Rep. Elizabeth Coulson
Filed: 4/10/2008
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1 | AMENDMENT TO HOUSE BILL 5595
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2 | AMENDMENT NO. ______. Amend House Bill 5595, AS AMENDED, by | ||||||
3 | replacing everything after the enacting clause with the | ||||||
4 | following:
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5 | "Section 5. The State Employees Group Insurance Act of 1971 | ||||||
6 | is amended by changing Section 6.11 as follows:
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7 | (5 ILCS 375/6.11)
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8 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
9 | Code
requirements. The program of health
benefits shall provide | ||||||
10 | the post-mastectomy care benefits required to be covered
by a | ||||||
11 | policy of accident and health insurance under Section 356t of | ||||||
12 | the Illinois
Insurance Code. The program of health benefits | ||||||
13 | shall provide the coverage
required under Sections 356g.5,
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14 | 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, | ||||||
15 | and 356z.11 and 356z.9 of the
Illinois Insurance Code.
The | ||||||
16 | program of health benefits must comply with Section 155.37 of |
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1 | the
Illinois Insurance Code.
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2 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
3 | 95-520, eff. 8-28-07; revised 12-4-07.)
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4 | Section 10. The Counties Code is amended by changing | ||||||
5 | Section 5-1069.3 as follows: | ||||||
6 | (55 ILCS 5/5-1069.3)
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7 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
8 | including a home
rule
county, is a self-insurer for purposes of | ||||||
9 | providing health insurance coverage
for its employees, the | ||||||
10 | coverage shall include coverage for the post-mastectomy
care | ||||||
11 | benefits required to be covered by a policy of accident and | ||||||
12 | health
insurance under Section 356t and the coverage required | ||||||
13 | under Sections 356g.5, 356u,
356w, 356x, 356z.6, and 356z.9, | ||||||
14 | 356z.10, and 356z.11 and 356z.9 of
the Illinois Insurance Code. | ||||||
15 | The requirement that health benefits be covered
as provided in | ||||||
16 | this Section is an
exclusive power and function of the State | ||||||
17 | and is a denial and limitation under
Article VII, Section 6, | ||||||
18 | subsection (h) of the Illinois Constitution. A home
rule county | ||||||
19 | to which this Section applies must comply with every provision | ||||||
20 | of
this Section.
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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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23 | Section 15. The Illinois Municipal Code is amended by |
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1 | changing Section 10-4-2.3 as follows: | ||||||
2 | (65 ILCS 5/10-4-2.3)
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3 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
4 | municipality, including a
home rule municipality, is a | ||||||
5 | self-insurer for purposes of providing health
insurance | ||||||
6 | coverage for its employees, the coverage shall include coverage | ||||||
7 | for
the post-mastectomy care benefits required to be covered by | ||||||
8 | a policy of
accident and health insurance under Section 356t | ||||||
9 | and the coverage required
under Sections 356g.5, 356u, 356w, | ||||||
10 | 356x, 356z.6, and 356z.9, 356z.10, and 356z.11 and 356z.9 of | ||||||
11 | the Illinois
Insurance
Code. The requirement that health
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12 | benefits be covered as provided in this is an exclusive power | ||||||
13 | and function of
the State and is a denial and limitation under | ||||||
14 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
15 | Constitution. A home rule municipality to which
this Section | ||||||
16 | applies must comply with every provision of this Section.
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17 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
18 | 95-520, eff. 8-28-07; revised 12-4-07.)
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19 | Section 20. The School Code is amended by changing Section | ||||||
20 | 10-22.3f as follows: | ||||||
21 | (105 ILCS 5/10-22.3f)
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22 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
23 | protection and
benefits
for employees shall provide the |
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1 | post-mastectomy care benefits required to be
covered by a | ||||||
2 | policy of accident and health insurance under Section 356t and | ||||||
3 | the
coverage required under Sections 356g.5, 356u, 356w, 356x,
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4 | 356z.6, and 356z.9 , and 356z.11 of
the
Illinois Insurance Code.
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5 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
6 | revised 12-4-07.)
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7 | Section 25. The Illinois Insurance Code is amended by | ||||||
8 | adding Section 356z.11 as follows: | ||||||
9 | (215 ILCS 5/356z.11 new) | ||||||
10 | Sec. 356z.11. Habilitative services for children. | ||||||
11 | (a) As used in this Section, "habilitative services" means | ||||||
12 | occupational therapy, physical therapy, speech therapy, and | ||||||
13 | other services prescribed by the insured's treating physician | ||||||
14 | pursuant to a treatment plan to enhance the ability of a child | ||||||
15 | to function with a congenital, genetic, or early acquired | ||||||
16 | disorder. A congenital or genetic disorder includes, but is not | ||||||
17 | limited to, hereditary disorders. An early acquired disorder | ||||||
18 | refers to a disorder resulting from illness, trauma, injury, or | ||||||
19 | some other event or condition suffered by a child prior to that | ||||||
20 | child developing functional life skills such as, but not | ||||||
21 | limited to, walking, talking, or self-help skills. Congenital, | ||||||
22 | genetic, and early acquired disorders may include, but are not | ||||||
23 | limited to, autism or an autism spectrum disorder, cerebral | ||||||
24 | palsy, and other disorders resulting from early childhood |
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1 | illness, trauma, or injury. | ||||||
2 | (b) A group or individual policy of accident and health | ||||||
3 | insurance or managed care plan amended, delivered, issued, or | ||||||
4 | renewed after the effective date of this amendatory Act of the | ||||||
5 | 95th General Assembly must provide coverage for habilitative | ||||||
6 | services for children under 19 years of age with a congenital, | ||||||
7 | genetic, or early acquired disorder so long as all of the | ||||||
8 | following conditions are met: | ||||||
9 | (1) A physician licensed to practice medicine in all | ||||||
10 | its branches has: | ||||||
11 | (A) diagnosed the child's congenital, genetic, or | ||||||
12 | early acquired disorder; and | ||||||
13 | (B) determined the treatment to be therapeutic and | ||||||
14 | not solely experimental or investigational. | ||||||
15 | (2) The treatment is administered under the | ||||||
16 | supervision of a physician licensed to practice medicine in | ||||||
17 | all its branches. | ||||||
18 | (c) The coverage required by this Section shall be subject | ||||||
19 | to other general exclusions and limitations of the policy, | ||||||
20 | including coordination of benefits, participating provider | ||||||
21 | requirements, restrictions on services provided by family or | ||||||
22 | household members, utilization review of health care services, | ||||||
23 | including review of medical necessity, case management, | ||||||
24 | experimental, and investigational treatments, and other | ||||||
25 | managed care provisions. | ||||||
26 | (d) Upon request of the reimbursing insurer, the provider |
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1 | under whose supervision the habilitative services are being | ||||||
2 | provided shall furnish medical records, clinical notes, or | ||||||
3 | other necessary data to allow the insurer to substantiate that | ||||||
4 | initial or continued medical treatment is medically necessary | ||||||
5 | and that the patient's condition is clinically improving. When | ||||||
6 | the treating provider anticipates that continued treatment is | ||||||
7 | or will be required to permit the patient to achieve | ||||||
8 | demonstrable progress, the insurer may request that the | ||||||
9 | provider furnish a treatment plan consisting of diagnosis, | ||||||
10 | proposed treatment by type, frequency, anticipated duration of | ||||||
11 | treatment, the anticipated goals of treatment, and how | ||||||
12 | frequently the treatment plan will be updated. | ||||||
13 | (e) Notwithstanding any other rulemaking authority that | ||||||
14 | may exist, neither the Governor nor any agency or agency head | ||||||
15 | under the jurisdiction of the Governor has any authority to | ||||||
16 | make or promulgate rules to implement or enforce the provisions | ||||||
17 | of this amendatory Act of the 95th General Assembly. If, | ||||||
18 | however, the Governor believes that rules are necessary to | ||||||
19 | implement or enforce the provisions of this amendatory Act of | ||||||
20 | the 95th General Assembly, the Governor may suggest rules to | ||||||
21 | the General Assembly by filing them with the Clerk of the House | ||||||
22 | and the Secretary of the Senate and by requesting that the | ||||||
23 | General Assembly authorize such rulemaking by law, enact those | ||||||
24 | suggested rules into law, or take any other appropriate action | ||||||
25 | in the General Assembly's discretion. Nothing contained in this | ||||||
26 | amendatory Act of the 95th General Assembly shall be |
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1 | interpreted to grant rulemaking authority under any other | ||||||
2 | Illinois statute where such authority is not otherwise | ||||||
3 | explicitly given. For the purposes of this amendatory Act of | ||||||
4 | the 95th General Assembly, "rules" is given the meaning | ||||||
5 | contained in Section 1-70 of the Illinois Administrative | ||||||
6 | Procedure Act, and "agency" and "agency head" are given the | ||||||
7 | meanings contained in Sections 1-20 and 1-25 of the Illinois | ||||||
8 | Administrative Procedure Act to the extent that such | ||||||
9 | definitions apply to agencies or agency heads under the | ||||||
10 | jurisdiction of the Governor. | ||||||
11 | Section 30. The Health Maintenance Organization Act is | ||||||
12 | amended by changing Section 5-3 as follows:
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13 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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14 | Sec. 5-3. Insurance Code provisions.
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15 | (a) Health Maintenance Organizations
shall be subject to | ||||||
16 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
17 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
18 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
19 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
20 | 356z.11 356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | ||||||
21 | 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, | ||||||
22 | 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section | ||||||
23 | 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, | ||||||
24 | XXV, and XXVI of the Illinois Insurance Code.
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1 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
2 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
3 | Maintenance Organizations in
the following categories are | ||||||
4 | deemed to be "domestic companies":
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5 | (1) a corporation authorized under the
Dental Service | ||||||
6 | Plan Act or the Voluntary Health Services Plans Act;
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7 | (2) a corporation organized under the laws of this | ||||||
8 | State; or
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9 | (3) a corporation organized under the laws of another | ||||||
10 | state, 30% or more
of the enrollees of which are residents | ||||||
11 | of this State, except a
corporation subject to | ||||||
12 | substantially the same requirements in its state of
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13 | organization as is a "domestic company" under Article VIII | ||||||
14 | 1/2 of the
Illinois Insurance Code.
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15 | (c) In considering the merger, consolidation, or other | ||||||
16 | acquisition of
control of a Health Maintenance Organization | ||||||
17 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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18 | (1) the Director shall give primary consideration to | ||||||
19 | the continuation of
benefits to enrollees and the financial | ||||||
20 | conditions of the acquired Health
Maintenance Organization | ||||||
21 | after the merger, consolidation, or other
acquisition of | ||||||
22 | control takes effect;
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23 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
24 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
25 | apply and (ii) the Director, in making
his determination | ||||||
26 | with respect to the merger, consolidation, or other
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1 | acquisition of control, need not take into account the | ||||||
2 | effect on
competition of the merger, consolidation, or | ||||||
3 | other acquisition of control;
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4 | (3) the Director shall have the power to require the | ||||||
5 | following
information:
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6 | (A) certification by an independent actuary of the | ||||||
7 | adequacy
of the reserves of the Health Maintenance | ||||||
8 | Organization sought to be acquired;
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9 | (B) pro forma financial statements reflecting the | ||||||
10 | combined balance
sheets of the acquiring company and | ||||||
11 | the Health Maintenance Organization sought
to be | ||||||
12 | acquired as of the end of the preceding year and as of | ||||||
13 | a date 90 days
prior to the acquisition, as well as pro | ||||||
14 | forma financial statements
reflecting projected | ||||||
15 | combined operation for a period of 2 years;
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16 | (C) a pro forma business plan detailing an | ||||||
17 | acquiring party's plans with
respect to the operation | ||||||
18 | of the Health Maintenance Organization sought to
be | ||||||
19 | acquired for a period of not less than 3 years; and
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20 | (D) such other information as the Director shall | ||||||
21 | require.
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22 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
23 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
24 | any health maintenance
organization of greater than 10% of its
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25 | enrollee population (including without limitation the health | ||||||
26 | maintenance
organization's right, title, and interest in and to |
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1 | its health care
certificates).
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2 | (e) In considering any management contract or service | ||||||
3 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
4 | Code, the Director (i) shall, in
addition to the criteria | ||||||
5 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
6 | into account the effect of the management contract or
service | ||||||
7 | agreement on the continuation of benefits to enrollees and the
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8 | financial condition of the health maintenance organization to | ||||||
9 | be managed or
serviced, and (ii) need not take into account the | ||||||
10 | effect of the management
contract or service agreement on | ||||||
11 | competition.
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12 | (f) Except for small employer groups as defined in the | ||||||
13 | Small Employer
Rating, Renewability and Portability Health | ||||||
14 | Insurance Act and except for
medicare supplement policies as | ||||||
15 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
16 | Maintenance Organization may by contract agree with a
group or | ||||||
17 | other enrollment unit to effect refunds or charge additional | ||||||
18 | premiums
under the following terms and conditions:
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19 | (i) the amount of, and other terms and conditions with | ||||||
20 | respect to, the
refund or additional premium are set forth | ||||||
21 | in the group or enrollment unit
contract agreed in advance | ||||||
22 | of the period for which a refund is to be paid or
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23 | additional premium is to be charged (which period shall not | ||||||
24 | be less than one
year); and
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25 | (ii) the amount of the refund or additional premium | ||||||
26 | shall not exceed 20%
of the Health Maintenance |
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1 | Organization's profitable or unprofitable experience
with | ||||||
2 | respect to the group or other enrollment unit for the | ||||||
3 | period (and, for
purposes of a refund or additional | ||||||
4 | premium, the profitable or unprofitable
experience shall | ||||||
5 | be calculated taking into account a pro rata share of the
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6 | Health Maintenance Organization's administrative and | ||||||
7 | marketing expenses, but
shall not include any refund to be | ||||||
8 | made or additional premium to be paid
pursuant to this | ||||||
9 | subsection (f)). The Health Maintenance Organization and | ||||||
10 | the
group or enrollment unit may agree that the profitable | ||||||
11 | or unprofitable
experience may be calculated taking into | ||||||
12 | account the refund period and the
immediately preceding 2 | ||||||
13 | plan years.
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14 | The Health Maintenance Organization shall include a | ||||||
15 | statement in the
evidence of coverage issued to each enrollee | ||||||
16 | describing the possibility of a
refund or additional premium, | ||||||
17 | and upon request of any group or enrollment unit,
provide to | ||||||
18 | the group or enrollment unit a description of the method used | ||||||
19 | to
calculate (1) the Health Maintenance Organization's | ||||||
20 | profitable experience with
respect to the group or enrollment | ||||||
21 | unit and the resulting refund to the group
or enrollment unit | ||||||
22 | or (2) the Health Maintenance Organization's unprofitable
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23 | experience with respect to the group or enrollment unit and the | ||||||
24 | resulting
additional premium to be paid by the group or | ||||||
25 | enrollment unit.
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26 | In no event shall the Illinois Health Maintenance |
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1 | Organization
Guaranty Association be liable to pay any | ||||||
2 | contractual obligation of an
insolvent organization to pay any | ||||||
3 | refund authorized under this Section.
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4 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
5 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
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6 | Section 35. The Voluntary Health Services Plans Act is | ||||||
7 | amended by changing Section 10 as follows:
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8 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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9 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
10 | services
plan corporations and all persons interested therein | ||||||
11 | or dealing therewith
shall be subject to the provisions of | ||||||
12 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
13 | 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, | ||||||
14 | 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, | ||||||
15 | 356z.9,
356z.10, 356z.11 356z.9 , 364.01, 367.2, 368a, 401, | ||||||
16 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
17 | and (15) of Section 367 of the Illinois
Insurance Code.
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18 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
19 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
20 | 8-28-07; revised 12-5-07.)
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21 | Section 90. The State Mandates Act is amended by adding | ||||||
22 | Section 8.32 as follows: |
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1 | (30 ILCS 805/8.32 new) | ||||||
2 | Sec. 8.32. Exempt mandate. Notwithstanding Sections 6 and 8 | ||||||
3 | of this Act, no reimbursement by the State is required for the | ||||||
4 | implementation of any mandate created by this amendatory Act of | ||||||
5 | the 95th General Assembly. ".
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