended by changing Section 10 as follows:
| ||
(215 ILCS 165/10) (from Ch. 32, par. 604)
| ||
(Text of Section before amendment by P.A. 95-958 )
| ||
Sec. 10. Application of Insurance Code provisions. Health | ||
services
plan corporations and all persons interested therein | ||
or dealing therewith
shall be subject to the provisions of | ||
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||
149, 155.37, 354, 355.2, 356g, 356g.5, 356r, 356t, 356u, 356v,
| ||
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||
356z.8, 356z.9,
356z.10, 356z.13
356z.11 ,
364.01, 367.2, 368a, | ||
401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs | ||
(7) and (15) of Section 367 of the Illinois
Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||
8-28-07; 95-876, eff. 8-21-08; 95-978, eff. 1-1-09; revised | ||
10-15-08.)
|
(Text of Section after amendment by P.A. 95-958 ) | ||
Sec. 10. Application of Insurance Code provisions. Health | ||
services
plan corporations and all persons interested therein | ||
or dealing therewith
shall be subject to the provisions of | ||
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||
149, 155.37, 354, 355.2, 356g, 356g.5, 356r, 356t, 356u, 356v,
| ||
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||
356z.8, 356z.9,
356z.10, 356z.11, 356z.12 , 356z.13
356z.11 , | ||
364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, | ||
and 412, and paragraphs (7) and (15) of Section 367 of the | ||
Illinois
Insurance Code.
| ||
Rulemaking authority to implement this amendatory Act of | ||
the 95th General Assembly, if any, is conditioned on the rules | ||
being adopted in accordance with all provisions of the Illinois | ||
Administrative Procedure Act and all rules and procedures of | ||
the Joint Committee on Administrative Rules; any purported rule | ||
not so adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||
8-28-07; 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, | ||
eff. 1-1-09; revised 10-15-08.) | ||
Article 90. | ||
Section 90-95. No acceleration or delay. Where this Act | ||
makes changes in a statute that is represented in this Act by |
text that is not yet or no longer in effect (for example, a | ||
Section represented by multiple versions), the use of that text | ||
does not accelerate or delay the taking effect of (i) the | ||
changes made by this Act or (ii) provisions derived from any | ||
other Public Act.
| ||
Section 90-99. Effective date. This Act takes effect upon | ||
becoming law.
|