Rep. Elaine Nekritz

Filed: 5/31/2008

 

 


 

 


 
09500SB0101ham002 LRB095 03635 DRJ 51832 a

1
AMENDMENT TO SENATE BILL 101

2     AMENDMENT NO. ______. Amend Senate Bill 101, AS AMENDED, by
3 replacing everything after the enacting clause with the
4 following:
 
 
5     "Section 5. The State Employees Group Insurance Act of 1971
6 is amended by changing Section 6.11 as follows:
 
7     (5 ILCS 375/6.11)
8     Sec. 6.11. Required health benefits; Illinois Insurance
9 Code requirements. The program of health benefits shall provide
10 the post-mastectomy care benefits required to be covered by a
11 policy of accident and health insurance under Section 356t of
12 the Illinois Insurance Code. The program of health benefits
13 shall provide the coverage required under Sections 356g.5,
14 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10,
15 and 356z.11 and 356z.9 of the Illinois Insurance Code. The

 

 

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1 program of health benefits must comply with Section 155.37 of
2 the Illinois Insurance Code.
3 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
4 95-520, eff. 8-28-07; revised 12-4-07.)
 
5     Section 10. The Counties Code is amended by changing
6 Section 5-1069.3 as follows:
 
7     (55 ILCS 5/5-1069.3)
8     Sec. 5-1069.3. Required health benefits. If a county,
9 including a home rule county, is a self-insurer for purposes of
10 providing health insurance coverage for its employees, the
11 coverage shall include coverage for the post-mastectomy care
12 benefits required to be covered by a policy of accident and
13 health insurance under Section 356t and the coverage required
14 under Sections 356g.5, 356u, 356w, 356x, 356z.6, and 356z.9,
15 356z.10, and 356z.11 and 356z.9 of the Illinois Insurance Code.
16 The requirement that health benefits be covered as provided in
17 this Section is an exclusive power and function of the State
18 and is a denial and limitation under Article VII, Section 6,
19 subsection (h) of the Illinois Constitution. A home rule county
20 to which this Section applies must comply with every provision
21 of this Section.
22 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
23 95-520, eff. 8-28-07; revised 12-4-07.)
 

 

 

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1     Section 15. The Illinois Municipal Code is amended by
2 changing Section 10-4-2.3 as follows:
 
3     (65 ILCS 5/10-4-2.3)
4     Sec. 10-4-2.3. Required health benefits. If a
5 municipality, including a home rule municipality, is a
6 self-insurer for purposes of providing health insurance
7 coverage for its employees, the coverage shall include coverage
8 for the post-mastectomy care benefits required to be covered by
9 a policy of accident and health insurance under Section 356t
10 and the coverage required under Sections 356g.5, 356u, 356w,
11 356x, 356z.6, and 356z.9, 356z.10, and 356z.11 and 356z.9 of
12 the Illinois Insurance Code. The requirement that health
13 benefits be covered as provided in this is an exclusive power
14 and function of the State and is a denial and limitation under
15 Article VII, Section 6, subsection (h) of the Illinois
16 Constitution. A home rule municipality to which this Section
17 applies must comply with 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 20. The School Code is amended by changing Section
21 10-22.3f as follows:
 
22     (105 ILCS 5/10-22.3f)
23     Sec. 10-22.3f. Required health benefits. Insurance

 

 

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1 protection and benefits for employees shall provide the
2 post-mastectomy care benefits required to be covered by a
3 policy of accident and health insurance under Section 356t and
4 the coverage required under Sections 356g.5, 356u, 356w, 356x,
5 356z.6, and 356z.9, and 356z.11 of the Illinois Insurance Code.
6 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
7 revised 12-4-07.)
 
8     Section 25. The Illinois Insurance Code is amended by
9 adding Sections 356z.11 and 370c as follows:
 
10     (215 ILCS 5/356z.11 new)
11     Sec. 356z.11. Habilitative services for children.
12     (a) As used in this Section, "habilitative services" means
13 occupational therapy, physical therapy, speech therapy, and
14 other services prescribed by the insured's treating physician
15 pursuant to a treatment plan to enhance the ability of a child
16 to function with a congenital, genetic, or early acquired
17 disorder. A congenital or genetic disorder includes, but is not
18 limited to, hereditary disorders. An early acquired disorder
19 refers to a disorder resulting from illness, trauma, injury, or
20 some other event or condition suffered by a child prior to that
21 child developing functional life skills such as, but not
22 limited to, walking, talking, or self-help skills. Congenital,
23 genetic, and early acquired disorders may include, but are not
24 limited to, autism or an autism spectrum disorder, cerebral

 

 

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1 palsy, and other disorders resulting from early childhood
2 illness, trauma, or injury.
3     (b) A group or individual policy of accident and health
4 insurance or managed care plan amended, delivered, issued, or
5 renewed after the effective date of this amendatory Act of the
6 95th General Assembly must provide coverage for habilitative
7 services for children under 19 years of age with a congenital,
8 genetic, or early acquired disorder so long as all of the
9 following conditions are met:
10         (1) A physician licensed to practice medicine in all
11     its branches has diagnosed the child's congenital,
12     genetic, or early acquired disorder.
13         (2) The treatment is administered by a licensed
14     speech-language pathologist, licensed audiologist,
15     licensed occupational therapist, licensed physical
16     therapist, licensed physician, licensed nurse, licensed
17     optometrist, licensed nutritionist, licensed social
18     worker, or licensed psychologist upon the referral of a
19     physician licensed to practice medicine in all its
20     branches.
21         (3) The initial or continued treatment must be
22     medically necessary and therapeutic and not experimental
23     or investigational.
24     (c) The coverage required by this Section shall be subject
25 to other general exclusions and limitations of the policy,
26 including coordination of benefits, participating provider

 

 

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1 requirements, restrictions on services provided by family or
2 household members, utilization review of health care services,
3 including review of medical necessity, case management,
4 experimental, and investigational treatments, and other
5 managed care provisions.
6     (d) Coverage under this Section does not apply to those
7 services that are solely educational in nature or otherwise
8 paid under State or federal law for purely educational
9 services. Nothing in this subsection (d) relieves an insurer or
10 similar third party from an otherwise valid obligation to
11 provide or to pay for services provided to a child with a
12 disability.
13     (e) Coverage under this Section for children under age 19
14 shall not apply to treatment of mental or emotional disorders
15 or illnesses as covered under Section 370 of this Code as well
16 as any other benefit based upon a specific diagnosis that may
17 be otherwise required by law.
18     (f) The provisions of this Section do not apply to
19 short-term travel, accident-only, limited, or specific disease
20 policies.
21     (g) Any denial of care for habilitative services shall be
22 subject to appeal and external independent review procedures as
23 provided by Section 45 of the Managed Care Reform and Patient
24 Rights Act.
25     (h) Upon request of the reimbursing insurer, the provider
26 under whose supervision the habilitative services are being

 

 

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1 provided shall furnish medical records, clinical notes, or
2 other necessary data to allow the insurer to substantiate that
3 initial or continued medical treatment is medically necessary
4 and that the patient's condition is clinically improving. When
5 the treating provider anticipates that continued treatment is
6 or will be required to permit the patient to achieve
7 demonstrable progress, the insurer may request that the
8 provider furnish a treatment plan consisting of diagnosis,
9 proposed treatment by type, frequency, anticipated duration of
10 treatment, the anticipated goals of treatment, and how
11 frequently the treatment plan will be updated.
12     (i) The Department may not adopt rules to amend the
13 provisions of the amendatory Act of the 95th General Assembly.
 
14     (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
15     Sec. 370c. Mental and emotional disorders.
16     (a) (1) On and after the effective date of this Section,
17 every insurer which delivers, issues for delivery or renews or
18 modifies group A&H policies providing coverage for hospital or
19 medical treatment or services for illness on an
20 expense-incurred basis shall offer to the applicant or group
21 policyholder subject to the insurers standards of
22 insurability, coverage for reasonable and necessary treatment
23 and services for mental, emotional or nervous disorders or
24 conditions, other than serious mental illnesses as defined in
25 item (2) of subsection (b), up to the limits provided in the

 

 

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1 policy for other disorders or conditions, except (i) the
2 insured may be required to pay up to 50% of expenses incurred
3 as a result of the treatment or services, and (ii) the annual
4 benefit limit may be limited to the lesser of $10,000 or 25% of
5 the lifetime policy limit.
6     (2) Each insured that is covered for mental, emotional or
7 nervous disorders or conditions shall be free to select the
8 physician licensed to practice medicine in all its branches,
9 licensed clinical psychologist, licensed clinical social
10 worker, or licensed clinical professional counselor of his
11 choice to treat such disorders, and the insurer shall pay the
12 covered charges of such physician licensed to practice medicine
13 in all its branches, licensed clinical psychologist, licensed
14 clinical social worker, or licensed clinical professional
15 counselor up to the limits of coverage, provided (i) the
16 disorder or condition treated is covered by the policy, and
17 (ii) the physician, licensed psychologist, licensed clinical
18 social worker, or licensed clinical professional counselor is
19 authorized to provide said services under the statutes of this
20 State and in accordance with accepted principles of his
21 profession.
22     (3) Insofar as this Section applies solely to licensed
23 clinical social workers and licensed clinical professional
24 counselors, those persons who may provide services to
25 individuals shall do so after the licensed clinical social
26 worker or licensed clinical professional counselor has

 

 

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1 informed the patient of the desirability of the patient
2 conferring with the patient's primary care physician and the
3 licensed clinical social worker or licensed clinical
4 professional counselor has provided written notification to
5 the patient's primary care physician, if any, that services are
6 being provided to the patient. That notification may, however,
7 be waived by the patient on a written form. Those forms shall
8 be retained by the licensed clinical social worker or licensed
9 clinical professional counselor for a period of not less than 5
10 years.
11     (b) (1) An insurer that provides coverage for hospital or
12 medical expenses under a group policy of accident and health
13 insurance or health care plan amended, delivered, issued, or
14 renewed after the effective date of this amendatory Act of the
15 92nd General Assembly shall provide coverage under the policy
16 for treatment of serious mental illness under the same terms
17 and conditions as coverage for hospital or medical expenses
18 related to other illnesses and diseases. The coverage required
19 under this Section must provide for same durational limits,
20 amount limits, deductibles, and co-insurance requirements for
21 serious mental illness as are provided for other illnesses and
22 diseases. This subsection does not apply to coverage provided
23 to employees by employers who have 50 or fewer employees.
24     (2) "Serious mental illness" means the following
25 psychiatric illnesses as defined in the most current edition of
26 the Diagnostic and Statistical Manual (DSM) published by the

 

 

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1 American Psychiatric Association:
2         (A) schizophrenia;
3         (B) paranoid and other psychotic disorders;
4         (C) bipolar disorders (hypomanic, manic, depressive,
5     and mixed);
6         (D) major depressive disorders (single episode or
7     recurrent);
8         (E) schizoaffective disorders (bipolar or depressive);
9         (F) pervasive developmental disorders;
10         (G) obsessive-compulsive disorders;
11         (H) depression in childhood and adolescence;
12         (I) panic disorder; and
13         (J) post-traumatic stress disorders (acute, chronic,
14     or with delayed onset).
15     (3) Upon request of the reimbursing insurer, a provider of
16 treatment of serious mental illness shall furnish medical
17 records or other necessary data that substantiate that initial
18 or continued treatment is at all times medically necessary. An
19 insurer shall provide a mechanism for the timely review by a
20 provider holding the same license and practicing in the same
21 specialty as the patient's provider, who is unaffiliated with
22 the insurer, jointly selected by the patient (or the patient's
23 next of kin or legal representative if the patient is unable to
24 act for himself or herself), the patient's provider, and the
25 insurer in the event of a dispute between the insurer and
26 patient's provider regarding the medical necessity of a

 

 

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1 treatment proposed by a patient's provider. If the reviewing
2 provider determines the treatment to be medically necessary,
3 the insurer shall provide reimbursement for the treatment.
4 Future contractual or employment actions by the insurer
5 regarding the patient's provider may not be based on the
6 provider's participation in this procedure. Nothing prevents
7 the insured from agreeing in writing to continue treatment at
8 his or her expense. When making a determination of the medical
9 necessity for a treatment modality for serous mental illness,
10 an insurer must make the determination in a manner that is
11 consistent with the manner used to make that determination with
12 respect to other diseases or illnesses covered under the
13 policy, including an appeals process.
14     (4) A group health benefit plan:
15         (A) shall provide coverage based upon medical
16     necessity for the following treatment of mental illness in
17     each calendar year:
18             (i) 45 days of inpatient treatment; and
19             (ii) beginning on June 26, 2006 (the effective date
20         of Public Act 94-921), 60 visits for outpatient
21         treatment including group and individual outpatient
22         treatment; and
23             (iii) for plans or policies delivered, issued for
24         delivery, renewed, or modified after January 1, 2007
25         (the effective date of Public Act 94-906), 20
26         additional outpatient visits for speech therapy for

 

 

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1         treatment of pervasive developmental disorders that
2         will be in addition to speech therapy provided pursuant
3         to item (ii) of this subparagraph (A);
4         (B) may not include a lifetime limit on the number of
5     days of inpatient treatment or the number of outpatient
6     visits covered under the plan; and
7         (C) shall include the same amount limits, deductibles,
8     copayments, and coinsurance factors for serious mental
9     illness as for physical illness.
10     (5) An issuer of a group health benefit plan may not count
11 toward the number of outpatient visits required to be covered
12 under this Section an outpatient visit for the purpose of
13 medication management and shall cover the outpatient visits
14 under the same terms and conditions as it covers outpatient
15 visits for the treatment of physical illness.
16     (6) An issuer of a group health benefit plan may provide or
17 offer coverage required under this Section through a managed
18 care plan.
19     (7) This Section shall not be interpreted to require a
20 group health benefit plan to provide coverage for treatment of:
21         (A) an addiction to a controlled substance or cannabis
22     that is used in violation of law; or
23         (B) mental illness resulting from the use of a
24     controlled substance or cannabis in violation of law.
25     (8) (Blank).
26     (c) This Section shall not be interpreted to require

 

 

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1 coverage for speech therapy or other habilitative services for
2 those individuals covered under Section 356z.11 of this Code.
3 (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05;
4 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff.
5 8-21-07.)
 
6     Section 30. The Health Maintenance Organization Act is
7 amended by changing Section 5-3 as follows:
 
8     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
9     Sec. 5-3. Insurance Code provisions.
10     (a) Health Maintenance Organizations shall be subject to
11 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
12 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
13 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
14 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
15 356z.11 356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
16 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2, 409,
17 412, 444, and 444.1, paragraph (c) of subsection (2) of Section
18 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
19 XXV, and XXVI of the Illinois Insurance Code.
20     (b) For purposes of the Illinois Insurance Code, except for
21 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
22 Maintenance Organizations in the following categories are
23 deemed to be "domestic companies":
24         (1) a corporation authorized under the Dental Service

 

 

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1     Plan Act or the Voluntary Health Services Plans Act;
2         (2) a corporation organized under the laws of this
3     State; or
4         (3) a corporation organized under the laws of another
5     state, 30% or more of the enrollees of which are residents
6     of this State, except a corporation subject to
7     substantially the same requirements in its state of
8     organization as is a "domestic company" under Article VIII
9     1/2 of the Illinois Insurance Code.
10     (c) In considering the merger, consolidation, or other
11 acquisition of control of a Health Maintenance Organization
12 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
13         (1) the Director shall give primary consideration to
14     the continuation of benefits to enrollees and the financial
15     conditions of the acquired Health Maintenance Organization
16     after the merger, consolidation, or other acquisition of
17     control takes effect;
18         (2)(i) the criteria specified in subsection (1)(b) of
19     Section 131.8 of the Illinois Insurance Code shall not
20     apply and (ii) the Director, in making his determination
21     with respect to the merger, consolidation, or other
22     acquisition of control, need not take into account the
23     effect on competition of the merger, consolidation, or
24     other acquisition of control;
25         (3) the Director shall have the power to require the
26     following information:

 

 

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1             (A) certification by an independent actuary of the
2         adequacy of the reserves of the Health Maintenance
3         Organization sought to be acquired;
4             (B) pro forma financial statements reflecting the
5         combined balance sheets of the acquiring company and
6         the Health Maintenance Organization sought to be
7         acquired as of the end of the preceding year and as of
8         a date 90 days prior to the acquisition, as well as pro
9         forma financial statements reflecting projected
10         combined operation for a period of 2 years;
11             (C) a pro forma business plan detailing an
12         acquiring party's plans with respect to the operation
13         of the Health Maintenance Organization sought to be
14         acquired for a period of not less than 3 years; and
15             (D) such other information as the Director shall
16         require.
17     (d) The provisions of Article VIII 1/2 of the Illinois
18 Insurance Code and this Section 5-3 shall apply to the sale by
19 any health maintenance organization of greater than 10% of its
20 enrollee population (including without limitation the health
21 maintenance organization's right, title, and interest in and to
22 its health care certificates).
23     (e) In considering any management contract or service
24 agreement subject to Section 141.1 of the Illinois Insurance
25 Code, the Director (i) shall, in addition to the criteria
26 specified in Section 141.2 of the Illinois Insurance Code, take

 

 

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1 into account the effect of the management contract or service
2 agreement on the continuation of benefits to enrollees and the
3 financial condition of the health maintenance organization to
4 be managed or serviced, and (ii) need not take into account the
5 effect of the management contract or service agreement on
6 competition.
7     (f) Except for small employer groups as defined in the
8 Small Employer Rating, Renewability and Portability Health
9 Insurance Act and except for medicare supplement policies as
10 defined in Section 363 of the Illinois Insurance Code, a Health
11 Maintenance Organization may by contract agree with a group or
12 other enrollment unit to effect refunds or charge additional
13 premiums under the following terms and conditions:
14         (i) the amount of, and other terms and conditions with
15     respect to, the refund or additional premium are set forth
16     in the group or enrollment unit contract agreed in advance
17     of the period for which a refund is to be paid or
18     additional premium is to be charged (which period shall not
19     be less than one year); and
20         (ii) the amount of the refund or additional premium
21     shall not exceed 20% of the Health Maintenance
22     Organization's profitable or unprofitable experience with
23     respect to the group or other enrollment unit for the
24     period (and, for purposes of a refund or additional
25     premium, the profitable or unprofitable experience shall
26     be calculated taking into account a pro rata share of the

 

 

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1     Health Maintenance Organization's administrative and
2     marketing expenses, but shall not include any refund to be
3     made or additional premium to be paid pursuant to this
4     subsection (f)). The Health Maintenance Organization and
5     the group or enrollment unit may agree that the profitable
6     or unprofitable experience may be calculated taking into
7     account the refund period and the immediately preceding 2
8     plan years.
9     The Health Maintenance Organization shall include a
10 statement in the evidence of coverage issued to each enrollee
11 describing the possibility of a refund or additional premium,
12 and upon request of any group or enrollment unit, provide to
13 the group or enrollment unit a description of the method used
14 to calculate (1) the Health Maintenance Organization's
15 profitable experience with respect to the group or enrollment
16 unit and the resulting refund to the group or enrollment unit
17 or (2) the Health Maintenance Organization's unprofitable
18 experience with respect to the group or enrollment unit and the
19 resulting additional premium to be paid by the group or
20 enrollment unit.
21     In no event shall the Illinois Health Maintenance
22 Organization Guaranty Association be liable to pay any
23 contractual obligation of an insolvent organization to pay any
24 refund authorized under this Section.
25 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
26 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
 

 

 

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1     Section 35. The Voluntary Health Services Plans Act is
2 amended by changing Section 10 as follows:
 
3     (215 ILCS 165/10)  (from Ch. 32, par. 604)
4     Sec. 10. Application of Insurance Code provisions. Health
5 services plan corporations and all persons interested therein
6 or dealing therewith shall be subject to the provisions of
7 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
8 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,
9 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
10 356z.9, 356z.10, 356z.11 356z.9, 364.01, 367.2, 368a, 401,
11 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
12 and (15) of Section 367 of the Illinois Insurance Code.
13 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
14 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
15 8-28-07; revised 12-5-07.)
 
16     Section 40. The Illinois Public Aid Code is amended by
17 changing Section 5-2 as follows:
 
18     (305 ILCS 5/5-2)  (from Ch. 23, par. 5-2)
19     Sec. 5-2. Classes of Persons Eligible. Medical assistance
20 under this Article shall be available to any of the following
21 classes of persons in respect to whom a plan for coverage has
22 been submitted to the Governor by the Illinois Department and

 

 

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1 approved by him:
2         1. Recipients of basic maintenance grants under
3     Articles III and IV.
4         2. Persons otherwise eligible for basic maintenance
5     under Articles III and IV but who fail to qualify
6     thereunder on the basis of need, and who have insufficient
7     income and resources to meet the costs of necessary medical
8     care, including but not limited to the following:
9             (a) All persons otherwise eligible for basic
10         maintenance under Article III but who fail to qualify
11         under that Article on the basis of need and who meet
12         either of the following requirements:
13                 (i) their income, as determined by the
14             Illinois Department in accordance with any federal
15             requirements, is equal to or less than 70% in
16             fiscal year 2001, equal to or less than 85% in
17             fiscal year 2002 and until a date to be determined
18             by the Department by rule, and equal to or less
19             than 100% beginning on the date determined by the
20             Department by rule, of the nonfarm income official
21             poverty line, as defined by the federal Office of
22             Management and Budget and revised annually in
23             accordance with Section 673(2) of the Omnibus
24             Budget Reconciliation Act of 1981, applicable to
25             families of the same size; or
26                 (ii) their income, after the deduction of

 

 

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1             costs incurred for medical care and for other types
2             of remedial care, is equal to or less than 70% in
3             fiscal year 2001, equal to or less than 85% in
4             fiscal year 2002 and until a date to be determined
5             by the Department by rule, and equal to or less
6             than 100% beginning on the date determined by the
7             Department by rule, of the nonfarm income official
8             poverty line, as defined in item (i) of this
9             subparagraph (a).
10             (b) All persons who would be determined eligible
11         for such basic maintenance under Article IV by
12         disregarding the maximum earned income permitted by
13         federal law.
14         3. Persons who would otherwise qualify for Aid to the
15     Medically Indigent under Article VII.
16         4. Persons not eligible under any of the preceding
17     paragraphs who fall sick, are injured, or die, not having
18     sufficient money, property or other resources to meet the
19     costs of necessary medical care or funeral and burial
20     expenses.
21         5.(a) Women during pregnancy, after the fact of
22     pregnancy has been determined by medical diagnosis, and
23     during the 60-day period beginning on the last day of the
24     pregnancy, together with their infants and children born
25     after September 30, 1983, whose income and resources are
26     insufficient to meet the costs of necessary medical care to

 

 

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1     the maximum extent possible under Title XIX of the Federal
2     Social Security Act.
3         (b) The Illinois Department and the Governor shall
4     provide a plan for coverage of the persons eligible under
5     paragraph 5(a) by April 1, 1990. Such plan shall provide
6     ambulatory prenatal care to pregnant women during a
7     presumptive eligibility period and establish an income
8     eligibility standard that is equal to 133% of the nonfarm
9     income official poverty line, as defined by the federal
10     Office of Management and Budget and revised annually in
11     accordance with Section 673(2) of the Omnibus Budget
12     Reconciliation Act of 1981, applicable to families of the
13     same size, provided that costs incurred for medical care
14     are not taken into account in determining such income
15     eligibility.
16         (c) The Illinois Department may conduct a
17     demonstration in at least one county that will provide
18     medical assistance to pregnant women, together with their
19     infants and children up to one year of age, where the
20     income eligibility standard is set up to 185% of the
21     nonfarm income official poverty line, as defined by the
22     federal Office of Management and Budget. The Illinois
23     Department shall seek and obtain necessary authorization
24     provided under federal law to implement such a
25     demonstration. Such demonstration may establish resource
26     standards that are not more restrictive than those

 

 

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1     established under Article IV of this Code.
2         6. Persons under the age of 18 who fail to qualify as
3     dependent under Article IV and who have insufficient income
4     and resources to meet the costs of necessary medical care
5     to the maximum extent permitted under Title XIX of the
6     Federal Social Security Act.
7         7. Persons who are under 21 years of age and would
8     qualify as disabled as defined under the Federal
9     Supplemental Security Income Program, provided medical
10     service for such persons would be eligible for Federal
11     Financial Participation, and provided the Illinois
12     Department determines that:
13             (a) the person requires a level of care provided by
14         a hospital, skilled nursing facility, or intermediate
15         care facility, as determined by a physician licensed to
16         practice medicine in all its branches;
17             (b) it is appropriate to provide such care outside
18         of an institution, as determined by a physician
19         licensed to practice medicine in all its branches;
20             (c) the estimated amount which would be expended
21         for care outside the institution is not greater than
22         the estimated amount which would be expended in an
23         institution.
24         8. Persons who become ineligible for basic maintenance
25     assistance under Article IV of this Code in programs
26     administered by the Illinois Department due to employment

 

 

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1     earnings and persons in assistance units comprised of
2     adults and children who become ineligible for basic
3     maintenance assistance under Article VI of this Code due to
4     employment earnings. The plan for coverage for this class
5     of persons shall:
6             (a) extend the medical assistance coverage for up
7         to 12 months following termination of basic
8         maintenance assistance; and
9             (b) offer persons who have initially received 6
10         months of the coverage provided in paragraph (a) above,
11         the option of receiving an additional 6 months of
12         coverage, subject to the following:
13                 (i) such coverage shall be pursuant to
14             provisions of the federal Social Security Act;
15                 (ii) such coverage shall include all services
16             covered while the person was eligible for basic
17             maintenance assistance;
18                 (iii) no premium shall be charged for such
19             coverage; and
20                 (iv) such coverage shall be suspended in the
21             event of a person's failure without good cause to
22             file in a timely fashion reports required for this
23             coverage under the Social Security Act and
24             coverage shall be reinstated upon the filing of
25             such reports if the person remains otherwise
26             eligible.

 

 

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1         9. Persons with acquired immunodeficiency syndrome
2     (AIDS) or with AIDS-related conditions with respect to whom
3     there has been a determination that but for home or
4     community-based services such individuals would require
5     the level of care provided in an inpatient hospital,
6     skilled nursing facility or intermediate care facility the
7     cost of which is reimbursed under this Article. Assistance
8     shall be provided to such persons to the maximum extent
9     permitted under Title XIX of the Federal Social Security
10     Act.
11         10. Participants in the long-term care insurance
12     partnership program established under the Illinois
13     Long-Term Care Partnership Program Act Partnership for
14     Long-Term Care Act who meet the qualifications for
15     protection of resources described in Section 15 25 of that
16     Act.
17         11. Persons with disabilities who are employed and
18     eligible for Medicaid, pursuant to Section
19     1902(a)(10)(A)(ii)(xv) of the Social Security Act, as
20     provided by the Illinois Department by rule. In
21     establishing eligibility standards under this paragraph
22     11, the Department shall, subject to federal approval:
23             (a) set the income eligibility standard at not
24         lower than 350% of the federal poverty level;
25             (b) exempt retirement accounts that the person
26         cannot access without penalty before the age of 59 1/2,

 

 

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1         and medical savings accounts established pursuant to
2         26 U.S.C. 220;
3             (c) allow non-exempt assets up to $25,000 as to
4         those assets accumulated during periods of eligibility
5         under this paragraph 11; and
6             (d) continue to apply subparagraphs (b) and (c) in
7         determining the eligibility of the person under this
8         Article even if the person loses eligibility under this
9         paragraph 11.
10         12. Subject to federal approval, persons who are
11     eligible for medical assistance coverage under applicable
12     provisions of the federal Social Security Act and the
13     federal Breast and Cervical Cancer Prevention and
14     Treatment Act of 2000. Those eligible persons are defined
15     to include, but not be limited to, the following persons:
16             (1) persons who have been screened for breast or
17         cervical cancer under the U.S. Centers for Disease
18         Control and Prevention Breast and Cervical Cancer
19         Program established under Title XV of the federal
20         Public Health Services Act in accordance with the
21         requirements of Section 1504 of that Act as
22         administered by the Illinois Department of Public
23         Health; and
24             (2) persons whose screenings under the above
25         program were funded in whole or in part by funds
26         appropriated to the Illinois Department of Public

 

 

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1         Health for breast or cervical cancer screening.
2         "Medical assistance" under this paragraph 12 shall be
3     identical to the benefits provided under the State's
4     approved plan under Title XIX of the Social Security Act.
5     The Department must request federal approval of the
6     coverage under this paragraph 12 within 30 days after the
7     effective date of this amendatory Act of the 92nd General
8     Assembly.
9         13. Subject to appropriation and to federal approval,
10     persons living with HIV/AIDS who are not otherwise eligible
11     under this Article and who qualify for services covered
12     under Section 5-5.04 as provided by the Illinois Department
13     by rule.
14         14. Subject to the availability of funds for this
15     purpose, the Department may provide coverage under this
16     Article to persons who reside in Illinois who are not
17     eligible under any of the preceding paragraphs and who meet
18     the income guidelines of paragraph 2(a) of this Section and
19     (i) have an application for asylum pending before the
20     federal Department of Homeland Security or on appeal before
21     a court of competent jurisdiction and are represented
22     either by counsel or by an advocate accredited by the
23     federal Department of Homeland Security and employed by a
24     not-for-profit organization in regard to that application
25     or appeal, or (ii) are receiving services through a
26     federally funded torture treatment center. Medical

 

 

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1     coverage under this paragraph 14 may be provided for up to
2     24 continuous months from the initial eligibility date so
3     long as an individual continues to satisfy the criteria of
4     this paragraph 14. If an individual has an appeal pending
5     regarding an application for asylum before the Department
6     of Homeland Security, eligibility under this paragraph 14
7     may be extended until a final decision is rendered on the
8     appeal. The Department may adopt rules governing the
9     implementation of this paragraph 14.
10         15. Subject to federal approval, persons with
11     medically improved disability who are employed or eligible
12     for Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi)
13     of the Social Security Act that meet applicable eligibility
14     standards established in paragraph 11. The Department may
15     not otherwise adopt any rule to implement this paragraph.
16     The Illinois Department and the Governor shall provide a
17 plan for coverage of the persons eligible under paragraph 7 as
18 soon as possible after July 1, 1984.
19     The eligibility of any such person for medical assistance
20 under this Article is not affected by the payment of any grant
21 under the Senior Citizens and Disabled Persons Property Tax
22 Relief and Pharmaceutical Assistance Act or any distributions
23 or items of income described under subparagraph (X) of
24 paragraph (2) of subsection (a) of Section 203 of the Illinois
25 Income Tax Act. The Department shall by rule establish the
26 amounts of assets to be disregarded in determining eligibility

 

 

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1 for medical assistance, which shall at a minimum equal the
2 amounts to be disregarded under the Federal Supplemental
3 Security Income Program. The amount of assets of a single
4 person to be disregarded shall not be less than $2,000, and the
5 amount of assets of a married couple to be disregarded shall
6 not be less than $3,000.
7     To the extent permitted under federal law, any person found
8 guilty of a second violation of Article VIIIA shall be
9 ineligible for medical assistance under this Article, as
10 provided in Section 8A-8.
11     The eligibility of any person for medical assistance under
12 this Article shall not be affected by the receipt by the person
13 of donations or benefits from fundraisers held for the person
14 in cases of serious illness, as long as neither the person nor
15 members of the person's family have actual control over the
16 donations or benefits or the disbursement of the donations or
17 benefits.
18 (Source: P.A. 94-629, eff. 1-1-06; 94-1043, eff. 7-24-06;
19 95-546, eff. 8-29-07; revised 1-22-08.)
 
20     Section 90. The State Mandates Act is amended by adding
21 Section 8.32 as follows:
 
22     (30 ILCS 805/8.32 new)
23     Sec. 8.32. Exempt mandate. Notwithstanding Sections 6 and 8
24 of this Act, no reimbursement by the State is required for the

 

 

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1 implementation of any mandate created by this amendatory Act of
2 the 95th General Assembly.
 
3     Section 99. Effective date. This Act takes effect upon
4 becoming law.".