SB2781 101ST GENERAL ASSEMBLY

LRB101 15490 BMS 64833 b

101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB2781

Introduced 2/4/2020, by Sen. Laura Fine

SYNOPSIS AS INTRODUCED:

215 ILCS 5/356c	from Ch. 73, par. 968c
215 ILCS 5/356z.41 new

Amends the Illinois Insurance Code. In provisions requiring coverage for newborn infants, provides that coverage for congenital defects shall include treatment of cranial facial anomalies. 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 involving the cranial facial area that is medically necessary to achieve normal function or appearance. 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. Provides that the coverage does not apply to a policy that covers only dental care. Defines "treatment". Effective January 1, 2021.

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 changing Section 356c and by adding Section 356z.41 as follows:

(215 ILCS 5/356c) (from Ch. 73, par. 968c)

Sec. 356c. (1) No policy of accident and health insurance providing coverage of hospital expenses or medical expenses or both on an expense incurred basis which in addition to covering the insured, also covers members of the insured's immediate family, shall contain any disclaimer, waiver or other limitation of coverage relative to the hospital or medical coverage or insurability of newborn infants from and after the moment of birth.

(2) Each such policy of accident and health insurance shall contain a provision stating that the accident and health insurance benefits applicable for children shall be granted immediately with respect to a newly born child from the moment of birth. The coverage for newly born children shall include coverage of illness, injury, congenital defects (including the treatment of cranial facial anomalies), birth abnormalities and premature birth.

(3) If payment of a specific premium is required to provide coverage for a child, the policy may require that notification of birth of a newly born child must be furnished to the insurer within 31 days after the date of birth in order to have the coverage continue beyond such 31 day period and may require payment of the appropriate premium.

(4) In the event that no other members of the insured's immediate family are covered, immediate coverage for the first newborn infant shall be provided if the insured applies for dependent's coverage within 31 days of the newborn's birth. Such coverage shall be contingent upon payment of the additional premium.

(5) The requirements of this Section shall apply, on or after the sixtieth day following the effective date of this Section, (a) to all such non-group policies delivered or issued for delivery, and (b) to all such group policies delivered, issued for delivery, renewed or amended. The insurers of such non-group policies in effect on the sixtieth day following the effective date of this Section shall extend to owners of said policies, on or before the first policy anniversary following such date, the opportunity to apply for the addition to their policies of a provision as set forth in paragraph (2) above, with, at the option of the insurer, payment of a premium appropriate thereto.

(Source: P.A. 85-220.)

(215 ILCS 5/356z.41 new)

Sec. 356z.41. Coverage for congenital anomaly or birth defect.

(a) 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.

(b) Coverage required under this Section includes any services to functionally improve, repair, or restore a body part involving the cranial facial area that is medically necessary to achieve normal function or appearance. 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.

(c) 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 involving the cranial facial area and includes treatment to any and all missing or abnormal body parts, including teeth, oral cavity, and their associated structures, that would otherwise be provided under the plan or coverage for any other injury and sickness, up to the age of 26, including:

(1) inpatient and outpatient care;

(2) reconstructive services and procedures and complications thereof, including prosthetics and appliances;

(3) adjunctive dental, orthodontic, or prosthodontic support, including ongoing or subsequent treatment required to maintain function or approximate a normal appearance;

(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 when performed in conjunction with the treatment described in this subsection (c).

"Treatment" does not include cosmetic surgery performed to reshape normal facial structure or to improve appearance or self-esteem.

(d) This Section does not apply to a policy that covers only dental care.

Section 99. Effective date. This Act takes effect January 1, 2021.