102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB4349

 

Introduced 1/5/2022, by Rep. Kathleen Willis

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
215 ILCS 5/356c  from Ch. 73, par. 968c
215 ILCS 5/356z.53 new

    Amends the Illinois Insurance Code. In provisions requiring coverage for newborn infants, provides that coverage for congenital defects shall include treatment of cranial facial anomalies. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any services to functionally improve, repair, or restore a body part involving the cranial facial area that is medically necessary to achieve normal function or appearance. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Provides that coverage for a congenital anomaly or birth defect shall include expenses for specified services and items up to the age of 19. Provides that coverage shall not be denied solely on the grounds that the treatment is for cosmetic purposes or is not for a functional defect or impairment. Provides that the coverage does not apply to a policy that covers only dental care. Defines "treatment". Makes conforming changes in the State Employees Group Insurance Act of 1971. Effective January 1, 2024.


LRB102 23027 BMS 32181 b

 

 

A BILL FOR

 

HB4349LRB102 23027 BMS 32181 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall
9provide the post-mastectomy care benefits required to be
10covered by a policy of accident and health insurance under
11Section 356t of the Illinois Insurance Code. The program of
12health benefits shall provide the coverage required under
13Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
14356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
15356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
16356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
17356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51,
18and 356z.53 and 356z.43 of the Illinois Insurance Code. The
19program of health benefits must comply with Sections 155.22a,
20155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of
21the Illinois Insurance Code. The Department of Insurance shall
22enforce the requirements of this Section with respect to
23Sections 370c and 370c.1 of the Illinois Insurance Code; all

 

 

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1other requirements of this Section shall be enforced by the
2Department of Central Management Services.
3    Rulemaking authority to implement Public Act 95-1045, if
4any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9(Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
10101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
111-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
12eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
13102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
1410-26-21.)
 
15    Section 10. The Illinois Insurance Code is amended by
16changing Section 356c and by adding Section 356z.53 as
17follows:
 
18    (215 ILCS 5/356c)  (from Ch. 73, par. 968c)
19    Sec. 356c. (1) No policy of accident and health insurance
20providing coverage of hospital expenses or medical expenses or
21both on an expense incurred basis which in addition to
22covering the insured, also covers members of the insured's
23immediate family, shall contain any disclaimer, waiver or
24other limitation of coverage relative to the hospital or

 

 

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1medical coverage or insurability of newborn infants from and
2after the moment of birth.
3    (2) Each such policy of accident and health insurance
4shall contain a provision stating that the accident and health
5insurance benefits applicable for children shall be granted
6immediately with respect to a newly born child from the moment
7of birth. The coverage for newly born children shall include
8coverage of illness, injury, congenital defects (including the
9treatment of cranial facial anomalies, including, but not
10limited to, cleft lip or cleft palate), birth abnormalities
11and premature birth.
12    (3) If payment of a specific premium is required to
13provide coverage for a child, the policy may require that
14notification of birth of a newly born child must be furnished
15to the insurer within 31 days after the date of birth in order
16to have the coverage continue beyond such 31 day period and may
17require payment of the appropriate premium.
18    (4) In the event that no other members of the insured's
19immediate family are covered, immediate coverage for the first
20newborn infant shall be provided if the insured applies for
21dependent's coverage within 31 days of the newborn's birth.
22Such coverage shall be contingent upon payment of the
23additional premium.
24    (5) The requirements of this Section shall apply, on or
25after the sixtieth day following the effective date of this
26Section, (a) to all such non-group policies delivered or

 

 

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1issued for delivery, and (b) to all such group policies
2delivered, issued for delivery, renewed or amended. The
3insurers of such non-group policies in effect on the sixtieth
4day following the effective date of this Section shall extend
5to owners of said policies, on or before the first policy
6anniversary following such date, the opportunity to apply for
7the addition to their policies of a provision as set forth in
8paragraph (2) above, with, at the option of the insurer,
9payment of a premium appropriate thereto.
10(Source: P.A. 85-220.)
 
11    (215 ILCS 5/356z.53 new)
12    Sec. 356z.53. Coverage for congenital anomaly or birth
13defect.
14    (a) An individual or group policy of accident and health
15insurance amended, delivered, issued, or renewed after the
16effective date of this amendatory Act of the 102nd General
17Assembly shall cover charges incurred and services provided
18for outpatient and inpatient care in conjunction with services
19that are provided to a covered individual related to the
20diagnosis and treatment of a congenital anomaly or birth
21defect, including, but not limited to, cleft lip and cleft
22palate.
23    (b) Coverage required under this Section includes any
24services to functionally improve, repair, or restore a body
25part involving the cranial facial area, including cleft lip

 

 

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1and cleft palate, that is medically necessary to achieve
2normal function or appearance. Any coverage provided may be
3subject to coverage limits, such as pre-authorization or
4pre-certification, as required by the plan or issuer that are
5no more restrictive than the predominant treatment limitations
6applied to substantially all medical and surgical benefits
7covered by the plan.
8    (c) As used in this Section, "treatment" includes
9inpatient and outpatient care and services performed to
10improve or restore body function, or performed to approximate
11a normal appearance, due to a congenital anomaly, such as
12cleft lip or cleft palate, involving the cranial facial area
13and includes treatment of gross abnormalities of the lip and
14palate and any condition or illness that is related to or
15developed as a result of cleft lip or cleft palate.
16"Treatment" does not include cosmetic surgery performed to
17reshape normal facial structure or to improve appearance or
18self-esteem.
19    (d) Coverage shall include, but not be limited to,
20expenses for the following services up to the age of 19:
21        (1) oral surgery of the lip, palate, jaw, and related
22    structures, including bone grafts;
23        (2) facial surgery of the lip, palate, jaw, nose, and
24    related structures, including bone grafts;
25        (3) prosthetic treatment and appliances and
26    prosthodontia, including obturators, speech appliances,

 

 

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1    and feeding appliances;
2        (4) orthodontic treatment and appliances and
3    orthodontia;
4        (5) preventative and restorative dentistry;
5        (6) otolaryngology treatment and management; and
6        (7) anesthetics provided by a dentist with a permit
7    provided under Section 8.1 of the Illinois Dental Practice
8    Act when performed in conjunction with the treatment
9    described in this Section.
10    Coverage shall not be denied solely on the grounds that
11the treatment is for cosmetic purposes or is not for a
12functional defect or impairment as provided in this Section.
13    (e) This Section does not apply to a policy that covers
14only dental care.
 
15    Section 99. Effective date. This Act takes effect January
161, 2024.