Rep. Elizabeth Coulson

Filed: 11/19/2008

 

 


 

 


 
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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, 356z.9, and 356z.10,
15 and 356z.14 of the Illinois Insurance Code. The program of
16 health benefits must comply with Section 155.37 of the Illinois

 

 

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1 Insurance Code.
2 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
3 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
4     Section 10. The Counties Code is amended by changing
5 Section 5-1069.3 as follows:
 
6     (55 ILCS 5/5-1069.3)
7     Sec. 5-1069.3. Required health benefits. If a county,
8 including a home rule county, is a self-insurer for purposes of
9 providing health insurance coverage for its employees, the
10 coverage shall include coverage for the post-mastectomy care
11 benefits required to be covered by a policy of accident and
12 health insurance under Section 356t and the coverage required
13 under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.9, and
14 356z.10, and 356z.14 of the Illinois Insurance Code. The
15 requirement that health benefits be covered as provided in this
16 Section is an exclusive power and function of the State and is
17 a denial and limitation under Article VII, Section 6,
18 subsection (h) of the Illinois Constitution. A home rule county
19 to which this Section applies must comply with every provision
20 of this Section.
21 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
22 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
23     Section 15. The Illinois Municipal Code is amended by

 

 

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1 changing Section 10-4-2.3 as follows:
 
2     (65 ILCS 5/10-4-2.3)
3     Sec. 10-4-2.3. Required health benefits. If a
4 municipality, including a home rule municipality, is a
5 self-insurer for purposes of providing health insurance
6 coverage for its employees, the coverage shall include coverage
7 for the post-mastectomy care benefits required to be covered by
8 a policy of accident and health insurance under Section 356t
9 and the coverage required under Sections 356g.5, 356u, 356w,
10 356x, 356z.6, 356z.9, and 356z.10, and 356z.14 of the Illinois
11 Insurance Code. The requirement that health benefits be covered
12 as provided in this is an exclusive power and function of the
13 State and is a denial and limitation under Article VII, Section
14 6, subsection (h) of the Illinois Constitution. A home rule
15 municipality to which this Section applies must comply with
16 every provision of this Section.
17 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
18 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
19     Section 20. The School Code is amended by changing Section
20 10-22.3f as follows:
 
21     (105 ILCS 5/10-22.3f)
22     Sec. 10-22.3f. Required health benefits. Insurance
23 protection and benefits for employees shall provide the

 

 

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1 post-mastectomy care benefits required to be covered by a
2 policy of accident and health insurance under Section 356t and
3 the coverage required under Sections 356g.5, 356u, 356w, 356x,
4 356z.6, and 356z.9, and 356z.14 of the Illinois Insurance Code.
5 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
6 95-876, eff. 8-21-08.)
 
7     Section 25. The Illinois Insurance Code is amended by
8 changing Section 370c and adding Section 356z.14 as follows:
 
9     (215 ILCS 5/356z.14 new)
10     Sec. 356z.14. Habilitative services for children.
11     (a) As used in this Section, "habilitative services" means
12 occupational therapy, physical therapy, speech therapy, and
13 other services prescribed by the insured's treating physician
14 pursuant to a treatment plan to enhance the ability of a child
15 to function with a congenital, genetic, or early acquired
16 disorder. A congenital or genetic disorder includes, but is not
17 limited to, hereditary disorders. An early acquired disorder
18 refers to a disorder resulting from illness, trauma, injury, or
19 some other event or condition suffered by a child prior to that
20 child developing functional life skills such as, but not
21 limited to, walking, talking, or self-help skills. Congenital,
22 genetic, and early acquired disorders may include, but are not
23 limited to, autism or an autism spectrum disorder, cerebral
24 palsy, and other disorders resulting from early childhood

 

 

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

 

 

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

 

 

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1 other necessary data to allow the insurer to substantiate that
2 initial or continued medical treatment is medically necessary
3 and that the patient's condition is clinically improving. When
4 the treating provider anticipates that continued treatment is
5 or will be required to permit the patient to achieve
6 demonstrable progress, the insurer may request that the
7 provider furnish a treatment plan consisting of diagnosis,
8 proposed treatment by type, frequency, anticipated duration of
9 treatment, the anticipated goals of treatment, and how
10 frequently the treatment plan will be updated.
11     (i) Rulemaking authority to implement this amendatory Act
12 of the 95th General Assembly, if any, is conditioned on the
13 rules being adopted in accordance with all provisions of the
14 Illinois Administrative Procedure Act and all rules and
15 procedures of the Joint Committee on Administrative Rules; any
16 purported rule not so adopted, for whatever reason, is
17 unauthorized.
 
18     (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
19     Sec. 370c. Mental and emotional disorders.
20     (a) (1) On and after the effective date of this Section,
21 every insurer which delivers, issues for delivery or renews or
22 modifies group A&H policies providing coverage for hospital or
23 medical treatment or services for illness on an
24 expense-incurred basis shall offer to the applicant or group
25 policyholder subject to the insurers standards of

 

 

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

 

 

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

 

 

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1 to employees by employers who have 50 or fewer employees.
2     (2) "Serious mental illness" means the following
3 psychiatric illnesses as defined in the most current edition of
4 the Diagnostic and Statistical Manual (DSM) published by the
5 American Psychiatric Association:
6         (A) schizophrenia;
7         (B) paranoid and other psychotic disorders;
8         (C) bipolar disorders (hypomanic, manic, depressive,
9     and mixed);
10         (D) major depressive disorders (single episode or
11     recurrent);
12         (E) schizoaffective disorders (bipolar or depressive);
13         (F) pervasive developmental disorders;
14         (G) obsessive-compulsive disorders;
15         (H) depression in childhood and adolescence;
16         (I) panic disorder; and
17         (J) post-traumatic stress disorders (acute, chronic,
18     or with delayed onset).
19     (3) Upon request of the reimbursing insurer, a provider of
20 treatment of serious mental illness shall furnish medical
21 records or other necessary data that substantiate that initial
22 or continued treatment is at all times medically necessary. An
23 insurer shall provide a mechanism for the timely review by a
24 provider holding the same license and practicing in the same
25 specialty as the patient's provider, who is unaffiliated with
26 the insurer, jointly selected by the patient (or the patient's

 

 

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

 

 

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1             (iii) for plans or policies delivered, issued for
2         delivery, renewed, or modified after January 1, 2007
3         (the effective date of Public Act 94-906), 20
4         additional outpatient visits for speech therapy for
5         treatment of pervasive developmental disorders that
6         will be in addition to speech therapy provided pursuant
7         to item (ii) of this subparagraph (A);
8         (B) may not include a lifetime limit on the number of
9     days of inpatient treatment or the number of outpatient
10     visits covered under the plan; and
11         (C) shall include the same amount limits, deductibles,
12     copayments, and coinsurance factors for serious mental
13     illness as for physical illness.
14     (5) An issuer of a group health benefit plan may not count
15 toward the number of outpatient visits required to be covered
16 under this Section an outpatient visit for the purpose of
17 medication management and shall cover the outpatient visits
18 under the same terms and conditions as it covers outpatient
19 visits for the treatment of physical illness.
20     (6) An issuer of a group health benefit plan may provide or
21 offer coverage required under this Section through a managed
22 care plan.
23     (7) This Section shall not be interpreted to require a
24 group health benefit plan to provide coverage for treatment of:
25         (A) an addiction to a controlled substance or cannabis
26     that is used in violation of law; or

 

 

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1         (B) mental illness resulting from the use of a
2     controlled substance or cannabis in violation of law.
3     (8) (Blank).
4     (c) This Section shall not be interpreted to require
5 coverage for speech therapy or other habilitative services for
6 those individuals covered under Section 356z.14 of this Code.
7 (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05;
8 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff.
9 8-21-07.)
 
10     Section 30. The Health Maintenance Organization Act is
11 amended by changing Section 5-3 as follows:
 
12     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
13     Sec. 5-3. Insurance Code provisions.
14     (a) Health Maintenance Organizations shall be subject to
15 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
16 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
17 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
18 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
19 356z.14, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
20 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
21 444, and 444.1, paragraph (c) of subsection (2) of Section 367,
22 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
23 and XXVI of the Illinois Insurance Code.
24     (b) For purposes of the Illinois Insurance Code, except for

 

 

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1 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
2 Maintenance Organizations in the following categories are
3 deemed to be "domestic companies":
4         (1) a corporation authorized under the Dental Service
5     Plan Act or the Voluntary Health Services Plans Act;
6         (2) a corporation organized under the laws of this
7     State; or
8         (3) a corporation organized under the laws of another
9     state, 30% or more of the enrollees of which are residents
10     of this State, except a corporation subject to
11     substantially the same requirements in its state of
12     organization as is a "domestic company" under Article VIII
13     1/2 of the Illinois Insurance Code.
14     (c) In considering the merger, consolidation, or other
15 acquisition of control of a Health Maintenance Organization
16 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
17         (1) the Director shall give primary consideration to
18     the continuation of benefits to enrollees and the financial
19     conditions of the acquired Health Maintenance Organization
20     after the merger, consolidation, or other acquisition of
21     control takes effect;
22         (2)(i) the criteria specified in subsection (1)(b) of
23     Section 131.8 of the Illinois Insurance Code shall not
24     apply and (ii) the Director, in making his determination
25     with respect to the merger, consolidation, or other
26     acquisition of control, need not take into account the

 

 

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

 

 

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1     (e) In considering any management contract or service
2 agreement subject to Section 141.1 of the Illinois Insurance
3 Code, the Director (i) shall, in addition to the criteria
4 specified in Section 141.2 of the Illinois Insurance Code, take
5 into account the effect of the management contract or service
6 agreement on the continuation of benefits to enrollees and the
7 financial condition of the health maintenance organization to
8 be managed or serviced, and (ii) need not take into account the
9 effect of the management contract or service agreement on
10 competition.
11     (f) Except for small employer groups as defined in the
12 Small Employer Rating, Renewability and Portability Health
13 Insurance Act and except for medicare supplement policies as
14 defined in Section 363 of the Illinois Insurance Code, a Health
15 Maintenance Organization may by contract agree with a group or
16 other enrollment unit to effect refunds or charge additional
17 premiums under the following terms and conditions:
18         (i) the amount of, and other terms and conditions with
19     respect to, the refund or additional premium are set forth
20     in the group or enrollment unit contract agreed in advance
21     of the period for which a refund is to be paid or
22     additional premium is to be charged (which period shall not
23     be less than one year); and
24         (ii) the amount of the refund or additional premium
25     shall not exceed 20% of the Health Maintenance
26     Organization's profitable or unprofitable experience with

 

 

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1     respect to the group or other enrollment unit for the
2     period (and, for purposes of a refund or additional
3     premium, the profitable or unprofitable experience shall
4     be calculated taking into account a pro rata share of the
5     Health Maintenance Organization's administrative and
6     marketing expenses, but shall not include any refund to be
7     made or additional premium to be paid pursuant to this
8     subsection (f)). The Health Maintenance Organization and
9     the group or enrollment unit may agree that the profitable
10     or unprofitable experience may be calculated taking into
11     account the refund period and the immediately preceding 2
12     plan years.
13     The Health Maintenance Organization shall include a
14 statement in the evidence of coverage issued to each enrollee
15 describing the possibility of a refund or additional premium,
16 and upon request of any group or enrollment unit, provide to
17 the group or enrollment unit a description of the method used
18 to calculate (1) the Health Maintenance Organization's
19 profitable experience with respect to the group or enrollment
20 unit and the resulting refund to the group or enrollment unit
21 or (2) the Health Maintenance Organization's unprofitable
22 experience with respect to the group or enrollment unit and the
23 resulting additional premium to be paid by the group or
24 enrollment unit.
25     In no event shall the Illinois Health Maintenance
26 Organization Guaranty Association be liable to pay any

 

 

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1 contractual obligation of an insolvent organization to pay any
2 refund authorized under this Section.
3 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
4 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
5 8-21-08.)
 
6     Section 35. The Voluntary Health Services Plans Act is
7 amended by changing Section 10 as follows:
 
8     (215 ILCS 165/10)  (from Ch. 32, par. 604)
9     Sec. 10. Application of Insurance Code provisions. Health
10 services plan corporations and all persons interested therein
11 or dealing therewith shall be subject to the provisions of
12 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
13 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,
14 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
15 356z.9, 356z.10, 356z.14, 364.01, 367.2, 368a, 401, 401.1, 402,
16 403, 403A, 408, 408.2, and 412, and paragraphs (7) and (15) of
17 Section 367 of the Illinois Insurance Code.
18 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
19 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
20 8-28-07; 95-876, eff. 8-21-08.)
 
21     Section 90. The State Mandates Act is amended by adding
22 Section 8.32 as follows:
 

 

 

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1     (30 ILCS 805/8.32 new)
2     Sec. 8.32. Exempt mandate. Notwithstanding Sections 6 and 8
3 of this Act, no reimbursement by the State is required for the
4 implementation of any mandate created by this amendatory Act of
5 the 95th General Assembly.".