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1 | MOTION
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2 | I move to accept the specific recommendations of the | ||||||
3 | Governor as to House Bill 953 in manner and form as follows:
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4 | AMENDMENT TO HOUSE BILL 953
| ||||||
5 | IN ACCEPTANCE OF GOVERNOR'S RECOMMENDATIONS
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6 | Amend House Bill 953 as follows:
| ||||||
7 | on page 1, below line 3, by inserting the following: | ||||||
8 | "Section 2. The State Employees Group Insurance Act of 1971 | ||||||
9 | is amended by changing Section 6.11 as follows:
| ||||||
10 | (5 ILCS 375/6.11)
| ||||||
11 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
12 | Code
requirements. The program of health
benefits shall provide | ||||||
13 | the post-mastectomy care benefits required to be covered
by a | ||||||
14 | policy of accident and health insurance under Section 356t of | ||||||
15 | the Illinois
Insurance Code. The program of health benefits | ||||||
16 | shall provide the coverage
required under Sections 356g.5,
| ||||||
17 | 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.8, and 356z.9, | ||||||
18 | 356z.10 and 356z.13 356z.9 of the
Illinois Insurance Code.
The | ||||||
19 | program of health benefits must comply with Section 155.37 of | ||||||
20 | the
Illinois Insurance Code.
| ||||||
21 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
22 | 95-520, eff. 8-28-07; revised 12-4-07.)
|
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| |||||||
1 | Section 2.5. The Counties Code is amended by changing | ||||||
2 | Section 5-1069.3 as follows: | ||||||
3 | (55 ILCS 5/5-1069.3)
| ||||||
4 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
5 | including a home
rule
county, is a self-insurer for purposes of | ||||||
6 | providing health insurance coverage
for its employees, the | ||||||
7 | coverage shall include coverage for the post-mastectomy
care | ||||||
8 | benefits required to be covered by a policy of accident and | ||||||
9 | health
insurance under Section 356t and the coverage required | ||||||
10 | under Sections 356g.5, 356u,
356w, 356x, 356z.6, 356z.8, and | ||||||
11 | 356z.9, 356z.10, and 356z.13 356z.9 of
the Illinois Insurance | ||||||
12 | Code. The requirement that health benefits be covered
as | ||||||
13 | provided in this Section is an
exclusive power and function of | ||||||
14 | the State and is a denial and limitation under
Article VII, | ||||||
15 | Section 6, subsection (h) of the Illinois Constitution. A home
| ||||||
16 | rule county to which this Section applies must comply with | ||||||
17 | every provision of
this Section.
| ||||||
18 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
19 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
20 | Section 3. The Illinois Municipal Code is amended by | ||||||
21 | changing Section 10-4-2.3 as follows: | ||||||
22 | (65 ILCS 5/10-4-2.3)
|
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| |||||||
1 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
2 | municipality, including a
home rule municipality, is a | ||||||
3 | self-insurer for purposes of providing health
insurance | ||||||
4 | coverage for its employees, the coverage shall include coverage | ||||||
5 | for
the post-mastectomy care benefits required to be covered by | ||||||
6 | a policy of
accident and health insurance under Section 356t | ||||||
7 | and the coverage required
under Sections 356g.5, 356u, 356w, | ||||||
8 | 356x, 356z.6, 356z.8, and 356z.9, 356z.10, and 356z.13 356z.9 | ||||||
9 | of the Illinois
Insurance
Code. The requirement that health
| ||||||
10 | benefits be covered as provided in this is an exclusive power | ||||||
11 | and function of
the State and is a denial and limitation under | ||||||
12 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
13 | Constitution. A home rule municipality to which
this Section | ||||||
14 | applies must comply with every provision of this Section.
| ||||||
15 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
16 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
17 | Section 4. The School Code is amended by changing Section | ||||||
18 | 10-22.3f as follows: | ||||||
19 | (105 ILCS 5/10-22.3f)
| ||||||
20 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
21 | protection and
benefits
for employees shall provide the | ||||||
22 | post-mastectomy care benefits required to be
covered by a | ||||||
23 | policy of accident and health insurance under Section 356t and |
| |||||||
| |||||||
1 | the
coverage required under Sections 356g.5, 356u, 356w, 356x,
| ||||||
2 | 356z.6, 356z.8, and 356z.9 , and 356z.13 of
the
Illinois | ||||||
3 | Insurance Code.
| ||||||
4 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
5 | revised 12-4-07.)"; and
| ||||||
6 | on page 1, line 5, after "Section 370c", by inserting "and | ||||||
7 | adding Section 356z.13"; and | ||||||
8 | on page 1, immediately below line 5, by inserting the | ||||||
9 | following: | ||||||
10 | "(215 ILCS 5/356z.13 new) | ||||||
11 | Sec. 356z.13. Autism spectrum disorders. | ||||||
12 | (a) A group or individual policy of accident and health | ||||||
13 | insurance or managed care plan amended, delivered, issued, or | ||||||
14 | renewed after the effective date of this amendatory Act of the | ||||||
15 | 95th General Assembly must provide individuals under 21 years | ||||||
16 | of age coverage for the diagnosis of autism spectrum disorders | ||||||
17 | and for the treatment of autism spectrum disorders to the | ||||||
18 | extent that the diagnosis and treatment of autism spectrum | ||||||
19 | disorders are not already covered by the policy of accident and | ||||||
20 | health insurance or managed care plan. | ||||||
21 | (b) Coverage provided under this Section shall be subject | ||||||
22 | to a maximum benefit of $36,000 per year, but shall not be |
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| |||||||
1 | subject to any limits on the number of visits to a service | ||||||
2 | provider. After December 30, 2009, the Director of the Division | ||||||
3 | of Insurance shall, on an annual basis, adjust the maximum | ||||||
4 | benefit for inflation using the Medical Care Component of the | ||||||
5 | United States Department of Labor Consumer Price Index for All | ||||||
6 | Urban Consumers. Payments made by an insurer on behalf of a | ||||||
7 | covered individual for any care, treatment, intervention, | ||||||
8 | service, or item, the provision of which was for the treatment | ||||||
9 | of a health condition not diagnosed as an autism spectrum | ||||||
10 | disorder, shall not be applied toward any maximum benefit | ||||||
11 | established under this subsection. | ||||||
12 | (c) Coverage under this Section shall be subject to | ||||||
13 | co-payment, deductible, and coinsurance provisions of a policy | ||||||
14 | of accident and health insurance or managed care plan to the | ||||||
15 | extent that other medical services covered by the policy of | ||||||
16 | accident and health insurance or managed care plan are subject | ||||||
17 | to these provisions. | ||||||
18 | (d) This Section shall not be construed as limiting | ||||||
19 | benefits that are otherwise available to an individual under a | ||||||
20 | policy of accident and health insurance or managed care plan | ||||||
21 | and benefits provided under this Section may not be subject to | ||||||
22 | dollar limits, deductibles, copayments, or coinsurance | ||||||
23 | provisions that are less favorable to the insured than the | ||||||
24 | dollar limits, deductibles, or coinsurance provisions that | ||||||
25 | apply to physical illness generally. | ||||||
26 | (e) An insurer may not deny or refuse to provide otherwise |
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| |||||||
1 | covered services, or refuse to renew, refuse to reissue, or | ||||||
2 | otherwise terminate or restrict coverage under an individual | ||||||
3 | contract to provide services to an individual because the | ||||||
4 | individual or their dependent is diagnosed with an autism | ||||||
5 | spectrum disorder or due to the individual utilizing benefits | ||||||
6 | in this Section. | ||||||
7 | (f) Upon request of the reimbursing insurer, a provider of | ||||||
8 | treatment for autism spectrum disorders shall furnish medical | ||||||
9 | records, clinical notes, or other necessary data that | ||||||
10 | substantiate that initial or continued medical treatment is | ||||||
11 | medically necessary and is resulting in improved clinical | ||||||
12 | status. When treatment is anticipated to require continued | ||||||
13 | services to achieve demonstrable progress, the insurer may | ||||||
14 | request a treatment plan consisting of diagnosis, proposed | ||||||
15 | treatment by type, frequency, anticipated duration of | ||||||
16 | treatment, the anticipated outcomes stated as goals, and the | ||||||
17 | frequency by which the treatment plan will be updated. | ||||||
18 | (g) When making a determination of medical necessity for a | ||||||
19 | treatment modality for autism spectrum disorders, an insurer | ||||||
20 | must make the determination in a manner that is consistent with | ||||||
21 | the manner used to make that determination with respect to | ||||||
22 | other diseases or illnesses covered under the policy, including | ||||||
23 | an appeals process. During the appeals process, any challenge | ||||||
24 | to medical necessity must be viewed as reasonable only if the | ||||||
25 | review includes a physician with expertise in the most current | ||||||
26 | and effective treatment modalities for autism spectrum |
| |||||||
| |||||||
1 | disorders. | ||||||
2 | (h) Coverage for medically necessary early intervention | ||||||
3 | services must be delivered by certified early intervention | ||||||
4 | specialists, as defined in the early intervention operational | ||||||
5 | standards by the Department of Human Services and in accordance | ||||||
6 | with applicable certification requirements. | ||||||
7 | (i) As used in this Section: | ||||||
8 | "Autism spectrum disorders" means pervasive developmental | ||||||
9 | disorders as defined in the most recent edition of the | ||||||
10 | Diagnostic and Statistical Manual of Mental Disorders, | ||||||
11 | including autism, Asperger's disorder, and pervasive | ||||||
12 | developmental disorder not otherwise specified. | ||||||
13 | "Diagnosis of autism spectrum disorders" means a diagnosis | ||||||
14 | of an individual with an autism spectrum disorder by (A) a | ||||||
15 | physician licensed to practice medicine in all its branches or | ||||||
16 | (B) a licensed clinical psychologist with expertise in | ||||||
17 | diagnosing autism spectrum disorders. | ||||||
18 | "Medically necessary" means any care, treatment, | ||||||
19 | intervention, service or item which will or is reasonably | ||||||
20 | expected to do any of the following: (i) prevent the onset of | ||||||
21 | an illness, condition, injury, disease or disability; (ii) | ||||||
22 | reduce or ameliorate the physical, mental or developmental | ||||||
23 | effects of an illness, condition, injury, disease or | ||||||
24 | disability; or (iii) assist to achieve or maintain maximum | ||||||
25 | functional activity in performing daily activities. | ||||||
26 | "Treatment for autism spectrum disorders" shall include |
| |||||||
| |||||||
1 | the following care prescribed, provided, or ordered for an | ||||||
2 | individual diagnosed with an autism spectrum disorder by (A) a | ||||||
3 | physician licensed to practice medicine in all its branches or | ||||||
4 | (B) a certified, registered, or licensed health care | ||||||
5 | professional with expertise in treating effects of autism | ||||||
6 | spectrum disorders when the care is determined to be medically | ||||||
7 | necessary and ordered by a physician licensed to practice | ||||||
8 | medicine in all its branches: | ||||||
9 | (1) Psychiatric care, including diagnostic services. | ||||||
10 | (2) Psychological assessments and treatments. | ||||||
11 | (3) Rehabilitative treatments. | ||||||
12 | (4) Therapeutic care, including behavioral speech, | ||||||
13 | occupational, and physical therapies that provide | ||||||
14 | treatment in the following areas: (i) self care and | ||||||
15 | feeding, (ii) pragmatic, receptive, and expressive | ||||||
16 | language, (iii) cognitive functioning, (iv) applied | ||||||
17 | behavior analysis, intervention, and modification, (v) | ||||||
18 | motor planning, and (vi) sensory processing. "; and | ||||||
19 | on page 7, below line 1, by inserting the following: | ||||||
20 | "Section 10. The Health Maintenance Organization Act is | ||||||
21 | amended by changing Section 5-3 as follows:
| ||||||
22 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
23 | Sec. 5-3. Insurance Code provisions.
|
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| |||||||
1 | (a) Health Maintenance Organizations
shall be subject to | ||||||
2 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
3 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
4 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
5 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10 | ||||||
6 | 356z.9 , 356z.13, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
7 | 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, | ||||||
8 | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||||||
9 | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||||||
10 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| ||||||
11 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
12 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
13 | Maintenance Organizations in
the following categories are | ||||||
14 | deemed to be "domestic companies":
| ||||||
15 | (1) a corporation authorized under the
Dental Service | ||||||
16 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
17 | (2) a corporation organized under the laws of this | ||||||
18 | State; or
| ||||||
19 | (3) a corporation organized under the laws of another | ||||||
20 | state, 30% or more
of the enrollees of which are residents | ||||||
21 | of this State, except a
corporation subject to | ||||||
22 | substantially the same requirements in its state of
| ||||||
23 | organization as is a "domestic company" under Article VIII | ||||||
24 | 1/2 of the
Illinois Insurance Code.
| ||||||
25 | (c) In considering the merger, consolidation, or other | ||||||
26 | acquisition of
control of a Health Maintenance Organization |
| |||||||
| |||||||
1 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
2 | (1) the Director shall give primary consideration to | ||||||
3 | the continuation of
benefits to enrollees and the financial | ||||||
4 | conditions of the acquired Health
Maintenance Organization | ||||||
5 | after the merger, consolidation, or other
acquisition of | ||||||
6 | control takes effect;
| ||||||
7 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
8 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
9 | apply and (ii) the Director, in making
his determination | ||||||
10 | with respect to the merger, consolidation, or other
| ||||||
11 | acquisition of control, need not take into account the | ||||||
12 | effect on
competition of the merger, consolidation, or | ||||||
13 | other acquisition of control;
| ||||||
14 | (3) the Director shall have the power to require the | ||||||
15 | following
information:
| ||||||
16 | (A) certification by an independent actuary of the | ||||||
17 | adequacy
of the reserves of the Health Maintenance | ||||||
18 | Organization sought to be acquired;
| ||||||
19 | (B) pro forma financial statements reflecting the | ||||||
20 | combined balance
sheets of the acquiring company and | ||||||
21 | the Health Maintenance Organization sought
to be | ||||||
22 | acquired as of the end of the preceding year and as of | ||||||
23 | a date 90 days
prior to the acquisition, as well as pro | ||||||
24 | forma financial statements
reflecting projected | ||||||
25 | combined operation for a period of 2 years;
| ||||||
26 | (C) a pro forma business plan detailing an |
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| |||||||
1 | acquiring party's plans with
respect to the operation | ||||||
2 | of the Health Maintenance Organization sought to
be | ||||||
3 | acquired for a period of not less than 3 years; and
| ||||||
4 | (D) such other information as the Director shall | ||||||
5 | require.
| ||||||
6 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
7 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
8 | any health maintenance
organization of greater than 10% of its
| ||||||
9 | enrollee population (including without limitation the health | ||||||
10 | maintenance
organization's right, title, and interest in and to | ||||||
11 | its health care
certificates).
| ||||||
12 | (e) In considering any management contract or service | ||||||
13 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
14 | Code, the Director (i) shall, in
addition to the criteria | ||||||
15 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
16 | into account the effect of the management contract or
service | ||||||
17 | agreement on the continuation of benefits to enrollees and the
| ||||||
18 | financial condition of the health maintenance organization to | ||||||
19 | be managed or
serviced, and (ii) need not take into account the | ||||||
20 | effect of the management
contract or service agreement on | ||||||
21 | competition.
| ||||||
22 | (f) Except for small employer groups as defined in the | ||||||
23 | Small Employer
Rating, Renewability and Portability Health | ||||||
24 | Insurance Act and except for
medicare supplement policies as | ||||||
25 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
26 | Maintenance Organization may by contract agree with a
group or |
| |||||||
| |||||||
1 | other enrollment unit to effect refunds or charge additional | ||||||
2 | premiums
under the following terms and conditions:
| ||||||
3 | (i) the amount of, and other terms and conditions with | ||||||
4 | respect to, the
refund or additional premium are set forth | ||||||
5 | in the group or enrollment unit
contract agreed in advance | ||||||
6 | of the period for which a refund is to be paid or
| ||||||
7 | additional premium is to be charged (which period shall not | ||||||
8 | be less than one
year); and
| ||||||
9 | (ii) the amount of the refund or additional premium | ||||||
10 | shall not exceed 20%
of the Health Maintenance | ||||||
11 | Organization's profitable or unprofitable experience
with | ||||||
12 | respect to the group or other enrollment unit for the | ||||||
13 | period (and, for
purposes of a refund or additional | ||||||
14 | premium, the profitable or unprofitable
experience shall | ||||||
15 | be calculated taking into account a pro rata share of the
| ||||||
16 | Health Maintenance Organization's administrative and | ||||||
17 | marketing expenses, but
shall not include any refund to be | ||||||
18 | made or additional premium to be paid
pursuant to this | ||||||
19 | subsection (f)). The Health Maintenance Organization and | ||||||
20 | the
group or enrollment unit may agree that the profitable | ||||||
21 | or unprofitable
experience may be calculated taking into | ||||||
22 | account the refund period and the
immediately preceding 2 | ||||||
23 | plan years.
| ||||||
24 | The Health Maintenance Organization shall include a | ||||||
25 | statement in the
evidence of coverage issued to each enrollee | ||||||
26 | describing the possibility of a
refund or additional premium, |
| |||||||
| |||||||
1 | and upon request of any group or enrollment unit,
provide to | ||||||
2 | the group or enrollment unit a description of the method used | ||||||
3 | to
calculate (1) the Health Maintenance Organization's | ||||||
4 | profitable experience with
respect to the group or enrollment | ||||||
5 | unit and the resulting refund to the group
or enrollment unit | ||||||
6 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
7 | experience with respect to the group or enrollment unit and the | ||||||
8 | resulting
additional premium to be paid by the group or | ||||||
9 | enrollment unit.
| ||||||
10 | In no event shall the Illinois Health Maintenance | ||||||
11 | Organization
Guaranty Association be liable to pay any | ||||||
12 | contractual obligation of an
insolvent organization to pay any | ||||||
13 | refund authorized under this Section.
| ||||||
14 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
15 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
16 | Section 15. The Voluntary Health Services Plans Act is | ||||||
17 | amended by changing Section 10 as follows:
| ||||||
18 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
19 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
20 | services
plan corporations and all persons interested therein | ||||||
21 | or dealing therewith
shall be subject to the provisions of | ||||||
22 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
23 | 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, |
| |||||||
| |||||||
1 | 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, | ||||||
2 | 356z.9,
356z.10 356z.9 , 356z.13, 364.01, 367.2, 368a, 401, | ||||||
3 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
4 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
5 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
6 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
7 | 8-28-07; revised 12-5-07.)".
| ||||||
8 | Date: _________________, 2008 ___________________________
|