SB3319 98TH GENERAL ASSEMBLY

LRB098 18154 RPM 55351 b

98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB3319

Introduced 2/14/2014, by Sen. Don Harmon

SYNOPSIS AS INTRODUCED:

See Index

Creates the Telehealth Act. Provides that telehealth services consist of (1) the provision of services and the mode of delivering health care services, including, but not limited to, primary care, counseling, psychiatry, emergency care, and specialty care and public health services via information and communication technologies, including, but not limited to, remote patient monitoring, to facilitate the examination, assessment, diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site and (2) as it relates to the delivery of health care, mental health care, or substance use disorder treatment, the use of interactive audio, video, or other telecommunications or electronic technology by a health care provider to deliver a health care service within the scope of practice of the health care provider from the distant site to the originating site at which the patient is located. Sets forth the requirements for the delivery of telehealth services and telepsychiatry services. Amends the Illinois Insurance Code, the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, and the Voluntary Health Services Plans Act to provide that health care plans and policies must provide coverage for telehealth services, including primary care, counseling, psychiatry, emergency care, and specialty care as set forth in the Illinois Insurance Code and as otherwise set forth in the Telehealth Act. Sets forth requirements concerning the coverage of telehealth services.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 1. Short title. This Act may be cited as the Telehealth Act.

Section 5. Definitions. As used in this Act:

"Distant site" means the location at which the health care provider rendering the service is located.

"Health care provider" means Illinois-licensed health care professionals, including, but not limited to, physicians licensed to practice medicine in all its branches, advanced practice nurses, physician assistants, licensed clinical psychologists, licensed clinical social workers, and licensed clinical professional counselors. Individuals not meeting the definition of "health care provider" are prohibited from providing telehealth services under this Act.

"Interactive telecommunications system" means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting 2-way, real-time interactive communication between the patient and the distant site health care provider. Telephones, facsimile machines, and electronic mail systems do not meet the definition of "interactive telecommunications system".

"Originating site" means the health care providers' office, local health departments, community mental health centers, rural health clinics, hospitals, substance use disorder facilities licensed by the Department of Human Services or the Department of Public Health, federally qualified health centers, and, in the case of individuals under the age of 18, elementary or secondary schools.

"Rural area" means a geographical area that is defined as rural by regulations issued by the Centers for Medicare and Medicaid Services or an area designated as underserved for behavioral health services by the Health Resources and Services Administration of the U.S. Department of Health and Human Services or a successor agency of either.

"Synchronous interaction" means a real-time interaction between a patient at an originating site and a health care provider located at a distant site.

"Telecommunication system" means an interactive telecommunications system that is used to transmit data between the originating and distant sites and is compliant with the Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules.

Section 10. Telehealth services.

(a) Telehealth services consist of the following:

(1) the provision of services and the mode of delivering health care services, including, but not limited to, primary care, counseling, psychiatry, emergency care, and specialty care and public health services via information and communication technologies, including, but not limited to, remote patient monitoring, to facilitate the examination, assessment, diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site; and

(2) as it relates to the delivery of health care, mental health care, or substance use disorder treatment, the use of interactive audio, video, or other telecommunications or electronic technology by a health care provider to deliver a health care service within the scope of practice of the health care provider from the distant site to the originating site at which the patient is located.

(b) Telehealth services does not include:

(1) an audio-only telephone conversation between a health care provider and a patient;

(2) an electronic mail message between a health care provider and a patient; or

(3) a facsimile transmission between a health care provider and a patient.

Section 15. Delivery of telehealth services.

(a) The requirements for the delivery of telehealth services are as follows:

(1) A physician or other health care provider must be onsite and available to the patient at the originating site, but need not be present in the same room as the patient. In the case of individuals under the age of 18, for an originating site in an elementary or secondary school, a health care provider or school administrator, counselor, social worker, nurse, or teacher must be onsite and available to the patient, but need not be present in the same room as the patient.

(2) The distant site provider must be a physician or other health care provider.

(3) Medical data may be exchanged through a Health Insurance Portability and Accountability Act of 1996-compliant telecommunication system.

(4) The interactive telecommunications system must, at a minimum, have the capability of allowing the consulting physician or other health care provider to examine the patient sufficiently to allow proper diagnosis. The system must also be capable of transmitting clearly audible sounds as well as clear video images.

(b) The specific requirements for the delivery of telepsychiatry services are as follows:

(1) A physician or other health care provider must be onsite and available to the patient at the originating site, but need not be present in the same room as the patient. In the case of individuals under the age of 18, for an originating site in an elementary or secondary school, a health care provider or school administrator, counselor, social worker, nurse, or teacher must be onsite and available to the patient at the originating site, but need not be present in the same room as the patient.

(2) The distant site provider must be a physician licensed by this State who has completed an approved general psychiatry residency program or be registered in an approved general psychiatry residency program or psychiatry fellowship program supervised by a physician who has completed an approved general psychiatry residency program. Patients must be located in this State. When treating patients age 16 and younger, the physician must also have completed an approved child and adolescent fellowship program and supervised by a physician who has completed an approved child and adolescent psychiatry fellowship program.

(3) The distant site provider must personally render the telepsychiatry service.

(4) Telepsychiatry services must be rendered using an interactive video telecommunications system.

(c) Both the originating and distant site must maintain records to document services provided to patients. All laws regarding the confidentiality of health care information and a patient's rights to his or her medical information shall apply to telehealth service interactions.

(d) This Act shall not be construed to alter the scope of practice of any health care provider or authorize the delivery of health care services in a setting or in a manner not otherwise authorized by law.

(e) Only health care providers licensed by the State of Illinois may provide telehealth services for patients located in Illinois.

Section 905. The State Employees Group Insurance Act of 1971 is amended by changing Section 6.11 as follows:

(5 ILCS 375/6.11)

Sec. 6.11. Required health benefits; Illinois Insurance Code requirements. The program of health benefits shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, and 356z.17, and 356z.22 of the Illinois Insurance Code. The program of health benefits must comply with Sections 155.22a, 155.37, 355b, and 356z.19 of the Illinois Insurance Code.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)

Section 910. The Counties Code is amended by changing Section 5-1069.3 as follows:

(55 ILCS 5/5-1069.3)

Sec. 5-1069.3. Required health benefits. If a county, including a home rule county, is a self-insurer for purposes of providing health insurance coverage for its employees, the coverage shall include coverage for the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, and 356z.15, and 356z.22 of the Illinois Insurance Code. The coverage shall comply with Sections 155.22a, 355b, and 356z.19 of the Illinois Insurance Code. The requirement that health benefits be covered as provided in this Section is an exclusive power and function of the State and is a denial and limitation under Article VII, Section 6, subsection (h) of the Illinois Constitution. A home rule county to which this Section applies must comply with every provision of this Section.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)

Section 915. The Illinois Municipal Code is amended by changing Section 10-4-2.3 as follows:

(65 ILCS 5/10-4-2.3)

Sec. 10-4-2.3. Required health benefits. If a municipality, including a home rule municipality, is a self-insurer for purposes of providing health insurance coverage for its employees, the coverage shall include coverage for the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, and 356z.15, and 356z.22 of the Illinois Insurance Code. The coverage shall comply with Sections 155.22a, 355b, and 356z.19 of the Illinois Insurance Code. The requirement that health benefits be covered as provided in this is an exclusive power and function of the State and is a denial and limitation under Article VII, Section 6, subsection (h) of the Illinois Constitution. A home rule municipality to which this Section applies must comply with every provision of this Section.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)

Section 920. The School Code is amended by changing Section 10-22.3f as follows:

(105 ILCS 5/10-22.3f)

Sec. 10-22.3f. Required health benefits. Insurance protection and benefits for employees shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, and 356z.15, and 356z.22 of the Illinois Insurance Code. Insurance policies shall comply with Section 356z.19 of the Illinois Insurance Code. The coverage shall comply with Sections 155.22a and 355b of the Illinois Insurance Code.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)

Section 925. The Illinois Insurance Code is amended by adding Section 356z.22 as follows:

(215 ILCS 5/356z.22 new)

Sec. 356z.22. Coverage for telehealth services.

(a) In this Section:

"Facility fee" means the reimbursement made to the originating site for the telehealth service.

"Health care provider" means Illinois-licensed health care professionals, including, but not limited to, physicians licensed to practice medicine in all its branches, advanced practice nurses, physician assistants, licensed clinical psychologists, licensed clinical social workers, licensed clinical professional counselors, and certified substance use disorder professionals employed by a licensed substance use disorder facility. Individuals not meeting the definition of "health care provider" are prohibited from providing telehealth services under this Act.

"Rural area" means a geographical area that is defined as rural by regulations issued by the Centers for Medicare and Medicaid Services or an area designated as underserved for behavioral health services by the Health Resources and Services Administration of the U.S. Department of Health and Human Services or a successor agency of either.

(b) An individual or group policy of accident and health insurance, a health maintenance organization policy, a nonprofit health services plan, or a managed care plan must provide coverage for telehealth services, including primary care, counseling, psychiatry, emergency care, and specialty care as set forth in this Section and as otherwise set forth in the Telehealth Act. Benefits for telehealth shall be limited to individuals who reside in rural areas, with the exception that any individual under the age of 18 shall receive benefits for telehealth services for behavioral health services, irrespective of whether the individual resides in a rural area.

(c) An individual or group policy of accident and health insurance, a health maintenance organization policy, a nonprofit health services plan, or a managed care plan:

(1) shall provide coverage under a health insurance policy or contract for health care services appropriately delivered through telehealth;

(2) may not exclude a health care service from coverage solely because it is provided through telehealth and is not provided through an in-person consultation or contact between a health care provider and a patient;

(3) may not require that in-person contact occur between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth;

(4) may not require the health care provider to document a barrier to an in-person visit for coverage of services to be provided via telehealth;

(5) may not require the use of telehealth when the health care provider has determined that it is not appropriate;

(6) consistent with the terms of this Section, shall reimburse a health care provider for the examination, assessment, diagnosis, consultation, and treatment of an insured patient for a health care service covered under a health insurance policy or contract that can appropriately be provided through telehealth;

(7) shall pay a facility fee to the originating site and the health care provider at the originating site for services provided;

(8) is not required to:

(A) reimburse a health care provider for a health care service delivered in-person or through telehealth that is not a covered benefit under the health insurance policy or contract;

(B) reimburse a health care provider for a health care service unless the service is provided via a synchronous interaction between the patient and the health care provider;

(C) reimburse a health care provider or facility for telehealth services that are not provided at an originating site, as defined in the Telehealth Act; or

(D) reimburse a health care provider or facility for telehealth services unless a written agreement exists between the originating site and the distant site, as those terms are defined in the Telehealth Act, that facilitates the provision of health care services sought by the patient, a copy of which shall be provided to the insurer, health maintenance organization policy, nonprofit health services plan, or managed care plan upon request; and

(9) may not impose a lifetime dollar maximum or limit the provision of mental health or substance use disorder services in a manner that violates State or federal parity laws.

(d) Coverage for telehealth services required under this Section may be subject to the same deductible, coinsurance, and copayment as if the telehealth services were provided through face-to-face interactions between patients and their health care providers. Nothing in this Section shall be deemed as requiring an insurer to provide benefits for a service that would not otherwise be covered if the services were provided through a face-to-face interaction between the patient and a health care provider.

(e) Whenever a beneficiary finds it medically necessary to utilize a non-preferred provider for telehealth services, the payor shall ensure that the beneficiary shall incur no greater out-of-pocket liability than had the beneficiary received telehealth services from a preferred provider. This subsection (e) does not apply to a beneficiary who willfully chooses to access a non-preferred provider for telehealth services available through the administrator's panel of participating providers.

Section 930. The Health Maintenance Organization Act is amended by changing Section 5-3 as follows:

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

Sec. 5-3. Insurance Code provisions.

(a) Health Maintenance Organizations shall be subject to the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

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

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

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

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

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

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

(2)(i) the criteria specified in subsection (1)(b) of Section 131.8 of the Illinois Insurance Code shall not apply and (ii) the Director, in making his determination with respect to the merger, consolidation, or other acquisition of control, need not take into account the effect on competition of the merger, consolidation, or other acquisition of control;

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

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

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

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

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

(d) The provisions of Article VIII 1/2 of the Illinois Insurance Code and this Section 5-3 shall apply to the sale by any health maintenance organization of greater than 10% of its enrollee population (including without limitation the health maintenance organization's right, title, and interest in and to its health care certificates).

(e) In considering any management contract or service agreement subject to Section 141.1 of the Illinois Insurance Code, the Director (i) shall, in addition to the criteria specified in Section 141.2 of the Illinois Insurance Code, take into account the effect of the management contract or service agreement on the continuation of benefits to enrollees and the financial condition of the health maintenance organization to be managed or serviced, and (ii) need not take into account the effect of the management contract or service agreement on competition.

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

(i) the amount of, and other terms and conditions with respect to, the refund or additional premium are set forth in the group or enrollment unit contract agreed in advance of the period for which a refund is to be paid or additional premium is to be charged (which period shall not be less than one year); and

(ii) the amount of the refund or additional premium shall not exceed 20% of the Health Maintenance Organization's profitable or unprofitable experience with respect to the group or other enrollment unit for the period (and, for purposes of a refund or additional premium, the profitable or unprofitable experience shall be calculated taking into account a pro rata share of the Health Maintenance Organization's administrative and marketing expenses, but shall not include any refund to be made or additional premium to be paid pursuant to this subsection (f)). The Health Maintenance Organization and the group or enrollment unit may agree that the profitable or unprofitable experience may be calculated taking into account the refund period and the immediately preceding 2 plan years.

The Health Maintenance Organization shall include a statement in the evidence of coverage issued to each enrollee describing the possibility of a refund or additional premium, and upon request of any group or enrollment unit, provide to the group or enrollment unit a description of the method used to calculate (1) the Health Maintenance Organization's profitable experience with respect to the group or enrollment unit and the resulting refund to the group or enrollment unit or (2) the Health Maintenance Organization's unprofitable experience with respect to the group or enrollment unit and the resulting additional premium to be paid by the group or enrollment unit.

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

(g) Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)

Section 935. The Limited Health Service Organization Act is amended by changing Section 4003 as follows:

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

Sec. 4003. Illinois Insurance Code provisions. Limited health service organizations shall be subject to the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v, 356z.10, 356z.21, 356z.22, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. For purposes of the Illinois Insurance Code, except for Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited health service organizations in the following categories are deemed to be domestic companies:

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

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

(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)

Section 940. The Voluntary Health Services Plans Act is amended by changing Section 10 as follows:

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

Sec. 10. Application of Insurance Code provisions. Health services plan corporations and all persons interested therein or dealing therewith shall be subject to the provisions of Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 364.01, 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and (15) of Section 367 of the Illinois Insurance Code.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)