95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
SB1900


 
Introduced 1/10/2008, by Sen. James A. DeLeo
 
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.11 new





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


215 ILCS 130/4003
  from Ch. 73, par. 1504-3


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


305 ILCS 5/5-16.8









    Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Illinois Insurance Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, the Voluntary Health Services Plans Act, and the Illinois Public Aid Code to provide coverage for autism spectrum disorders to the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by the policy or plan.  Provides that this coverage shall be subject to a maximum benefit of $36,000 per year, but shall not be subject to any limits on the number of visits to an autism service provider. Makes other changes.  Effective immediately.
















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FISCAL NOTE ACT MAY APPLY


STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT
















 


 


A BILL FOR









 











SB1900

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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 356g.5,

13
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, 
14
and 356z.11
356z.9 of the
Illinois Insurance Code.
The program 
15
of health benefits must comply with Section 155.37 of the

16
Illinois 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; revised 12-4-07.)



 
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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1
    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, and 356z.9, 
8
356z.10, and
356z.11 356z.9 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; revised 12-4-07.)


 
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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1
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, and 356z.9, 356z.10, and  356z.11
356z.9 of the 
4
Illinois
Insurance
Code.  The requirement that health
benefits 
5
be covered as provided in this is an exclusive power and 
6
function of
the State and is a denial and limitation under 
7
Article VII, Section 6,
subsection (h) of the Illinois 
8
Constitution.  A home rule municipality to which
this Section 
9
applies must comply with 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; revised 12-4-07.)


 
12
    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.11 of
the
Illinois Insurance Code.


21
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
22
revised 12-4-07.)


 
23
    Section 25. The Illinois Insurance Code is amended  by 
 


 






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1
adding Section 356z.11 as follows:
 
2
    (215 ILCS 5/356z.11 new)

3
    Sec. 356z.11. 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 an autism 
16
service provider. After December 30, 2009, the Director of the 
17
Division of Insurance shall, on an annual basis, adjust the 
18
maximum benefit for inflation using the Medical Care Component 
19
of the United States Department of Labor Consumer Price Index 
20
for All Urban Consumers.  Payments made by an insurer on behalf 
21
of a covered individual for any care, treatment, intervention, 
22
service, or item, the provision of which was for the treatment 
23
of a health condition unrelated to the covered individual's 
24
autism spectrum disorder, shall not be applied toward any 
25
maximum benefit established under this subsection.
 


 






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1
    (c) Coverage under this Section shall be subject to 
2
co-payment, 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 which are otherwise available to an individual under a 
9
policy of accident and health insurance or managed care plan.
10
    (e)  As used in this Section:
11
    "Autism service provider" means any person, entity, or 
12
group that provides treatment of autism spectrum disorders.
13
    "Autism spectrum disorders" means any of the pervasive 
14
developmental disorders as defined in the most recent edition 
15
of the Diagnostic and Statistical Manual of Mental Disorders, 
16
including autistic disorder, Asperger's disorder, and 
17
pervasive developmental disorder not otherwise specified.
18
    "Diagnosis of autism spectrum disorders" means medically 
19
necessary assessments, evaluations, or tests in order to 
20
diagnose whether an individual has an autism spectrum disorder.
21
    "Treatment for autism spectrum disorders" shall include 
22
the following care prescribed, provided, or ordered for an 
23
individual diagnosed with an autism spectrum disorder by a 
24
licensed physician, licensed psychologist, or certified 
25
registered nurse practitioner if the care is determined to be 
26
medically necessary:
 


 






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        (i)  Psychiatric care.
2
        (ii) Psychological care.
3
        (iii)  Rehabilitative care.
4
        (iv)  Therapeutic care, including speech, occupational, 
5
    and physical therapy.
6
        (v)  Pharmacy care.
7
        (vi)  Applied behavior analysis therapy.
8
        (vii)  Any care, treatment, intervention, service or 
9
    item for individuals with an autism spectrum disorder which 
10
    is determined by the Department of Health Care and Family 
11
    Services, based upon its review of best practices or 
12
    evidenced-based research, to be medically necessary.


 
13
    Section 30. The Health Maintenance Organization Act is 
14
amended  by changing Section 5-3 as follows:
 


15
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)


16
    Sec. 5-3. Insurance Code provisions. 

17
    (a) Health Maintenance Organizations
shall be subject to 
18
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
19
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
20
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
21
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10

22
356z.9, 356z.11, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 
23
368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 
24
409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of 
 


 






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1
Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, 
2
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 
 


 






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1
    apply and (ii) the Director, in making
his determination 
2
    with respect to the merger, consolidation, or other

3
    acquisition of control, need not take into account the 
4
    effect on
competition of the merger, consolidation, or 
5
    other acquisition of control;


6
        (3) the Director shall have the power to require the 
7
    following
information:


8
            (A) certification by an independent actuary of the 
9
        adequacy
of the reserves of the Health Maintenance 
10
        Organization sought to be acquired;


11
            (B) pro forma financial statements reflecting the 
12
        combined balance
sheets of the acquiring company and 
13
        the Health Maintenance Organization sought
to be 
14
        acquired as of the end of the preceding year and as of 
15
        a date 90 days
prior to the acquisition, as well as pro 
16
        forma financial statements
reflecting projected 
17
        combined operation for a period of 2 years;


18
            (C) a pro forma business plan detailing an 
19
        acquiring party's plans with
respect to the operation 
20
        of the Health Maintenance Organization sought to
be 
21
        acquired for a period of not less than 3 years; and


22
            (D) such other information as the Director shall 
23
        require.

24
    (d) The provisions of Article VIII 1/2 of the Illinois 
25
Insurance Code
and this Section 5-3 shall apply to the sale by 
26
any health maintenance
organization of greater than 10% of its

 


 






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1
enrollee population (including without limitation the health 
2
maintenance
organization's right, title, and interest in and to 
3
its health care
certificates).

4
    (e) In considering any management contract or service 
5
agreement subject
to Section 141.1 of the Illinois Insurance 
6
Code, the Director (i) shall, in
addition to the criteria 
7
specified in Section 141.2 of the Illinois
Insurance Code, take 
8
into account the effect of the management contract or
service 
9
agreement on the continuation of benefits to enrollees and the

10
financial condition of the health maintenance organization to 
11
be managed or
serviced, and (ii) need not take into account the 
12
effect of the management
contract or service agreement on 
13
competition.

14
    (f) Except for small employer groups as defined in the 
15
Small Employer
Rating, Renewability and Portability Health 
16
Insurance Act and except for
medicare supplement policies as 
17
defined in Section 363 of the Illinois
Insurance Code, a Health 
18
Maintenance Organization may by contract agree with a
group or 
19
other enrollment unit to effect refunds or charge additional 
20
premiums
under the following terms and conditions:


21
        (i) the amount of, and other terms and conditions with 
22
    respect to, the
refund or additional premium are set forth 
23
    in the group or enrollment unit
contract agreed in advance 
24
    of the period for which a refund is to be paid or

25
    additional premium is to be charged (which period shall not 
26
    be less than one
year); and


 


 






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        (ii) the amount of the refund or additional premium 
2
    shall not exceed 20%
of the Health Maintenance 
3
    Organization's profitable or unprofitable experience
with 
4
    respect to the group or other enrollment unit for the 
5
    period (and, for
purposes of a refund or additional 
6
    premium, the profitable or unprofitable
experience shall 
7
    be calculated taking into account a pro rata share of the

8
    Health Maintenance Organization's administrative and 
9
    marketing expenses, but
shall not include any refund to be 
10
    made or additional premium to be paid
pursuant to this 
11
    subsection (f)).  The Health Maintenance Organization and 
12
    the
group or enrollment unit may agree that the profitable 
13
    or unprofitable
experience may be calculated taking into 
14
    account the refund period and the
immediately preceding 2 
15
    plan years.

16
    The Health Maintenance Organization shall include a 
17
statement in the
evidence of coverage issued to each enrollee 
18
describing the possibility of a
refund or additional premium, 
19
and upon request of any group or enrollment unit,
provide to 
20
the group or enrollment unit a description of the method used 
21
to
calculate (1) the Health Maintenance Organization's 
22
profitable experience with
respect to the group or enrollment 
23
unit and the resulting refund to the group
or enrollment unit 
24
or (2) the Health Maintenance Organization's unprofitable

25
experience with respect to the group or enrollment unit and the 
26
resulting
additional premium to be paid by the group or 
 


 






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1
enrollment unit.

2
    In no event shall the Illinois Health Maintenance 
3
Organization
Guaranty Association be liable to pay any 
4
contractual obligation of an
insolvent organization to pay any 
5
refund authorized under this Section.

6
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; 
7
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)


 
8
    Section 35. The Limited Health Service Organization Act is 
9
amended  by changing Section 4003 as follows:
 



10
    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)


11
    Sec. 4003. Illinois Insurance Code provisions. Limited 
12
health service
organizations shall be subject to the provisions 
13
of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, 
14
147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, 
15
155.04, 155.37, 355.2, 356v, 356z.10
356z.9, 356z.11, 368a, 
16
401, 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and 
17
444.1 and Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, 
18
XXV, and XXVI of the Illinois Insurance Code.  For purposes of 
19
the
Illinois Insurance Code, except for Sections 444 and 444.1 
20
and Articles XIII
and XIII 1/2, limited health service 
21
organizations in the following categories
are deemed to be 
22
domestic companies:


23
        (1) a corporation under the laws of this State; or


24
        (2) a corporation organized under the laws of another 
 


 






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1
    state, 30% of more
of the enrollees of which are residents 
2
    of this State, except a corporation
subject to 
3
    substantially the same requirements in its state of 
4
    organization as
is a domestic company under Article VIII 
5
    1/2 of the Illinois Insurance Code.

6
(Source: P.A. 95-520, eff. 8-28-07; revised 12-5-07.)


 
7
    Section 40. The Voluntary Health Services Plans Act is 
8
amended  by changing Section 10 as follows:
 



9
    (215 ILCS 165/10)  (from Ch. 32, par. 604)


10
    Sec. 10. Application of Insurance Code provisions. Health 
11
services
plan corporations and all persons interested therein 
12
or dealing therewith
shall be subject to the provisions of 
13
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
14
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, 
15
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 
16
356z.9,
356z.10
356z.9, 356z.11, 364.01, 367.2, 368a, 401, 
17
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) 
18
and (15) of Section 367 of the Illinois
Insurance Code.

19
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; 
20
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. 
21
8-28-07; revised 12-5-07.)


 
22
    Section 45. The Illinois Public Aid Code is amended  by 
23
changing Section 5-16.8 as follows:
 



 


 






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1
    (305 ILCS 5/5-16.8)


2
    Sec. 5-16.8. Required health benefits. The medical 
3
assistance program
shall
(i) provide the post-mastectomy care 
4
benefits required to be covered by a policy of
accident and 
5
health insurance under Section 356t and the coverage required

6
under Sections 356g.5, 356u, 356w, 356x, and 356z.6, and 
7
356z.11 of the Illinois
Insurance Code and (ii) be subject to 
8
the provisions of Section 364.01 of the Illinois
Insurance 
9
Code.

10
(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07.)


 

11
    Section 99. Effective date. This Act takes effect upon 
12
becoming law.