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    AN ACT concerning health.

 
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 356g.5,

13
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, and 356z.10, 
14
and 356z.14
 of the
Illinois Insurance Code.
The program of 
15
health benefits must comply with Section 155.37 of the
Illinois 
16
Insurance Code.

17
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
18
95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)

 
19
    Section 10. The Counties Code is amended  by changing 
20
Section 5-1069.3 as follows:
 
21
    (55 ILCS 5/5-1069.3)

 


 






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    Sec. 5-1069.3. Required health benefits.   If a county, 
2
including a home
rule
county, is a self-insurer for purposes of 
3
providing health insurance coverage
for its employees, the 
4
coverage shall include coverage for the post-mastectomy
care 
5
benefits required to be covered by a policy of accident and 
6
health
insurance under Section 356t and the coverage required 
7
under Sections 356g.5, 356u,
356w, 356x, 356z.6, 356z.9, and 
8
356z.10, and 356z.14
 of
the Illinois Insurance Code.  The 
9
requirement that health benefits be covered
as provided in this 
10
Section is an
exclusive power and function of the State and is 
11
a denial and limitation under
Article VII, Section 6, 
12
subsection (h) of the Illinois Constitution.  A home
rule county 
13
to which this Section applies must comply with every provision 
14
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; 95-876, eff. 8-21-08.)

 
17
    Section 15. The Illinois Municipal Code is amended  by 
18
changing Section 10-4-2.3 as follows:
 
19
    (65 ILCS 5/10-4-2.3)

20
    Sec. 10-4-2.3. Required health benefits.   If a 
21
municipality, including a
home rule municipality, is a 
22
self-insurer for purposes of providing health
insurance 
23
coverage for its employees, the coverage shall include coverage 
24
for
the post-mastectomy care benefits required to be covered by 
 


 






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a policy of
accident and health insurance under Section 356t 
2
and the coverage required
under Sections 356g.5, 356u, 356w, 
3
356x, 356z.6, 356z.9, and  356z.10, and 356z.14
 of the Illinois

4
Insurance
Code.  The requirement that health
benefits be covered 
5
as provided in this is an exclusive power and function of
the 
6
State and is a denial and limitation under Article VII, Section 
7
6,
subsection (h) of the Illinois Constitution.  A home rule 
8
municipality to which
this Section applies must comply with 
9
every provision of this Section.


10
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
11
95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)

 
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    Section 20. The School Code is amended  by changing Section 
13
10-22.3f as follows:
 
14
    (105 ILCS 5/10-22.3f)

15
    Sec. 10-22.3f. Required health benefits.   Insurance 
16
protection and
benefits
for employees shall provide the 
17
post-mastectomy care benefits required to be
covered by a 
18
policy of accident and health insurance under Section 356t and 
19
the
coverage required under Sections 356g.5, 356u, 356w, 356x,


20
356z.6, and 356z.9, and 356z.14 of
the
Illinois Insurance Code.


21
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
22
95-876, eff. 8-21-08.)

 
23
    Section 25. The Illinois Insurance Code is amended  by 
 


 






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adding Section 356z.14 as follows:
 
2
    (215 ILCS 5/356z.14  new)
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    Sec. 356z.14. Autism spectrum disorders.
4
    (a)  A group or individual policy of accident and health 
5
insurance or managed care plan amended, delivered, issued, or 
6
renewed after the effective date of this amendatory Act of the 
7
95th General Assembly must provide individuals under 21 years 
8
of age coverage for the diagnosis of autism spectrum disorders 
9
and for the treatment of autism spectrum disorders to the 
10
extent that the diagnosis and treatment of autism spectrum 
11
disorders are not already covered by the policy of accident and 
12
health insurance or managed care plan.
13
    (b) Coverage provided under this Section shall be subject 
14
to a maximum benefit of $36,000 per year, but shall not be 
15
subject to any limits on the number of visits to a service 
16
provider. After December 30, 2009, the Director of the Division 
17
of Insurance shall, on an annual basis, adjust the maximum 
18
benefit for inflation using the Medical Care Component of the 
19
United States Department of Labor Consumer Price Index for All 
20
Urban Consumers.  Payments made by an insurer on behalf of a 
21
covered individual for any care, treatment, intervention, 
22
service, or item, the provision of which was for the treatment 
23
of a health condition not diagnosed as an autism spectrum 
24
disorder, shall not be applied toward any maximum benefit 
25
established under this subsection.
 


 






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    (c) Coverage under this Section shall be subject to 
2
copayment, deductible, and coinsurance provisions of a policy 
3
of accident and health insurance or managed care plan to the 
4
extent that other medical services covered by the policy of 
5
accident and health insurance or managed care plan are subject 
6
to these provisions.
7
    (d)  This Section shall not be construed as limiting 
8
benefits that are otherwise available to an individual under a 
9
policy of accident and health insurance or managed care plan 
10
and benefits provided under this Section may not be subject to 
11
dollar limits, deductibles, copayments, or coinsurance 
12
provisions that are less favorable to the insured than the 
13
dollar limits, deductibles, or coinsurance provisions that 
14
apply to physical illness generally.
15
    (e) An insurer may not deny or refuse to provide otherwise 
16
covered services, or refuse to renew, refuse to reissue, or 
17
otherwise terminate or restrict coverage under an individual 
18
contract to provide services to an individual because the 
19
individual or their dependent is diagnosed with an autism 
20
spectrum disorder or due to the individual utilizing benefits 
21
in this Section.
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    (f) Upon request of the reimbursing insurer, a provider of 
23
treatment for autism spectrum disorders shall furnish medical 
24
records, clinical notes, or other necessary data that 
25
substantiate that initial or continued medical treatment is 
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medically necessary and is resulting in improved clinical 
 


 






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status.  When treatment is anticipated to require continued 
2
services to achieve demonstrable progress, the insurer may 
3
request a treatment plan consisting of diagnosis, proposed 
4
treatment by type, frequency, anticipated duration of 
5
treatment, the anticipated outcomes stated as goals, and the 
6
frequency by which the treatment plan will be updated. 
7
    (g) When making a determination of medical necessity for a 
8
treatment modality for autism spectrum disorders, an insurer 
9
must make the determination in a manner that is consistent with 
10
the manner used to make that determination with respect to 
11
other diseases or illnesses covered under the policy, including 
12
an appeals process.  During the appeals process, any challenge 
13
to medical necessity must be viewed as reasonable only if the 
14
review includes a physician with expertise in the most current 
15
and effective treatment modalities for autism spectrum 
16
disorders.
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    (h) Coverage for medically necessary early intervention 
18
services must be delivered by certified early intervention 
19
specialists, as defined in 89 Ill. Admin. Code 500 and any 
20
subsequent amendments thereto. 
21
    (i)  As used in this Section:
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    "Autism spectrum disorders" means pervasive developmental 
23
disorders as defined in the most recent edition of the 
24
Diagnostic and Statistical Manual of Mental Disorders, 
25
including autism, Asperger's disorder, and pervasive 
26
developmental disorder not otherwise specified.
 


 






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    "Diagnosis of autism spectrum disorders" means one or more 
2
tests, evaluations, or assessments to diagnose whether an 
3
individual has autism spectrum disorder that is prescribed, 
4
performed, or ordered by (A) a physician licensed to practice 
5
medicine in all its branches or (B) a licensed clinical 
6
psychologist with expertise in diagnosing autism spectrum 
7
disorders.
8
    "Medically necessary" means any care, treatment, 
9
intervention, service or item which will or is reasonably 
10
expected to do any of the following: (i) prevent the onset of 
11
an illness, condition, injury, disease or disability; (ii) 
12
reduce or ameliorate the physical, mental or developmental 
13
effects of an illness, condition, injury, disease or 
14
disability; or (iii) assist to achieve or maintain maximum 
15
functional activity in performing daily activities. 
16
    "Treatment for autism spectrum disorders" shall include 
17
the following care prescribed, provided, or ordered for an 
18
individual diagnosed with an autism spectrum disorder by (A) a 
19
physician licensed to practice medicine in all its branches or 
20
(B) a certified, registered, or licensed health care 
21
professional with expertise in treating effects of autism 
22
spectrum disorders when the care is determined to be medically 
23
necessary and ordered by a physician licensed to practice 
24
medicine in all its branches:
25
        (1)  Psychiatric care, meaning direct, consultative, or 
26
    diagnostic services provided by a licensed psychiatrist.
 


 






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        (2) Psychological care, meaning direct or consultative 
2
    services provided by a licensed psychologist.
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        (3)  Habilitative or rehabilitative care, meaning 
4
    professional, counseling, and guidance services and 
5
    treatment programs, including applied behavior analysis, 
6
    that are intended to develop, maintain, and restore the 
7
    functioning of an individual. As used in this subsection 
8
    (i),  "applied behavior analysis" means the design, 
9
    implementation, and evaluation of environmental 
10
    modifications using behavioral stimuli and consequences to 
11
    produce socially significant improvement in human 
12
    behavior, including the use of direct observation, 
13
    measurement, and functional analysis of the relations 
14
    between environment and behavior.
15
        (4)  Therapeutic care, including behavioral, speech, 
16
    occupational, and physical therapies that provide 
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    treatment in the following areas: (i) self care and 
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    feeding, (ii) pragmatic, receptive, and expressive 
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    language, (iii) cognitive functioning, (iv) applied 
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    behavior analysis, intervention, and modification, (v) 
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    motor planning, and (vi) sensory processing.
22
    (j) Rulemaking authority to implement this amendatory Act 
23
of the 95th General Assembly, if any, is conditioned on the 
24
rules being adopted in accordance with all provisions of the 
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Illinois Administrative Procedure Act and all rules and 
26
procedures of the Joint Committee on Administrative Rules; any 
 


 






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purported rule not so adopted, for whatever reason, is 
2
unauthorized. 
 
3
    Section 30. The Health Maintenance Organization Act is 
4
amended  by changing Section 5-3 as follows:
 


5
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)



6
    Sec. 5-3. Insurance Code provisions. 

7
    (a) Health Maintenance Organizations
shall be subject to 
8
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
9
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
10
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
11
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 
12
356z.14, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 
13
368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 
14
444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, 
15
and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, 
16
and XXVI of the Illinois Insurance Code.

17
    (b) For purposes of the Illinois Insurance Code, except for 
18
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
19
Maintenance Organizations in
the following categories are 
20
deemed to be "domestic companies":


21
        (1) a corporation authorized under the
Dental Service 
22
    Plan Act or the Voluntary Health Services Plans Act;


23
        (2) a corporation organized under the laws of this 
24
    State; or


 


 






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        (3) a corporation organized under the laws of another 
2
    state, 30% or more
of the enrollees of which are residents 
3
    of this State, except a
corporation subject to 
4
    substantially the same requirements in its state of

5
    organization as is a "domestic company" under Article VIII 
6
    1/2 of the
Illinois Insurance Code.

7
    (c) In considering the merger, consolidation, or other 
8
acquisition of
control of a Health Maintenance Organization 
9
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


10
        (1) the Director shall give primary consideration to 
11
    the continuation of
benefits to enrollees and the financial 
12
    conditions of the acquired Health
Maintenance Organization 
13
    after the merger, consolidation, or other
acquisition of 
14
    control takes effect;


15
        (2)(i) the criteria specified in subsection (1)(b) of 
16
    Section 131.8 of
the Illinois Insurance Code shall not 
17
    apply and (ii) the Director, in making
his determination 
18
    with respect to the merger, consolidation, or other

19
    acquisition of control, need not take into account the 
20
    effect on
competition of the merger, consolidation, or 
21
    other acquisition of control;


22
        (3) the Director shall have the power to require the 
23
    following
information:


24
            (A) certification by an independent actuary of the 
25
        adequacy
of the reserves of the Health Maintenance 
26
        Organization sought to be acquired;


 


 






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            (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 
 


 






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be managed or
serviced, and (ii) need not take into account the 
2
effect of the management
contract or service agreement on 
3
competition.

4
    (f) Except for small employer groups as defined in the 
5
Small Employer
Rating, Renewability and Portability Health 
6
Insurance Act and except for
medicare supplement policies as 
7
defined in Section 363 of the Illinois
Insurance Code, a Health 
8
Maintenance Organization may by contract agree with a
group or 
9
other enrollment unit to effect refunds or charge additional 
10
premiums
under the following terms and conditions:


11
        (i) the amount of, and other terms and conditions with 
12
    respect to, the
refund or additional premium are set forth 
13
    in the group or enrollment unit
contract agreed in advance 
14
    of the period for which a refund is to be paid or

15
    additional premium is to be charged (which period shall not 
16
    be less than one
year); and


17
        (ii) the amount of the refund or additional premium 
18
    shall not exceed 20%
of the Health Maintenance 
19
    Organization's profitable or unprofitable experience
with 
20
    respect to the group or other enrollment unit for the 
21
    period (and, for
purposes of a refund or additional 
22
    premium, the profitable or unprofitable
experience shall 
23
    be calculated taking into account a pro rata share of the

24
    Health Maintenance Organization's administrative and 
25
    marketing expenses, but
shall not include any refund to be 
26
    made or additional premium to be paid
pursuant to this 
 


 






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    subsection (f)).  The Health Maintenance Organization and 
2
    the
group or enrollment unit may agree that the profitable 
3
    or unprofitable
experience may be calculated taking into 
4
    account the refund period and the
immediately preceding 2 
5
    plan years.

6
    The Health Maintenance Organization shall include a 
7
statement in the
evidence of coverage issued to each enrollee 
8
describing the possibility of a
refund or additional premium, 
9
and upon request of any group or enrollment unit,
provide to 
10
the group or enrollment unit a description of the method used 
11
to
calculate (1) the Health Maintenance Organization's 
12
profitable experience with
respect to the group or enrollment 
13
unit and the resulting refund to the group
or enrollment unit 
14
or (2) the Health Maintenance Organization's unprofitable

15
experience with respect to the group or enrollment unit and the 
16
resulting
additional premium to be paid by the group or 
17
enrollment unit.

18
    In no event shall the Illinois Health Maintenance 
19
Organization
Guaranty Association be liable to pay any 
20
contractual obligation of an
insolvent organization to pay any 
21
refund authorized under this Section.

22
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; 
23
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. 
24
8-21-08.)

 
25
    Section 35. The Voluntary Health Services Plans Act is 
 


 






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amended  by changing Section 10 as follows:
 



2
    (215 ILCS 165/10)  (from Ch. 32, par. 604)


3
    Sec. 10. Application of Insurance Code provisions. Health 
4
services
plan corporations and all persons interested therein 
5
or dealing therewith
shall be subject to the provisions of 
6
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
7
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, 
8
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 
9
356z.9,
356z.10, 356z.14, 364.01, 367.2, 368a, 401, 401.1,
402,

10
403, 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of 
11
Section 367 of the Illinois
Insurance Code.

12
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; 
13
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. 
14
8-28-07; 95-876, eff. 8-21-08.)


 

15
    Section 99. Effective date. This Act takes effect upon 
16
becoming law.