93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB4598

 

Introduced 2/4/2004, by Naomi D. Jakobsson

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/356z.6 new
215 ILCS 105/8   from Ch. 73, par. 1308
215 ILCS 125/5-3   from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10   from Ch. 32, par. 604
305 ILCS 5/5-5   from Ch. 23, par. 5-5

    Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, Illinois Insurance Code, the Comprehensive Health Insurance Plan Act, the Health Maintenance Organization Act, the Voluntary Health Services Plans Act, and the Public Aid Code. Provides coverage for services rendered by a licensed athletic trainer in accordance with the Illinois Athletic Trainers Practice Act if those services are ordered by a physician licensed to practice medicine in all of its branches. Effective immediately.


LRB093 20553 SAS 46361 b

FISCAL NOTE ACT MAY APPLY
HOME RULE NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

HB4598 LRB093 20553 SAS 46361 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The State Employees Group Insurance Act of 1971
5 is amended by changing Section 6.11 as follows:
 
6     (5 ILCS 375/6.11)
7     Sec. 6.11. Required health benefits; Illinois Insurance
8 Code requirements. The program of health benefits shall provide
9 the post-mastectomy care benefits required to be covered by a
10 policy of accident and health insurance under Section 356t of
11 the Illinois Insurance Code. The program of health benefits
12 shall provide the coverage required under Sections 356u, 356w,
13 356x, 356z.2, and 356z.4, and 356z.6 of the Illinois Insurance
14 Code. The program of health benefits must comply with Section
15 155.37 of the Illinois Insurance Code.
16 (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03;
17 93-102, eff. 1-1-04.)
 
18     Section 10. The Counties Code is amended by changing
19 Section 5-1069.3 as follows:
 
20     (55 ILCS 5/5-1069.3)
21     Sec. 5-1069.3. Required health benefits. If a county,
22 including a home rule county, is a self-insurer for purposes of
23 providing health insurance coverage for its employees, the
24 coverage shall include coverage for the post-mastectomy care
25 benefits required to be covered by a policy of accident and
26 health insurance under Section 356t and the coverage required
27 under Sections 356u, 356w, and 356x, and 356z.6 of the Illinois
28 Insurance Code. The requirement that health benefits be covered
29 as provided in this Section is an exclusive power and function
30 of the State and is a denial and limitation under Article VII,

 

 

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1 Section 6, subsection (h) of the Illinois Constitution. A home
2 rule county to which this Section applies must comply with
3 every provision of this Section.
4 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
 
5     Section 15. The Illinois Municipal Code is amended by
6 changing Section 10-4-2.3 as follows:
 
7     (65 ILCS 5/10-4-2.3)
8     Sec. 10-4-2.3. Required health benefits. If a
9 municipality, including a home rule municipality, is a
10 self-insurer for purposes of providing health insurance
11 coverage for its employees, the coverage shall include coverage
12 for the post-mastectomy care benefits required to be covered by
13 a policy of accident and health insurance under Section 356t
14 and the coverage required under Sections 356u, 356w, and 356x,
15 and 356z.6 of the Illinois Insurance Code. The requirement that
16 health benefits be covered as provided in this is an exclusive
17 power and function of the State and is a denial and limitation
18 under Article VII, Section 6, subsection (h) of the Illinois
19 Constitution. A home rule municipality to which this Section
20 applies must comply with every provision of this Section.
21 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
 
22     Section 20. The School Code is amended by changing Section
23 10-22.3f as follows:
 
24     (105 ILCS 5/10-22.3f)
25     Sec. 10-22.3f. Required health benefits. Insurance
26 protection and benefits for employees shall provide the
27 post-mastectomy care benefits required to be covered by a
28 policy of accident and health insurance under Section 356t and
29 the coverage required under Sections 356u, 356w, and 356x, and
30 356z.6 of the Illinois Insurance Code.
31 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
 

 

 

HB4598 - 3 - LRB093 20553 SAS 46361 b

1     Section 25. The Illinois Insurance Code is amended by
2 adding Section 356z.6 as follows:
 
3     (215 ILCS 5/356z.6 new)
4     Sec. 356z.6. Athletic Trainers. A group or individual
5 policy of accident and health insurance or managed care plan
6 amended, delivered, issued, or renewed after the effective date
7 of this amendatory Act of the 93rd General Assembly must
8 provide coverage for services rendered by a licensed athletic
9 trainer in accordance with the Illinois Athletic Trainers
10 Practice Act if those services are ordered by a physician
11 licensed to practice medicine in all of its branches.
 
12     Section 30. The Comprehensive Health Insurance Plan Act is
13 amended by changing Section 8 as follows:
 
14     (215 ILCS 105/8)  (from Ch. 73, par. 1308)
15     Sec. 8. Minimum benefits.
16     a. Availability. The Plan shall offer in an annually
17 renewable policy major medical expense coverage to every
18 eligible person who is not eligible for Medicare. Major medical
19 expense coverage offered by the Plan shall pay an eligible
20 person's covered expenses, subject to limit on the deductible
21 and coinsurance payments authorized under paragraph (4) of
22 subsection d of this Section, up to a lifetime benefit limit of
23 $1,000,000 per covered individual. The maximum limit under this
24 subsection shall not be altered by the Board, and no actuarial
25 equivalent benefit may be substituted by the Board. Any person
26 who otherwise would qualify for coverage under the Plan, but is
27 excluded because he or she is eligible for Medicare, shall be
28 eligible for any separate Medicare supplement policy or
29 policies which the Board may offer.
30     b. Outline of benefits. Covered expenses shall be limited
31 to the usual and customary charge, including negotiated fees,
32 in the locality for the following services and articles when
33 prescribed by a physician and determined by the Plan to be

 

 

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1 medically necessary for the following areas of services,
2 subject to such separate deductibles, co-payments, exclusions,
3 and other limitations on benefits as the Board shall establish
4 and approve, and the other provisions of this Section:
5         (1) Hospital services, except that any services
6     provided by a hospital that is located more than 75 miles
7     outside the State of Illinois shall be covered only for a
8     maximum of 45 days in any calendar year. With respect to
9     covered expenses incurred during any calendar year ending
10     on or after December 31, 1999, inpatient hospitalization of
11     an eligible person for the treatment of mental illness at a
12     hospital located within the State of Illinois shall be
13     subject to the same terms and conditions as for any other
14     illness.
15         (2) Professional services for the diagnosis or
16     treatment of injuries, illnesses or conditions, other than
17     dental and mental and nervous disorders as described in
18     paragraph (17), which are rendered by a physician, or by
19     other licensed professionals at the physician's direction.
20     This includes reconstruction of the breast on which a
21     mastectomy was performed; surgery and reconstruction of
22     the other breast to produce a symmetrical appearance; and
23     prostheses and treatment of physical complications at all
24     stages of the mastectomy, including lymphedemas.
25         (2.5) Professional services provided by a physician to
26     children under the age of 16 years for physical
27     examinations and age appropriate immunizations ordered by
28     a physician licensed to practice medicine in all its
29     branches.
30         (3) (Blank).
31         (4) Outpatient prescription drugs that by law require a
32     prescription written by a physician licensed to practice
33     medicine in all its branches subject to such separate
34     deductible, copayment, and other limitations or
35     restrictions as the Board shall approve, including the use
36     of a prescription drug card or any other program, or both.

 

 

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1         (5) Skilled nursing services of a licensed skilled
2     nursing facility for not more than 120 days during a policy
3     year.
4         (6) Services of a home health agency in accord with a
5     home health care plan, up to a maximum of 270 visits per
6     year.
7         (7) Services of a licensed hospice for not more than
8     180 days during a policy year.
9         (8) Use of radium or other radioactive materials.
10         (9) Oxygen.
11         (10) Anesthetics.
12         (11) Orthoses and prostheses other than dental.
13         (12) Rental or purchase in accordance with Board
14     policies or procedures of durable medical equipment, other
15     than eyeglasses or hearing aids, for which there is no
16     personal use in the absence of the condition for which it
17     is prescribed.
18         (13) Diagnostic x-rays and laboratory tests.
19         (14) Oral surgery (i) for excision of partially or
20     completely unerupted impacted teeth when not performed in
21     connection with the routine extraction or repair of teeth;
22     (ii) for excision of tumors or cysts of the jaws, cheeks,
23     lips, tongue, and roof and floor of the mouth; (iii)
24     required for correction of cleft lip and palate and other
25     craniofacial and maxillofacial birth defects; or (iv) for
26     treatment of injuries to natural teeth or a fractured jaw
27     due to an accident.
28         (15) Physical, speech, and functional occupational
29     therapy as medically necessary and provided by appropriate
30     licensed professionals.
31         (16) Emergency and other medically necessary
32     transportation provided by a licensed ambulance service to
33     the nearest health care facility qualified to treat a
34     covered illness, injury, or condition, subject to the
35     provisions of the Emergency Medical Systems (EMS) Act.
36         (17) Outpatient services for diagnosis and treatment

 

 

HB4598 - 6 - LRB093 20553 SAS 46361 b

1     of mental and nervous disorders provided that a covered
2     person shall be required to make a copayment not to exceed
3     50% and that the Plan's payment shall not exceed such
4     amounts as are established by the Board.
5         (18) Human organ or tissue transplants specified by the
6     Board that are performed at a hospital designated by the
7     Board as a participating transplant center for that
8     specific organ or tissue transplant.
9         (19) Naprapathic services, as appropriate, provided by
10     a licensed naprapathic practitioner.
11         (20) Services rendered by a licensed athletic trainer
12     in accordance with the Illinois Athletic Trainers Practice
13     Act if those services are ordered by a physician licensed
14     to practice medicine in all of its branches.
15     c. Exclusions. Covered expenses of the Plan shall not
16 include the following:
17         (1) Any charge for treatment for cosmetic purposes
18     other than for reconstructive surgery when the service is
19     incidental to or follows surgery resulting from injury,
20     sickness or other diseases of the involved part or surgery
21     for the repair or treatment of a congenital bodily defect
22     to restore normal bodily functions.
23         (2) Any charge for care that is primarily for rest,
24     custodial, educational, or domiciliary purposes.
25         (3) Any charge for services in a private room to the
26     extent it is in excess of the institution's charge for its
27     most common semiprivate room, unless a private room is
28     prescribed as medically necessary by a physician.
29         (4) That part of any charge for room and board or for
30     services rendered or articles prescribed by a physician,
31     dentist, or other health care personnel that exceeds the
32     reasonable and customary charge in the locality or for any
33     services or supplies not medically necessary for the
34     diagnosed injury or illness.
35         (5) Any charge for services or articles the provision
36     of which is not within the scope of licensure of the

 

 

HB4598 - 7 - LRB093 20553 SAS 46361 b

1     institution or individual providing the services or
2     articles.
3         (6) Any expense incurred prior to the effective date of
4     coverage by the Plan for the person on whose behalf the
5     expense is incurred.
6         (7) Dental care, dental surgery, dental treatment, any
7     other dental procedure involving the teeth or
8     periodontium, or any dental appliances, including crowns,
9     bridges, implants, or partial or complete dentures, except
10     as specifically provided in paragraph (14) of subsection b
11     of this Section.
12         (8) Eyeglasses, contact lenses, hearing aids or their
13     fitting.
14         (9) Illness or injury due to acts of war.
15         (10) Services of blood donors and any fee for failure
16     to replace the first 3 pints of blood provided to a covered
17     person each policy year.
18         (11) Personal supplies or services provided by a
19     hospital or nursing home, or any other nonmedical or
20     nonprescribed supply or service.
21         (12) Routine maternity charges for a pregnancy, except
22     where added as optional coverage with payment of an
23     additional premium for pregnancy resulting from conception
24     occurring after the effective date of the optional
25     coverage.
26         (13) (Blank).
27         (14) Any expense or charge for services, drugs, or
28     supplies that are: (i) not provided in accord with
29     generally accepted standards of current medical practice;
30     (ii) for procedures, treatments, equipment, transplants,
31     or implants, any of which are investigational,
32     experimental, or for research purposes; (iii)
33     investigative and not proven safe and effective; or (iv)
34     for, or resulting from, a gender transformation operation.
35         (15) Any expense or charge for routine physical
36     examinations or tests except as provided in item (2.5) of

 

 

HB4598 - 8 - LRB093 20553 SAS 46361 b

1     subsection b of this Section.
2         (16) Any expense for which a charge is not made in the
3     absence of insurance or for which there is no legal
4     obligation on the part of the patient to pay.
5         (17) Any expense incurred for benefits provided under
6     the laws of the United States and this State, including
7     Medicare, Medicaid, and other medical assistance, maternal
8     and child health services and any other program that is
9     administered or funded by the Department of Human Services,
10     Department of Public Aid, or Department of Public Health,
11     military service-connected disability payments, medical
12     services provided for members of the armed forces and their
13     dependents or employees of the armed forces of the United
14     States, and medical services financed on behalf of all
15     citizens by the United States.
16         (18) Any expense or charge for in vitro fertilization,
17     artificial insemination, or any other artificial means
18     used to cause pregnancy.
19         (19) Any expense or charge for oral contraceptives used
20     for birth control or any other temporary birth control
21     measures.
22         (20) Any expense or charge for sterilization or
23     sterilization reversals.
24         (21) Any expense or charge for weight loss programs,
25     exercise equipment, or treatment of obesity, except when
26     certified by a physician as morbid obesity (at least 2
27     times normal body weight).
28         (22) Any expense or charge for acupuncture treatment
29     unless used as an anesthetic agent for a covered surgery.
30         (23) Any expense or charge for or related to organ or
31     tissue transplants other than those performed at a hospital
32     with a Board approved organ transplant program that has
33     been designated by the Board as a preferred or exclusive
34     provider organization for that specific organ or tissue
35     transplant.
36         (24) Any expense or charge for procedures, treatments,

 

 

HB4598 - 9 - LRB093 20553 SAS 46361 b

1     equipment, or services that are provided in special
2     settings for research purposes or in a controlled
3     environment, are being studied for safety, efficiency, and
4     effectiveness, and are awaiting endorsement by the
5     appropriate national medical speciality college for
6     general use within the medical community.
7     d. Deductibles and coinsurance.
8     The Plan coverage defined in Section 6 shall provide for a
9 choice of deductibles per individual as authorized by the
10 Board. If 2 individual members of the same family household,
11 who are both covered persons under the Plan, satisfy the same
12 applicable deductibles, no other member of that family who is
13 also a covered person under the Plan shall be required to meet
14 any deductibles for the balance of that calendar year. The
15 deductibles must be applied first to the authorized amount of
16 covered expenses incurred by the covered person. A mandatory
17 coinsurance requirement shall be imposed at the rate authorized
18 by the Board in excess of the mandatory deductible, the
19 coinsurance in the aggregate not to exceed such amounts as are
20 authorized by the Board per annum. At its discretion the Board
21 may, however, offer catastrophic coverages or other policies
22 that provide for larger deductibles with or without coinsurance
23 requirements. The deductibles and coinsurance factors may be
24 adjusted annually according to the Medical Component of the
25 Consumer Price Index.
26     e. Scope of coverage.
27         (1) In approving any of the benefit plans to be offered
28     by the Plan, the Board shall establish such benefit levels,
29     deductibles, coinsurance factors, exclusions, and
30     limitations as it may deem appropriate and that it believes
31     to be generally reflective of and commensurate with health
32     insurance coverage that is provided in the individual
33     market in this State.
34         (2) The benefit plans approved by the Board may also
35     provide for and employ various cost containment measures
36     and other requirements including, but not limited to,

 

 

HB4598 - 10 - LRB093 20553 SAS 46361 b

1     preadmission certification, prior approval, second
2     surgical opinions, concurrent utilization review programs,
3     individual case management, preferred provider
4     organizations, health maintenance organizations, and other
5     cost effective arrangements for paying for covered
6     expenses.
7     f. Preexisting conditions.
8         (1) Except for federally eligible individuals
9     qualifying for Plan coverage under Section 15 of this Act
10     or eligible persons who qualify for the waiver authorized
11     in paragraph (3) of this subsection, plan coverage shall
12     exclude charges or expenses incurred during the first 6
13     months following the effective date of coverage as to any
14     condition for which medical advice, care or treatment was
15     recommended or received during the 6 month period
16     immediately preceding the effective date of coverage.
17         (2) (Blank).
18         (3) Waiver: The preexisting condition exclusions as
19     set forth in paragraph (1) of this subsection shall be
20     waived to the extent to which the eligible person (a) has
21     satisfied similar exclusions under any prior individual
22     health insurance policy that was involuntarily terminated
23     because of the insolvency of the issuer of the policy and
24     (b) has applied for Plan coverage within 90 days following
25     the involuntary termination of that individual health
26     insurance coverage.
27     g. Other sources primary; nonduplication of benefits.
28         (1) The Plan shall be the last payor of benefits
29     whenever any other benefit or source of third party payment
30     is available. Subject to the provisions of subsection e of
31     Section 7, benefits otherwise payable under Plan coverage
32     shall be reduced by all amounts paid or payable by Medicare
33     or any other government program or through any health
34     insurance coverage or group health plan, whether by
35     insurance, reimbursement, or otherwise, or through any
36     third party liability, settlement, judgment, or award,

 

 

HB4598 - 11 - LRB093 20553 SAS 46361 b

1     regardless of the date of the settlement, judgment, or
2     award, whether the settlement, judgment, or award is in the
3     form of a contract, agreement, or trust on behalf of a
4     minor or otherwise and whether the settlement, judgment, or
5     award is payable to the covered person, his or her
6     dependent, estate, personal representative, or guardian in
7     a lump sum or over time, and by all hospital or medical
8     expense benefits paid or payable under any worker's
9     compensation coverage, automobile medical payment, or
10     liability insurance, whether provided on the basis of fault
11     or nonfault, and by any hospital or medical benefits paid
12     or payable under or provided pursuant to any State or
13     federal law or program.
14         (2) The Plan shall have a cause of action against any
15     covered person or any other person or entity for the
16     recovery of any amount paid to the extent the amount was
17     for treatment, services, or supplies not covered in this
18     Section or in excess of benefits as set forth in this
19     Section.
20         (3) Whenever benefits are due from the Plan because of
21     sickness or an injury to a covered person resulting from a
22     third party's wrongful act or negligence and the covered
23     person has recovered or may recover damages from a third
24     party or its insurer, the Plan shall have the right to
25     reduce benefits or to refuse to pay benefits that otherwise
26     may be payable by the amount of damages that the covered
27     person has recovered or may recover regardless of the date
28     of the sickness or injury or the date of any settlement,
29     judgment, or award resulting from that sickness or injury.
30         During the pendency of any action or claim that is
31     brought by or on behalf of a covered person against a third
32     party or its insurer, any benefits that would otherwise be
33     payable except for the provisions of this paragraph (3)
34     shall be paid if payment by or for the third party has not
35     yet been made and the covered person or, if incapable, that
36     person's legal representative agrees in writing to pay back

 

 

HB4598 - 12 - LRB093 20553 SAS 46361 b

1     promptly the benefits paid as a result of the sickness or
2     injury to the extent of any future payments made by or for
3     the third party for the sickness or injury. This agreement
4     is to apply whether or not liability for the payments is
5     established or admitted by the third party or whether those
6     payments are itemized.
7         Any amounts due the plan to repay benefits may be
8     deducted from other benefits payable by the Plan after
9     payments by or for the third party are made.
10         (4) Benefits due from the Plan may be reduced or
11     refused as an offset against any amount otherwise
12     recoverable under this Section.
13     h. Right of subrogation; recoveries.
14         (1) Whenever the Plan has paid benefits because of
15     sickness or an injury to any covered person resulting from
16     a third party's wrongful act or negligence, or for which an
17     insurer is liable in accordance with the provisions of any
18     policy of insurance, and the covered person has recovered
19     or may recover damages from a third party that is liable
20     for the damages, the Plan shall have the right to recover
21     the benefits it paid from any amounts that the covered
22     person has received or may receive regardless of the date
23     of the sickness or injury or the date of any settlement,
24     judgment, or award resulting from that sickness or injury.
25     The Plan shall be subrogated to any right of recovery the
26     covered person may have under the terms of any private or
27     public health care coverage or liability coverage,
28     including coverage under the Workers' Compensation Act or
29     the Workers' Occupational Diseases Act, without the
30     necessity of assignment of claim or other authorization to
31     secure the right of recovery. To enforce its subrogation
32     right, the Plan may (i) intervene or join in an action or
33     proceeding brought by the covered person or his personal
34     representative, including his guardian, conservator,
35     estate, dependents, or survivors, against any third party
36     or the third party's insurer that may be liable or (ii)

 

 

HB4598 - 13 - LRB093 20553 SAS 46361 b

1     institute and prosecute legal proceedings against any
2     third party or the third party's insurer that may be liable
3     for the sickness or injury in an appropriate court either
4     in the name of the Plan or in the name of the covered
5     person or his personal representative, including his
6     guardian, conservator, estate, dependents, or survivors.
7         (2) If any action or claim is brought by or on behalf
8     of a covered person against a third party or the third
9     party's insurer, the covered person or his personal
10     representative, including his guardian, conservator,
11     estate, dependents, or survivors, shall notify the Plan by
12     personal service or registered mail of the action or claim
13     and of the name of the court in which the action or claim
14     is brought, filing proof thereof in the action or claim.
15     The Plan may, at any time thereafter, join in the action or
16     claim upon its motion so that all orders of court after
17     hearing and judgment shall be made for its protection. No
18     release or settlement of a claim for damages and no
19     satisfaction of judgment in the action shall be valid
20     without the written consent of the Plan to the extent of
21     its interest in the settlement or judgment and of the
22     covered person or his personal representative.
23         (3) In the event that the covered person or his
24     personal representative fails to institute a proceeding
25     against any appropriate third party before the fifth month
26     before the action would be barred, the Plan may, in its own
27     name or in the name of the covered person or personal
28     representative, commence a proceeding against any
29     appropriate third party for the recovery of damages on
30     account of any sickness, injury, or death to the covered
31     person. The covered person shall cooperate in doing what is
32     reasonably necessary to assist the Plan in any recovery and
33     shall not take any action that would prejudice the Plan's
34     right to recovery. The Plan shall pay to the covered person
35     or his personal representative all sums collected from any
36     third party by judgment or otherwise in excess of amounts

 

 

HB4598 - 14 - LRB093 20553 SAS 46361 b

1     paid in benefits under the Plan and amounts paid or to be
2     paid as costs, attorneys fees, and reasonable expenses
3     incurred by the Plan in making the collection or enforcing
4     the judgment.
5         (4) In the event that a covered person or his personal
6     representative, including his guardian, conservator,
7     estate, dependents, or survivors, recovers damages from a
8     third party for sickness or injury caused to the covered
9     person, the covered person or the personal representative
10     shall pay to the Plan from the damages recovered the amount
11     of benefits paid or to be paid on behalf of the covered
12     person.
13         (5) When the action or claim is brought by the covered
14     person alone and the covered person incurs a personal
15     liability to pay attorney's fees and costs of litigation,
16     the Plan's claim for reimbursement of the benefits provided
17     to the covered person shall be the full amount of benefits
18     paid to or on behalf of the covered person under this Act
19     less a pro rata share that represents the Plan's reasonable
20     share of attorney's fees paid by the covered person and
21     that portion of the cost of litigation expenses determined
22     by multiplying by the ratio of the full amount of the
23     expenditures to the full amount of the judgement, award, or
24     settlement.
25         (6) In the event of judgment or award in a suit or
26     claim against a third party or insurer, the court shall
27     first order paid from any judgement or award the reasonable
28     litigation expenses incurred in preparation and
29     prosecution of the action or claim, together with
30     reasonable attorney's fees. After payment of those
31     expenses and attorney's fees, the court shall apply out of
32     the balance of the judgment or award an amount sufficient
33     to reimburse the Plan the full amount of benefits paid on
34     behalf of the covered person under this Act, provided the
35     court may reduce and apportion the Plan's portion of the
36     judgement proportionate to the recovery of the covered

 

 

HB4598 - 15 - LRB093 20553 SAS 46361 b

1     person. The burden of producing evidence sufficient to
2     support the exercise by the court of its discretion to
3     reduce the amount of a proven charge sought to be enforced
4     against the recovery shall rest with the party seeking the
5     reduction. The court may consider the nature and extent of
6     the injury, economic and non-economic loss, settlement
7     offers, comparative negligence as it applies to the case at
8     hand, hospital costs, physician costs, and all other
9     appropriate costs. The Plan shall pay its pro rata share of
10     the attorney fees based on the Plan's recovery as it
11     compares to the total judgment. Any reimbursement rights of
12     the Plan shall take priority over all other liens and
13     charges existing under the laws of this State with the
14     exception of any attorney liens filed under the Attorneys
15     Lien Act.
16         (7) The Plan may compromise or settle and release any
17     claim for benefits provided under this Act or waive any
18     claims for benefits, in whole or in part, for the
19     convenience of the Plan or if the Plan determines that
20     collection would result in undue hardship upon the covered
21     person.
22 (Source: P.A. 91-639, eff. 8-20-99; 91-735, eff. 6-2-00; 92-2,
23 eff. 5-1-01; 92-630, eff. 7-11-02.)
 
24     Section 35. The Health Maintenance Organization Act is
25 amended by changing Section 5-3 as follows:
 
26     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
27     Sec. 5-3. Insurance Code provisions.
28     (a) Health Maintenance Organizations shall be subject to
29 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
30 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
31 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
32 356y, 356z.2, 356z.4, 356z.5, 356z.6, 367.2, 367.2-5, 367i,
33 368a, 368b, 368c, 368d, 368e, 401, 401.1, 402, 403, 403A, 408,
34 408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection

 

 

HB4598 - 16 - LRB093 20553 SAS 46361 b

1 (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
2 XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
3     (b) For purposes of the Illinois Insurance Code, except for
4 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
5 Maintenance Organizations in the following categories are
6 deemed to be "domestic companies":
7         (1) a corporation authorized under the Dental Service
8     Plan Act or the Voluntary Health Services Plans Act;
9         (2) a corporation organized under the laws of this
10     State; or
11         (3) a corporation organized under the laws of another
12     state, 30% or more of the enrollees of which are residents
13     of this State, except a corporation subject to
14     substantially the same requirements in its state of
15     organization as is a "domestic company" under Article VIII
16     1/2 of the Illinois Insurance Code.
17     (c) In considering the merger, consolidation, or other
18 acquisition of control of a Health Maintenance Organization
19 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
20         (1) the Director shall give primary consideration to
21     the continuation of benefits to enrollees and the financial
22     conditions of the acquired Health Maintenance Organization
23     after the merger, consolidation, or other acquisition of
24     control takes effect;
25         (2)(i) the criteria specified in subsection (1)(b) of
26     Section 131.8 of the Illinois Insurance Code shall not
27     apply and (ii) the Director, in making his determination
28     with respect to the merger, consolidation, or other
29     acquisition of control, need not take into account the
30     effect on competition of the merger, consolidation, or
31     other acquisition of control;
32         (3) the Director shall have the power to require the
33     following information:
34             (A) certification by an independent actuary of the
35         adequacy of the reserves of the Health Maintenance
36         Organization sought to be acquired;

 

 

HB4598 - 17 - LRB093 20553 SAS 46361 b

1             (B) pro forma financial statements reflecting the
2         combined balance sheets of the acquiring company and
3         the Health Maintenance Organization sought to be
4         acquired as of the end of the preceding year and as of
5         a date 90 days prior to the acquisition, as well as pro
6         forma financial statements reflecting projected
7         combined operation for a period of 2 years;
8             (C) a pro forma business plan detailing an
9         acquiring party's plans with respect to the operation
10         of the Health Maintenance Organization sought to be
11         acquired for a period of not less than 3 years; and
12             (D) such other information as the Director shall
13         require.
14     (d) The provisions of Article VIII 1/2 of the Illinois
15 Insurance Code and this Section 5-3 shall apply to the sale by
16 any health maintenance organization of greater than 10% of its
17 enrollee population (including without limitation the health
18 maintenance organization's right, title, and interest in and to
19 its health care certificates).
20     (e) In considering any management contract or service
21 agreement subject to Section 141.1 of the Illinois Insurance
22 Code, the Director (i) shall, in addition to the criteria
23 specified in Section 141.2 of the Illinois Insurance Code, take
24 into account the effect of the management contract or service
25 agreement on the continuation of benefits to enrollees and the
26 financial condition of the health maintenance organization to
27 be managed or serviced, and (ii) need not take into account the
28 effect of the management contract or service agreement on
29 competition.
30     (f) Except for small employer groups as defined in the
31 Small Employer Rating, Renewability and Portability Health
32 Insurance Act and except for medicare supplement policies as
33 defined in Section 363 of the Illinois Insurance Code, a Health
34 Maintenance Organization may by contract agree with a group or
35 other enrollment unit to effect refunds or charge additional
36 premiums under the following terms and conditions:

 

 

HB4598 - 18 - LRB093 20553 SAS 46361 b

1         (i) the amount of, and other terms and conditions with
2     respect to, the refund or additional premium are set forth
3     in the group or enrollment unit contract agreed in advance
4     of the period for which a refund is to be paid or
5     additional premium is to be charged (which period shall not
6     be less than one year); and
7         (ii) the amount of the refund or additional premium
8     shall not exceed 20% of the Health Maintenance
9     Organization's profitable or unprofitable experience with
10     respect to the group or other enrollment unit for the
11     period (and, for purposes of a refund or additional
12     premium, the profitable or unprofitable experience shall
13     be calculated taking into account a pro rata share of the
14     Health Maintenance Organization's administrative and
15     marketing expenses, but shall not include any refund to be
16     made or additional premium to be paid pursuant to this
17     subsection (f)). The Health Maintenance Organization and
18     the group or enrollment unit may agree that the profitable
19     or unprofitable experience may be calculated taking into
20     account the refund period and the immediately preceding 2
21     plan years.
22     The Health Maintenance Organization shall include a
23 statement in the evidence of coverage issued to each enrollee
24 describing the possibility of a refund or additional premium,
25 and upon request of any group or enrollment unit, provide to
26 the group or enrollment unit a description of the method used
27 to calculate (1) the Health Maintenance Organization's
28 profitable experience with respect to the group or enrollment
29 unit and the resulting refund to the group or enrollment unit
30 or (2) the Health Maintenance Organization's unprofitable
31 experience with respect to the group or enrollment unit and the
32 resulting additional premium to be paid by the group or
33 enrollment unit.
34     In no event shall the Illinois Health Maintenance
35 Organization Guaranty Association be liable to pay any
36 contractual obligation of an insolvent organization to pay any

 

 

HB4598 - 19 - LRB093 20553 SAS 46361 b

1 refund authorized under this Section.
2 (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261,
3 eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; revised
4 9-25-03.)
 
5     Section 40. The Voluntary Health Services Plans Act is
6 amended by changing Section 10 as follows:
 
7     (215 ILCS 165/10)  (from Ch. 32, par. 604)
8     Sec. 10. Application of Insurance Code provisions. Health
9 services plan corporations and all persons interested therein
10 or dealing therewith shall be subject to the provisions of
11 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
12 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v, 356w, 356x,
13 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 367.2, 368a, 401,
14 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
15 and (15) of Section 367 of the Illinois Insurance Code.
16 (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
17 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04;
18 93-529, eff. 8-14-03; revised 9-25-03.)
 
19     Section 45. The Illinois Public Aid Code is amended by
20 changing Section 5-5 as follows:
 
21     (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
22     Sec. 5-5. Medical services. The Illinois Department, by
23 rule, shall determine the quantity and quality of and the rate
24 of reimbursement for the medical assistance for which payment
25 will be authorized, and the medical services to be provided,
26 which may include all or part of the following: (1) inpatient
27 hospital services; (2) outpatient hospital services; (3) other
28 laboratory and X-ray services; (4) skilled nursing home
29 services; (5) physicians' services whether furnished in the
30 office, the patient's home, a hospital, a skilled nursing home,
31 or elsewhere; (6) medical care, or any other type of remedial
32 care furnished by licensed practitioners; (7) home health care

 

 

HB4598 - 20 - LRB093 20553 SAS 46361 b

1 services; (8) private duty nursing service; (9) clinic
2 services; (10) dental services; (11) physical therapy and
3 related services; (12) prescribed drugs, dentures, and
4 prosthetic devices; and eyeglasses prescribed by a physician
5 skilled in the diseases of the eye, or by an optometrist,
6 whichever the person may select; (13) other diagnostic,
7 screening, preventive, and rehabilitative services; (14)
8 transportation and such other expenses as may be necessary;
9 (15) medical treatment of sexual assault survivors, as defined
10 in Section 1a of the Sexual Assault Survivors Emergency
11 Treatment Act, for injuries sustained as a result of the sexual
12 assault, including examinations and laboratory tests to
13 discover evidence which may be used in criminal proceedings
14 arising from the sexual assault; (16) the diagnosis and
15 treatment of sickle cell anemia; and (17) any other medical
16 care, and any other type of remedial care recognized under the
17 laws of this State, but not including abortions, or induced
18 miscarriages or premature births, unless, in the opinion of a
19 physician, such procedures are necessary for the preservation
20 of the life of the woman seeking such treatment, or except an
21 induced premature birth intended to produce a live viable child
22 and such procedure is necessary for the health of the mother or
23 her unborn child. The Illinois Department, by rule, shall
24 prohibit any physician from providing medical assistance to
25 anyone eligible therefor under this Code where such physician
26 has been found guilty of performing an abortion procedure in a
27 wilful and wanton manner upon a woman who was not pregnant at
28 the time such abortion procedure was performed. The term "any
29 other type of remedial care" shall include nursing care and
30 nursing home service for persons who rely on treatment by
31 spiritual means alone through prayer for healing.
32     Notwithstanding any other provision of this Section, a
33 comprehensive tobacco use cessation program that includes
34 purchasing prescription drugs or prescription medical devices
35 approved by the Food and Drug administration shall be covered
36 under the medical assistance program under this Article for

 

 

HB4598 - 21 - LRB093 20553 SAS 46361 b

1 persons who are otherwise eligible for assistance under this
2 Article.
3     For persons eligible for assistance under this Article, the
4 Illinois Department shall require coverage for services
5 rendered by a licensed athletic trainer in accordance with the
6 Illinois Athletic Trainers Practice Act if those services are
7 ordered by a physician licensed to practice medicine in all of
8 its branches.
9     Notwithstanding any other provision of this Code, the
10 Illinois Department may not require, as a condition of payment
11 for any laboratory test authorized under this Article, that a
12 physician's handwritten signature appear on the laboratory
13 test order form. The Illinois Department may, however, impose
14 other appropriate requirements regarding laboratory test order
15 documentation.
16     The Illinois Department of Public Aid shall provide the
17 following services to persons eligible for assistance under
18 this Article who are participating in education, training or
19 employment programs operated by the Department of Human
20 Services as successor to the Department of Public Aid:
21         (1) dental services, which shall include but not be
22     limited to prosthodontics; and
23         (2) eyeglasses prescribed by a physician skilled in the
24     diseases of the eye, or by an optometrist, whichever the
25     person may select.
26     The Illinois Department, by rule, may distinguish and
27 classify the medical services to be provided only in accordance
28 with the classes of persons designated in Section 5-2.
29     The Illinois Department shall authorize the provision of,
30 and shall authorize payment for, screening by low-dose
31 mammography for the presence of occult breast cancer for women
32 35 years of age or older who are eligible for medical
33 assistance under this Article, as follows: a baseline mammogram
34 for women 35 to 39 years of age and an annual mammogram for
35 women 40 years of age or older. All screenings shall include a
36 physical breast exam, instruction on self-examination and

 

 

HB4598 - 22 - LRB093 20553 SAS 46361 b

1 information regarding the frequency of self-examination and
2 its value as a preventative tool. As used in this Section,
3 "low-dose mammography" means the x-ray examination of the
4 breast using equipment dedicated specifically for mammography,
5 including the x-ray tube, filter, compression device, image
6 receptor, and cassettes, with an average radiation exposure
7 delivery of less than one rad mid-breast, with 2 views for each
8 breast.
9     Any medical or health care provider shall immediately
10 recommend, to any pregnant woman who is being provided prenatal
11 services and is suspected of drug abuse or is addicted as
12 defined in the Alcoholism and Other Drug Abuse and Dependency
13 Act, referral to a local substance abuse treatment provider
14 licensed by the Department of Human Services or to a licensed
15 hospital which provides substance abuse treatment services.
16 The Department of Public Aid shall assure coverage for the cost
17 of treatment of the drug abuse or addiction for pregnant
18 recipients in accordance with the Illinois Medicaid Program in
19 conjunction with the Department of Human Services.
20     All medical providers providing medical assistance to
21 pregnant women under this Code shall receive information from
22 the Department on the availability of services under the Drug
23 Free Families with a Future or any comparable program providing
24 case management services for addicted women, including
25 information on appropriate referrals for other social services
26 that may be needed by addicted women in addition to treatment
27 for addiction.
28     The Illinois Department, in cooperation with the
29 Departments of Human Services (as successor to the Department
30 of Alcoholism and Substance Abuse) and Public Health, through a
31 public awareness campaign, may provide information concerning
32 treatment for alcoholism and drug abuse and addiction, prenatal
33 health care, and other pertinent programs directed at reducing
34 the number of drug-affected infants born to recipients of
35 medical assistance.
36     Neither the Illinois Department of Public Aid nor the

 

 

HB4598 - 23 - LRB093 20553 SAS 46361 b

1 Department of Human Services shall sanction the recipient
2 solely on the basis of her substance abuse.
3     The Illinois Department shall establish such regulations
4 governing the dispensing of health services under this Article
5 as it shall deem appropriate. The Department should seek the
6 advice of formal professional advisory committees appointed by
7 the Director of the Illinois Department for the purpose of
8 providing regular advice on policy and administrative matters,
9 information dissemination and educational activities for
10 medical and health care providers, and consistency in
11 procedures to the Illinois Department.
12     The Illinois Department may develop and contract with
13 Partnerships of medical providers to arrange medical services
14 for persons eligible under Section 5-2 of this Code.
15 Implementation of this Section may be by demonstration projects
16 in certain geographic areas. The Partnership shall be
17 represented by a sponsor organization. The Department, by rule,
18 shall develop qualifications for sponsors of Partnerships.
19 Nothing in this Section shall be construed to require that the
20 sponsor organization be a medical organization.
21     The sponsor must negotiate formal written contracts with
22 medical providers for physician services, inpatient and
23 outpatient hospital care, home health services, treatment for
24 alcoholism and substance abuse, and other services determined
25 necessary by the Illinois Department by rule for delivery by
26 Partnerships. Physician services must include prenatal and
27 obstetrical care. The Illinois Department shall reimburse
28 medical services delivered by Partnership providers to clients
29 in target areas according to provisions of this Article and the
30 Illinois Health Finance Reform Act, except that:
31         (1) Physicians participating in a Partnership and
32     providing certain services, which shall be determined by
33     the Illinois Department, to persons in areas covered by the
34     Partnership may receive an additional surcharge for such
35     services.
36         (2) The Department may elect to consider and negotiate

 

 

HB4598 - 24 - LRB093 20553 SAS 46361 b

1     financial incentives to encourage the development of
2     Partnerships and the efficient delivery of medical care.
3         (3) Persons receiving medical services through
4     Partnerships may receive medical and case management
5     services above the level usually offered through the
6     medical assistance program.
7     Medical providers shall be required to meet certain
8 qualifications to participate in Partnerships to ensure the
9 delivery of high quality medical services. These
10 qualifications shall be determined by rule of the Illinois
11 Department and may be higher than qualifications for
12 participation in the medical assistance program. Partnership
13 sponsors may prescribe reasonable additional qualifications
14 for participation by medical providers, only with the prior
15 written approval of the Illinois Department.
16     Nothing in this Section shall limit the free choice of
17 practitioners, hospitals, and other providers of medical
18 services by clients. In order to ensure patient freedom of
19 choice, the Illinois Department shall immediately promulgate
20 all rules and take all other necessary actions so that provided
21 services may be accessed from therapeutically certified
22 optometrists to the full extent of the Illinois Optometric
23 Practice Act of 1987 without discriminating between service
24 providers.
25     The Department shall apply for a waiver from the United
26 States Health Care Financing Administration to allow for the
27 implementation of Partnerships under this Section.
28     The Illinois Department shall require health care
29 providers to maintain records that document the medical care
30 and services provided to recipients of Medical Assistance under
31 this Article. The Illinois Department shall require health care
32 providers to make available, when authorized by the patient, in
33 writing, the medical records in a timely fashion to other
34 health care providers who are treating or serving persons
35 eligible for Medical Assistance under this Article. All
36 dispensers of medical services shall be required to maintain

 

 

HB4598 - 25 - LRB093 20553 SAS 46361 b

1 and retain business and professional records sufficient to
2 fully and accurately document the nature, scope, details and
3 receipt of the health care provided to persons eligible for
4 medical assistance under this Code, in accordance with
5 regulations promulgated by the Illinois Department. The rules
6 and regulations shall require that proof of the receipt of
7 prescription drugs, dentures, prosthetic devices and
8 eyeglasses by eligible persons under this Section accompany
9 each claim for reimbursement submitted by the dispenser of such
10 medical services. No such claims for reimbursement shall be
11 approved for payment by the Illinois Department without such
12 proof of receipt, unless the Illinois Department shall have put
13 into effect and shall be operating a system of post-payment
14 audit and review which shall, on a sampling basis, be deemed
15 adequate by the Illinois Department to assure that such drugs,
16 dentures, prosthetic devices and eyeglasses for which payment
17 is being made are actually being received by eligible
18 recipients. Within 90 days after the effective date of this
19 amendatory Act of 1984, the Illinois Department shall establish
20 a current list of acquisition costs for all prosthetic devices
21 and any other items recognized as medical equipment and
22 supplies reimbursable under this Article and shall update such
23 list on a quarterly basis, except that the acquisition costs of
24 all prescription drugs shall be updated no less frequently than
25 every 30 days as required by Section 5-5.12.
26     The rules and regulations of the Illinois Department shall
27 require that a written statement including the required opinion
28 of a physician shall accompany any claim for reimbursement for
29 abortions, or induced miscarriages or premature births. This
30 statement shall indicate what procedures were used in providing
31 such medical services.
32     The Illinois Department shall require all dispensers of
33 medical services, other than an individual practitioner or
34 group of practitioners, desiring to participate in the Medical
35 Assistance program established under this Article to disclose
36 all financial, beneficial, ownership, equity, surety or other

 

 

HB4598 - 26 - LRB093 20553 SAS 46361 b

1 interests in any and all firms, corporations, partnerships,
2 associations, business enterprises, joint ventures, agencies,
3 institutions or other legal entities providing any form of
4 health care services in this State under this Article.
5     The Illinois Department may require that all dispensers of
6 medical services desiring to participate in the medical
7 assistance program established under this Article disclose,
8 under such terms and conditions as the Illinois Department may
9 by rule establish, all inquiries from clients and attorneys
10 regarding medical bills paid by the Illinois Department, which
11 inquiries could indicate potential existence of claims or liens
12 for the Illinois Department.
13     Enrollment of a vendor that provides non-emergency medical
14 transportation, defined by the Department by rule, shall be
15 conditional for 180 days. During that time, the Department of
16 Public Aid may terminate the vendor's eligibility to
17 participate in the medical assistance program without cause.
18 That termination of eligibility is not subject to the
19 Department's hearing process.
20     The Illinois Department shall establish policies,
21 procedures, standards and criteria by rule for the acquisition,
22 repair and replacement of orthotic and prosthetic devices and
23 durable medical equipment. Such rules shall provide, but not be
24 limited to, the following services: (1) immediate repair or
25 replacement of such devices by recipients without medical
26 authorization; and (2) rental, lease, purchase or
27 lease-purchase of durable medical equipment in a
28 cost-effective manner, taking into consideration the
29 recipient's medical prognosis, the extent of the recipient's
30 needs, and the requirements and costs for maintaining such
31 equipment. Such rules shall enable a recipient to temporarily
32 acquire and use alternative or substitute devices or equipment
33 pending repairs or replacements of any device or equipment
34 previously authorized for such recipient by the Department.
35 Rules under clause (2) above shall not provide for purchase or
36 lease-purchase of durable medical equipment or supplies used

 

 

HB4598 - 27 - LRB093 20553 SAS 46361 b

1 for the purpose of oxygen delivery and respiratory care.
2     The Department shall execute, relative to the nursing home
3 prescreening project, written inter-agency agreements with the
4 Department of Human Services and the Department on Aging, to
5 effect the following: (i) intake procedures and common
6 eligibility criteria for those persons who are receiving
7 non-institutional services; and (ii) the establishment and
8 development of non-institutional services in areas of the State
9 where they are not currently available or are undeveloped.
10     The Illinois Department shall develop and operate, in
11 cooperation with other State Departments and agencies and in
12 compliance with applicable federal laws and regulations,
13 appropriate and effective systems of health care evaluation and
14 programs for monitoring of utilization of health care services
15 and facilities, as it affects persons eligible for medical
16 assistance under this Code.
17     The Illinois Department shall report annually to the
18 General Assembly, no later than the second Friday in April of
19 1979 and each year thereafter, in regard to:
20         (a) actual statistics and trends in utilization of
21     medical services by public aid recipients;
22         (b) actual statistics and trends in the provision of
23     the various medical services by medical vendors;
24         (c) current rate structures and proposed changes in
25     those rate structures for the various medical vendors; and
26         (d) efforts at utilization review and control by the
27     Illinois Department.
28     The period covered by each report shall be the 3 years
29 ending on the June 30 prior to the report. The report shall
30 include suggested legislation for consideration by the General
31 Assembly. The filing of one copy of the report with the
32 Speaker, one copy with the Minority Leader and one copy with
33 the Clerk of the House of Representatives, one copy with the
34 President, one copy with the Minority Leader and one copy with
35 the Secretary of the Senate, one copy with the Legislative
36 Research Unit, and such additional copies with the State

 

 

HB4598 - 28 - LRB093 20553 SAS 46361 b

1 Government Report Distribution Center for the General Assembly
2 as is required under paragraph (t) of Section 7 of the State
3 Library Act shall be deemed sufficient to comply with this
4 Section.
5 (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02;
6 92-789, eff. 8-6-02; 93-632, eff. 2-1-04.)
 
7     Section 99. Effective date. This Act takes effect upon
8 becoming law.