103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB3974

 

Introduced 2/17/2023, by Rep. Joyce Mason

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.61 new

    Amends the Illinois Insurance Code. 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 service to functionally improve, repair, or restore any 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 the coverage does not apply to a policy that covers only dental care. Defines "treatment". Effective January 1, 2024.


LRB103 29802 BMS 56209 b

 

 

A BILL FOR

 

HB3974LRB103 29802 BMS 56209 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 Illinois Insurance Code is amended by
5adding Section 356z.61 as follows:
 
6    (215 ILCS 5/356z.61 new)
7    Sec. 356z.61. Coverage for congenital anomaly or birth
8defect.
9    (a) An individual or group policy of accident and health
10insurance amended, delivered, issued, or renewed after the
11effective date of this amendatory Act of the 103rd General
12Assembly shall cover charges incurred and services provided
13for outpatient and inpatient care in conjunction with services
14that are provided to a covered individual related to the
15diagnosis and treatment of a congenital anomaly or birth
16defect, including, but not limited to, cleft lip and cleft
17palate.
18    (b) Coverage required under this Section includes any
19services to functionally improve, repair, or restore a body
20part involving the cranial facial area, including cleft lip
21and cleft palate, that is medically necessary to achieve
22normal function or appearance. Any coverage provided may be
23subject to coverage limits, such as pre-authorization or

 

 

HB3974- 2 -LRB103 29802 BMS 56209 b

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

 

 

HB3974- 3 -LRB103 29802 BMS 56209 b

1        (5) preventative and restorative dentistry;
2        (6) otolaryngology treatment and management; and
3        (7) anesthetics provided by a dentist with a permit
4    provided under Section 8.1 of the Illinois Dental Practice
5    Act when performed in conjunction with the treatment
6    described in this Section.
7    Coverage shall not be denied solely on the grounds that
8the treatment is for cosmetic purposes or is not for a
9functional defect or impairment as provided in this Section.
10    (e) This Section does not apply to a policy that covers
11only dental care.
 
12    Section 99. Effective date. This Act takes effect January
131, 2024.