HB0953AVM001

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MOTION


 

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    I move to accept the specific recommendations of the 
3
Governor as to House Bill 953 in manner and form as follows:

4

AMENDMENT TO HOUSE BILL 953


5

IN ACCEPTANCE OF GOVERNOR'S RECOMMENDATIONS


6
    Amend House Bill 953 as follows:

 
7
on page 1, below line 3, by inserting the following:
 
8
    "Section 2. The State Employees Group Insurance Act of 1971 
9
is amended  by changing Section 6.11 as follows:
 


10
    (5 ILCS 375/6.11)



11
    Sec. 6.11. Required health benefits; Illinois Insurance 
12
Code
requirements.  The program of health
benefits shall provide 
13
the post-mastectomy care benefits required to be covered
by a 
14
policy of accident and health insurance under Section 356t of 
15
the Illinois
Insurance Code.  The program of health benefits 
16
shall provide the coverage
required under Sections 356g.5,

17
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.8, and 356z.9, 
18
356z.10 and 356z.13 356z.9 of the
Illinois Insurance Code.
The 
19
program of health benefits must comply with Section 155.37 of 
20
the
Illinois Insurance Code.

21
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
22
95-520, eff. 8-28-07; revised 12-4-07.)

 
 


 






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    Section 2.5. The Counties Code is amended  by changing 
2
Section 5-1069.3 as follows:
 
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    (55 ILCS 5/5-1069.3)

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    Sec. 5-1069.3. Required health benefits.   If a county, 
5
including a home
rule
county, is a self-insurer for purposes of 
6
providing health insurance coverage
for its employees, the 
7
coverage shall include coverage for the post-mastectomy
care 
8
benefits required to be covered by a policy of accident and 
9
health
insurance under Section 356t and the coverage required 
10
under Sections 356g.5, 356u,
356w, 356x, 356z.6, 356z.8, and 
11
356z.9, 356z.10, and 356z.13  356z.9 of
the Illinois Insurance 
12
Code.  The requirement that health benefits be covered
as 
13
provided in this Section is an
exclusive power and function of 
14
the State and is a denial and limitation under
Article VII, 
15
Section 6, subsection (h) of the Illinois Constitution.  A home

16
rule county to which this Section applies must comply with 
17
every provision of
this Section.


18
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
19
95-520, eff. 8-28-07; revised 12-4-07.)

 
20
    Section 3. The Illinois Municipal Code is amended  by 
21
changing Section 10-4-2.3 as follows:
 
22
    (65 ILCS 5/10-4-2.3)

 


 






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    Sec. 10-4-2.3. Required health benefits.   If a 
2
municipality, including a
home rule municipality, is a 
3
self-insurer for purposes of providing health
insurance 
4
coverage for its employees, the coverage shall include coverage 
5
for
the post-mastectomy care benefits required to be covered by 
6
a policy of
accident and health insurance under Section 356t 
7
and the coverage required
under Sections 356g.5, 356u, 356w, 
8
356x, 356z.6, 356z.8, and 356z.9, 356z.10, and  356z.13 356z.9 
9
of the Illinois
Insurance
Code.  The requirement that health

10
benefits be covered as provided in this is an exclusive power 
11
and function of
the State and is a denial and limitation under 
12
Article VII, Section 6,
subsection (h) of the Illinois 
13
Constitution.  A home rule municipality to which
this Section 
14
applies must comply with every provision 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 4. The School Code is amended  by changing Section 
18
10-22.3f as follows:
 
19
    (105 ILCS 5/10-22.3f)

20
    Sec. 10-22.3f. Required health benefits.   Insurance 
21
protection and
benefits
for employees shall provide the 
22
post-mastectomy care benefits required to be
covered by a 
23
policy of accident and health insurance under Section 356t and 
 


 






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the
coverage required under Sections 356g.5, 356u, 356w, 356x,


2
356z.6, 356z.8, and 356z.9, and 356z.13 of
the
Illinois 
3
Insurance Code.


4
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
5
revised 12-4-07.)"; and

 
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on page 1, line 5, after "Section 370c", by inserting "and 
7
adding Section 356z.13"; and
 
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on page 1, immediately below line 5, by inserting the 
9
following:
 
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    "(215 ILCS 5/356z.13  new)
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    Sec. 356z.13. Autism spectrum disorders.
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    (a) A group or individual policy of accident and health 
13
insurance or managed care plan amended, delivered, issued, or 
14
renewed after the effective date of this amendatory Act of the 
15
95th General Assembly must provide individuals under 21 years 
16
of age coverage for the diagnosis of autism spectrum disorders 
17
and for the treatment of autism spectrum disorders to the 
18
extent that the diagnosis and treatment of autism spectrum 
19
disorders are not already covered by the policy of accident and 
20
health insurance or managed care plan.
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    (b) Coverage provided under this Section shall be subject 
22
to a maximum benefit of $36,000 per year, but shall not be 
 


 






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subject to any limits on the number of visits to a service 
2
provider. After December 30, 2009, the Director of the Division 
3
of Insurance shall, on an annual basis, adjust the maximum 
4
benefit for inflation using the Medical Care Component of the 
5
United States Department of Labor Consumer Price Index for All 
6
Urban Consumers. Payments made by an insurer on behalf of a 
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covered individual for any care, treatment, intervention, 
8
service, or item, the provision of which was for the treatment 
9
of a health condition not diagnosed as an autism spectrum 
10
disorder, shall not be applied toward any maximum benefit 
11
established under this subsection.
12
    (c) Coverage under this Section shall be subject to 
13
co-payment, deductible, and coinsurance provisions of a policy 
14
of accident and health insurance or managed care plan to the 
15
extent that other medical services covered by the policy of 
16
accident and health insurance or managed care plan are subject 
17
to these provisions.
18
    (d) This Section shall not be construed as limiting 
19
benefits that are otherwise available to an individual under a 
20
policy of accident and health insurance or managed care plan 
21
and benefits provided under this Section may not be subject to 
22
dollar limits, deductibles, copayments, or coinsurance 
23
provisions that are less favorable to the insured than the 
24
dollar limits, deductibles, or coinsurance provisions that 
25
apply to physical illness generally.
26
    (e) An insurer may not deny or refuse to provide otherwise 
 


 






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covered services, or refuse to renew, refuse to reissue, or 
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otherwise terminate or restrict coverage under an individual 
3
contract to provide services to an individual because the 
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individual or their dependent is diagnosed with an autism 
5
spectrum disorder or due to the individual utilizing benefits 
6
in this Section.
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    (f) Upon request of the reimbursing insurer, a provider of 
8
treatment for autism spectrum disorders shall furnish medical 
9
records, clinical notes, or other necessary data that 
10
substantiate that initial or continued medical treatment is 
11
medically necessary and is resulting in improved clinical 
12
status. When treatment is anticipated to require continued 
13
services to achieve demonstrable progress, the insurer may 
14
request a treatment plan consisting of diagnosis, proposed 
15
treatment by type, frequency, anticipated duration of 
16
treatment, the anticipated outcomes stated as goals, and the 
17
frequency by which the treatment plan will be updated.
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    (g) When making a determination of medical necessity for a 
19
treatment modality for autism spectrum disorders, an insurer 
20
must make the determination in a manner that is consistent with 
21
the manner used to make that determination with respect to 
22
other diseases or illnesses covered under the policy, including 
23
an appeals process. During the appeals process, any challenge 
24
to medical necessity must be viewed as reasonable only if the 
25
review includes a physician with expertise in the most current 
26
and effective treatment modalities for autism spectrum 
 


 






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disorders.
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    (h) Coverage for medically necessary early intervention 
3
services must be delivered by certified early intervention 
4
specialists, as defined in the early intervention operational 
5
standards by the Department of Human Services and in accordance 
6
with applicable certification requirements.
7
    (i) As used in this Section:
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    "Autism spectrum disorders" means pervasive developmental 
9
disorders as defined in the most recent edition of the 
10
Diagnostic and Statistical Manual of Mental Disorders, 
11
including autism, Asperger's disorder, and pervasive 
12
developmental disorder not otherwise specified.
13
    "Diagnosis of autism spectrum disorders" means a diagnosis 
14
of an individual with an autism spectrum disorder by (A) a 
15
physician licensed to practice medicine in all its branches or 
16
(B) a licensed clinical psychologist with expertise in 
17
diagnosing autism spectrum disorders.
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    "Medically necessary" means any care, treatment, 
19
intervention, service or item which will or is reasonably 
20
expected to do any of the following: (i) prevent the onset of 
21
an illness, condition, injury, disease or disability; (ii) 
22
reduce or ameliorate the physical, mental or developmental 
23
effects of an illness, condition, injury, disease or 
24
disability; or (iii) assist to achieve or maintain maximum 
25
functional activity in performing daily activities.
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    "Treatment for autism spectrum disorders" shall include 
 


 






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the following care prescribed, provided, or ordered for an 
2
individual diagnosed with an autism spectrum disorder by (A) a 
3
physician licensed to practice medicine in all its branches or 
4
(B) a certified, registered, or licensed health care 
5
professional with expertise in treating effects of autism 
6
spectrum disorders when the care is determined to be medically 
7
necessary and ordered by a physician licensed to practice 
8
medicine in all its branches:
9
        (1) Psychiatric care, including diagnostic services.
10
        (2) Psychological assessments and treatments.
11
        (3) Rehabilitative treatments.
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        (4) Therapeutic care, including behavioral speech, 
13
    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."; and
 
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on page 7, below line 1, by inserting the following:
 
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    "Section 10. The Health Maintenance Organization Act is 
21
amended  by changing Section 5-3 as follows:
 


22
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)




23
    Sec. 5-3. Insurance Code provisions. 

 


 






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    (a) Health Maintenance Organizations
shall be subject to 
2
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
3
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
4
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
5
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10 
6
356z.9, 356z.13, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 
7
368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 
8
409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of 
9
Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, 
10
XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

11
    (b) For purposes of the Illinois Insurance Code, except for 
12
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
13
Maintenance Organizations in
the following categories are 
14
deemed to be "domestic companies":


15
        (1) a corporation authorized under the
Dental Service 
16
    Plan Act or the Voluntary Health Services Plans Act;


17
        (2) a corporation organized under the laws of this 
18
    State; or


19
        (3) a corporation organized under the laws of another 
20
    state, 30% or more
of the enrollees of which are residents 
21
    of this State, except a
corporation subject to 
22
    substantially the same requirements in its state of

23
    organization as is a "domestic company" under Article VIII 
24
    1/2 of the
Illinois Insurance Code.

25
    (c) In considering the merger, consolidation, or other 
26
acquisition of
control of a Health Maintenance Organization 
 


 






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pursuant to Article VIII 1/2
of the Illinois Insurance Code,


2
        (1) the Director shall give primary consideration to 
3
    the continuation of
benefits to enrollees and the financial 
4
    conditions of the acquired Health
Maintenance Organization 
5
    after the merger, consolidation, or other
acquisition of 
6
    control takes effect;


7
        (2)(i) the criteria specified in subsection (1)(b) of 
8
    Section 131.8 of
the Illinois Insurance Code shall not 
9
    apply and (ii) the Director, in making
his determination 
10
    with respect to the merger, consolidation, or other

11
    acquisition of control, need not take into account the 
12
    effect on
competition of the merger, consolidation, or 
13
    other acquisition of control;


14
        (3) the Director shall have the power to require the 
15
    following
information:


16
            (A) certification by an independent actuary of the 
17
        adequacy
of the reserves of the Health Maintenance 
18
        Organization sought to be acquired;


19
            (B) pro forma financial statements reflecting the 
20
        combined balance
sheets of the acquiring company and 
21
        the Health Maintenance Organization sought
to be 
22
        acquired as of the end of the preceding year and as of 
23
        a date 90 days
prior to the acquisition, as well as pro 
24
        forma financial statements
reflecting projected 
25
        combined operation for a period of 2 years;


26
            (C) a pro forma business plan detailing an 
 


 






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        acquiring party's plans with
respect to the operation 
2
        of the Health Maintenance Organization sought to
be 
3
        acquired for a period of not less than 3 years; and


4
            (D) such other information as the Director shall 
5
        require.

6
    (d) The provisions of Article VIII 1/2 of the Illinois 
7
Insurance Code
and this Section 5-3 shall apply to the sale by 
8
any health maintenance
organization of greater than 10% of its

9
enrollee population (including without limitation the health 
10
maintenance
organization's right, title, and interest in and to 
11
its health care
certificates).

12
    (e) In considering any management contract or service 
13
agreement subject
to Section 141.1 of the Illinois Insurance 
14
Code, the Director (i) shall, in
addition to the criteria 
15
specified in Section 141.2 of the Illinois
Insurance Code, take 
16
into account the effect of the management contract or
service 
17
agreement on the continuation of benefits to enrollees and the

18
financial condition of the health maintenance organization to 
19
be managed or
serviced, and (ii) need not take into account the 
20
effect of the management
contract or service agreement on 
21
competition.

22
    (f) Except for small employer groups as defined in the 
23
Small Employer
Rating, Renewability and Portability Health 
24
Insurance Act and except for
medicare supplement policies as 
25
defined in Section 363 of the Illinois
Insurance Code, a Health 
26
Maintenance Organization may by contract agree with a
group or 
 


 






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other enrollment unit to effect refunds or charge additional 
2
premiums
under the following terms and conditions:


3
        (i) the amount of, and other terms and conditions with 
4
    respect to, the
refund or additional premium are set forth 
5
    in the group or enrollment unit
contract agreed in advance 
6
    of the period for which a refund is to be paid or

7
    additional premium is to be charged (which period shall not 
8
    be less than one
year); and


9
        (ii) the amount of the refund or additional premium 
10
    shall not exceed 20%
of the Health Maintenance 
11
    Organization's profitable or unprofitable experience
with 
12
    respect to the group or other enrollment unit for the 
13
    period (and, for
purposes of a refund or additional 
14
    premium, the profitable or unprofitable
experience shall 
15
    be calculated taking into account a pro rata share of the

16
    Health Maintenance Organization's administrative and 
17
    marketing expenses, but
shall not include any refund to be 
18
    made or additional premium to be paid
pursuant to this 
19
    subsection (f)).  The Health Maintenance Organization and 
20
    the
group or enrollment unit may agree that the profitable 
21
    or unprofitable
experience may be calculated taking into 
22
    account the refund period and the
immediately preceding 2 
23
    plan years.

24
    The Health Maintenance Organization shall include a 
25
statement in the
evidence of coverage issued to each enrollee 
26
describing the possibility of a
refund or additional premium, 
 


 






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and upon request of any group or enrollment unit,
provide to 
2
the group or enrollment unit a description of the method used 
3
to
calculate (1) the Health Maintenance Organization's 
4
profitable experience with
respect to the group or enrollment 
5
unit and the resulting refund to the group
or enrollment unit 
6
or (2) the Health Maintenance Organization's unprofitable

7
experience with respect to the group or enrollment unit and the 
8
resulting
additional premium to be paid by the group or 
9
enrollment unit.

10
    In no event shall the Illinois Health Maintenance 
11
Organization
Guaranty Association be liable to pay any 
12
contractual obligation of an
insolvent organization to pay any 
13
refund authorized under this Section.

14
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; 
15
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)

 
16
    Section 15. The Voluntary Health Services Plans Act is 
17
amended  by changing Section 10 as follows:
 



18
    (215 ILCS 165/10)  (from Ch. 32, par. 604)


19
    Sec. 10. Application of Insurance Code provisions. Health 
20
services
plan corporations and all persons interested therein 
21
or dealing therewith
shall be subject to the provisions of 
22
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
23
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, 
 


 






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356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 
2
356z.9,
356z.10 356z.9, 356z.13, 364.01, 367.2, 368a, 401, 
3
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) 
4
and (15) of Section 367 of the Illinois
Insurance Code.

5
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; 
6
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. 
7
8-28-07; revised 12-5-07.)".

 

8
Date: _________________, 2008    ___________________________