SB2255 101ST GENERAL ASSEMBLY

LRB101 12399 SMS 60462 b

101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB2255

Introduced 5/9/2019, by Sen. Laura Fine

SYNOPSIS AS INTRODUCED:

215 ILCS 5/356z.33 new

Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any service to functionally improve, repair, or restore any body part that is medically necessary to achieve normal body function or appearance, as determined by the treating physician or dentist. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Defines "treatment". Effective immediately.

A BILL FOR

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by adding Section 356z.33 as follows:

(215 ILCS 5/356z.33 new)

Sec. 356z.33. Coverage for congenital anomaly or birth defect.

(a) As used in this Section, "treatment" includes inpatient and outpatient care and services performed to improve or restore body function, or performed to approximate a normal appearance, due to congenital anomaly or birth defect and includes treatment to any and all missing or abnormal body parts, including teeth, the oral cavity, and their associated structures, that would otherwise be provided under the plan or coverage for any other injury and sickness, including:

(1) inpatient and outpatient care, reconstructive services and procedures, and complications thereof, including prosthetics and appliances;

(2) adjunctive dental, orthodontic, or prosthodontic support from birth until the medical or surgical treatment of the defect or anomaly has been completed, including ongoing or subsequent treatment required to maintain function or approximate a normal appearance;

(3) procedures that do not materially restore or improve the function of the body part being treated;

(4) procedures for secondary conditions and follow-up treatment; and

(5) anesthetics provided by a dentist with a permit provided under Section 8.1 of the Illinois Dental Practice Act.

"Treatment" does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.

(b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 101st General Assembly shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect.

(c) Coverage required under this Section includes any service to functionally improve, repair, or restore any body part that is medically necessary to achieve normal body function or appearance, as determined by the treating physician or dentist. Any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan.

Section 99. Effective date. This Act takes effect upon becoming law.