Health Care Availability and Access Committee

Adopted in House Comm. on Nov 19, 2008

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 874

2     AMENDMENT NO. ______. Amend Senate Bill 874 by replacing
3 everything after the enacting clause with the following:
 
4     "Section 5. The State Employees Group Insurance Act of 1971
5 is amended by changing Section 6.11 as follows:
 
6     (5 ILCS 375/6.11)
7     Sec. 6.11. Required health benefits; Illinois Insurance
8 Code requirements. The program of health benefits shall provide
9 the post-mastectomy care benefits required to be covered by a
10 policy of accident and health insurance under Section 356t of
11 the Illinois Insurance Code. The program of health benefits
12 shall provide the coverage required under Sections 356f.1,
13 356g.5, 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, and
14 356z.10, and 356z.14 of the Illinois Insurance Code. The
15 program of health benefits must comply with Section 155.37 of
16 the Illinois Insurance Code.

 

 

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1 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
2 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
3     Section 10. The Counties Code is amended by changing
4 Section 5-1069.3 as follows:
 
5     (55 ILCS 5/5-1069.3)
6     Sec. 5-1069.3. Required health benefits. If a county,
7 including a home rule county, is a self-insurer for purposes of
8 providing health insurance coverage for its employees, the
9 coverage shall include coverage for the post-mastectomy care
10 benefits required to be covered by a policy of accident and
11 health insurance under Section 356t and the coverage required
12 under Sections 356f.1, 356g.5, 356u, 356w, 356x, 356z.6,
13 356z.9, and 356z.10, and 356z.14 of the Illinois Insurance
14 Code. The requirement that health benefits be covered as
15 provided in this Section is an exclusive power and function of
16 the State and is a denial and limitation under Article VII,
17 Section 6, subsection (h) of the Illinois Constitution. A home
18 rule county to which this Section applies must comply with
19 every provision of this Section.
20 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
21 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
22     Section 15. The Illinois Municipal Code is amended by
23 changing Section 10-4-2.3 as follows:
 

 

 

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

 

 

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1 policy of accident and health insurance under Section 356t and
2 the coverage required under Sections 356f.1, 356g.5, 356u,
3 356w, 356x, 356z.6, and 356z.9, and 356z.14 of the Illinois
4 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 adding Section 356f.1 as follows:
 
9     (215 ILCS 5/356f.1 new)
10     Sec. 356f.1. Health care services appeals, complaints, and
11 external independent reviews.
12     (a) A policy of accident or health insurance or managed
13 care plan shall establish and maintain an appeals procedure as
14 outlined in this Section. Compliance with this Section's
15 appeals procedures shall satisfy a policy or plan's obligation
16 to provide appeal procedures under any other State law or
17 rules.
18     (b) When an appeal concerns a decision or action by a
19 policy of accident or health insurance or managed care plan,
20 its employees, or its subcontractors that relates to (i) health
21 care services, including, but not limited to, procedures or
22 treatments for an enrollee with an ongoing course of treatment
23 ordered by a health care provider, the denial of which could
24 significantly increase the risk to an enrollee's health, or

 

 

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1 (ii) a treatment referral, service, procedure, or other health
2 care service, the denial of which could significantly increase
3 the risk to an enrollee's health, the policy or plan must allow
4 for the filing of an appeal either orally or in writing. Upon
5 submission of the appeal, a policy or plan must notify the
6 party filing the appeal, as soon as possible, but in no event
7 more than 24 hours after the submission of the appeal, of all
8 information that the plan requires to evaluate the appeal. The
9 policy or plan shall render a decision on the appeal within 24
10 hours after receipt of the required information. The policy or
11 plan shall notify the party filing the appeal and the enrollee,
12 enrollee's primary care physician, and any health care provider
13 who recommended the health care service involved in the appeal
14 of its decision orally followed-up by a written notice of the
15 determination.
16     (c) For all appeals related to health care services
17 including, but not limited to, procedures or treatments for an
18 enrollee and not covered by subsection (b) above, the policy or
19 plan shall establish a procedure for the filing of such
20 appeals. Upon submission of an appeal under this subsection, a
21 policy or plan must notify the party filing an appeal, within 3
22 business days, of all information that the policy or plan
23 requires to evaluate the appeal. The policy or plan shall
24 render a decision on the appeal within 15 business days after
25 receipt of the required information. The policy or plan shall
26 notify the party filing the appeal, the enrollee, the

 

 

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1 enrollee's primary care physician, and any health care provider
2 who recommended the health care service involved in the appeal
3 orally of its decision followed-up by a written notice of the
4 determination.
5     (d) An appeal under subsection (b) or (c) may be filed by
6 the enrollee, the enrollee's designee or guardian, the
7 enrollee's primary care physician, or the enrollee's health
8 care provider. A policy or plan shall designate a clinical peer
9 to review appeals, because these appeals pertain to medical or
10 clinical matters and such an appeal must be reviewed by an
11 appropriate health care professional. No one reviewing an
12 appeal may have had any involvement in the initial
13 determination that is the subject of the appeal. The written
14 notice of determination required under subsections (b) and (c)
15 shall include (i) clear and detailed reasons for the
16 determination, (ii) the medical or clinical criteria for the
17 determination, which shall be based upon sound clinical
18 evidence and reviewed on a periodic basis, and (iii) in the
19 case of an adverse determination, the procedures for requesting
20 an external independent review under subsection (f).
21     (e) If an appeal filed under subsection (b) or (c) is
22 denied for a reason including, but not limited to, the service,
23 procedure, or treatment is not viewed as medically necessary,
24 denial of specific tests or procedures, denial of referral to
25 specialist physicians or denial of hospitalization requests or
26 length of stay requests, any involved party may request an

 

 

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1 external independent review under subsection (f) of the adverse
2 determination.
3     (f) The party seeking an external independent review shall
4 so notify the policy or plan. The policy or plan shall seek to
5 resolve all external independent reviews in the most
6 expeditious manner and shall make a determination and provide
7 notice of the determination no more than 24 hours after the
8 receipt of all necessary information when a delay would
9 significantly increase the risk to an enrollee's health or when
10 extended health care services for an enrollee undergoing a
11 course of treatment prescribed by a health care provider are at
12 issue.
13         (1) Within 30 days after the enrollee receives written
14     notice of an adverse determination, if the enrollee decides
15     to initiate an external independent review, the enrollee
16     shall send to the policy or plan a written request for an
17     external independent review, including any information or
18     documentation to support the enrollee's request for the
19     covered service or claim for a covered service.
20         (2) Within 30 days after the policy or plan receives a
21     request for an external independent review from an enrollee
22     or, within 24 hours after the receipt of a request if a
23     delay would significantly increase the risk to the
24     enrollee's health, the policy or plan shall:
25             (a) provide a mechanism for joint selection of an
26         external independent reviewer by the enrollee, the

 

 

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1         enrollee's physician or other health care provider,
2         and the policy or plan; and
3             (b) forward to the independent reviewer all
4         medical records and supporting documentation
5         pertaining to the case, a summary description of the
6         applicable issues including a statement of the
7         decision made by, the criteria used, and the medical
8         and clinical reasons for that decision.
9         (3) Within 5 days after receipt of all necessary
10     information or within 24 hours when a delay would
11     significantly increase the risk to an enrollee's health,
12     the independent reviewer shall evaluate and analyze the
13     case and render a decision that is based on whether or not
14     the health care service or claim for the health care
15     service is medically appropriate. The decision by the
16     independent reviewer is final. If the external independent
17     reviewer determines the health care service to be medically
18     appropriate, the policy or plan shall pay for the health
19     care service.
20         (4) The policy or plan shall be solely responsible for
21     paying the fees of the external independent reviewer who is
22     selected to perform the review.
23         (5) An external independent reviewer who acts in good
24     faith shall have immunity from any civil or criminal
25     liability or professional discipline as a result of acts or
26     omissions with respect to any external independent review,

 

 

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1     unless the acts or omissions constitute wilful and wanton
2     misconduct. For purposes of any proceeding, the good faith
3     of the person participating shall be presumed.
4         (6) Future contractual or employment action by the
5     policy or plan regarding the patient's physician or other
6     health care provider shall not be based solely on the
7     physician's or other health care provider's participation
8     in this procedure.
9         (7) For the purposes of this Section, an external
10     independent reviewer shall:
11             (a) be a clinical peer;
12             (b) have no direct financial interest in
13         connection with the case; and
14             (c) have not been informed of the specific identity
15         of the enrollee.
16     (g) Nothing in this Section shall be construed to require a
17 policy or plan to pay for a health care service not covered
18 under the enrollee's certificate of coverage or policy.
19     (h) A policy of accident or health insurance or managed
20 care plan shall provide each enrollee, prospective enrollee,
21 and enrollee representative with written notification of the
22 policy's or plan's appeal process and any external review
23 appeals process that is available to the enrollee. This
24 notification shall be provided at the time the insured enrolls
25 in the health insurance or managed care plan, renews such
26 enrollment, or requests to reverse or modify an adverse

 

 

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1 determination made by the insurer or managed care plan. The
2 notice outlined in this subsection (h) shall describe the
3 policy's or plan's appeals process, any applicable forms, and
4 the time frames for appeals, complaints, and external review
5 appeals and shall include a phone number to call for more
6 information from the policy or plan concerning the appeals
7 process.
8     (i) Rulemaking authority to implement this amendatory Act
9 of the 95th General Assembly, if any, is conditioned on the
10 rules being adopted in accordance with all provisions of the
11 Illinois Administrative Procedure Act and all rules and
12 procedures of the Joint Committee on Administrative Rules; any
13 purported rule not so adopted, for whatever reason, is
14 unauthorized.
 
15     Section 30. The Health Maintenance Organization Act is
16 amended by changing Section 5-3 as follows:
 
17     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
18     Sec. 5-3. Insurance Code provisions.
19     (a) Health Maintenance Organizations shall be subject to
20 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
21 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
22 154.6, 154.7, 154.8, 155.04, 355.2, 356f.1, 356m, 356v, 356w,
23 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
24 356z.10, 356z.14, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,

 

 

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1 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2,
2 409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
3 Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
4 XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
5     (b) For purposes of the Illinois Insurance Code, except for
6 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
7 Maintenance Organizations in the following categories are
8 deemed to be "domestic companies":
9         (1) a corporation authorized under the Dental Service
10     Plan Act or the Voluntary Health Services Plans Act;
11         (2) a corporation organized under the laws of this
12     State; or
13         (3) a corporation organized under the laws of another
14     state, 30% or more of the enrollees of which are residents
15     of this State, except a corporation subject to
16     substantially the same requirements in its state of
17     organization as is a "domestic company" under Article VIII
18     1/2 of the Illinois Insurance Code.
19     (c) In considering the merger, consolidation, or other
20 acquisition of control of a Health Maintenance Organization
21 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
22         (1) the Director shall give primary consideration to
23     the continuation of benefits to enrollees and the financial
24     conditions of the acquired Health Maintenance Organization
25     after the merger, consolidation, or other acquisition of
26     control takes effect;

 

 

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1         (2)(i) the criteria specified in subsection (1)(b) of
2     Section 131.8 of the Illinois Insurance Code shall not
3     apply and (ii) the Director, in making his determination
4     with respect to the merger, consolidation, or other
5     acquisition of control, need not take into account the
6     effect on competition of the merger, consolidation, or
7     other acquisition of control;
8         (3) the Director shall have the power to require the
9     following information:
10             (A) certification by an independent actuary of the
11         adequacy of the reserves of the Health Maintenance
12         Organization sought to be acquired;
13             (B) pro forma financial statements reflecting the
14         combined balance sheets of the acquiring company and
15         the Health Maintenance Organization sought to be
16         acquired as of the end of the preceding year and as of
17         a date 90 days prior to the acquisition, as well as pro
18         forma financial statements reflecting projected
19         combined operation for a period of 2 years;
20             (C) a pro forma business plan detailing an
21         acquiring party's plans with respect to the operation
22         of the Health Maintenance Organization sought to be
23         acquired for a period of not less than 3 years; and
24             (D) such other information as the Director shall
25         require.
26     (d) The provisions of Article VIII 1/2 of the Illinois

 

 

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1 Insurance Code and this Section 5-3 shall apply to the sale by
2 any health maintenance organization of greater than 10% of its
3 enrollee population (including without limitation the health
4 maintenance organization's right, title, and interest in and to
5 its health care certificates).
6     (e) In considering any management contract or service
7 agreement subject to Section 141.1 of the Illinois Insurance
8 Code, the Director (i) shall, in addition to the criteria
9 specified in Section 141.2 of the Illinois Insurance Code, take
10 into account the effect of the management contract or service
11 agreement on the continuation of benefits to enrollees and the
12 financial condition of the health maintenance organization to
13 be managed or serviced, and (ii) need not take into account the
14 effect of the management contract or service agreement on
15 competition.
16     (f) Except for small employer groups as defined in the
17 Small Employer Rating, Renewability and Portability Health
18 Insurance Act and except for medicare supplement policies as
19 defined in Section 363 of the Illinois Insurance Code, a Health
20 Maintenance Organization may by contract agree with a group or
21 other enrollment unit to effect refunds or charge additional
22 premiums under the following terms and conditions:
23         (i) the amount of, and other terms and conditions with
24     respect to, the refund or additional premium are set forth
25     in the group or enrollment unit contract agreed in advance
26     of the period for which a refund is to be paid or

 

 

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1     additional premium is to be charged (which period shall not
2     be less than one year); and
3         (ii) the amount of the refund or additional premium
4     shall not exceed 20% of the Health Maintenance
5     Organization's profitable or unprofitable experience with
6     respect to the group or other enrollment unit for the
7     period (and, for purposes of a refund or additional
8     premium, the profitable or unprofitable experience shall
9     be calculated taking into account a pro rata share of the
10     Health Maintenance Organization's administrative and
11     marketing expenses, but shall not include any refund to be
12     made or additional premium to be paid pursuant to this
13     subsection (f)). The Health Maintenance Organization and
14     the group or enrollment unit may agree that the profitable
15     or unprofitable experience may be calculated taking into
16     account the refund period and the immediately preceding 2
17     plan years.
18     The Health Maintenance Organization shall include a
19 statement in the evidence of coverage issued to each enrollee
20 describing the possibility of a refund or additional premium,
21 and upon request of any group or enrollment unit, provide to
22 the group or enrollment unit a description of the method used
23 to calculate (1) the Health Maintenance Organization's
24 profitable experience with respect to the group or enrollment
25 unit and the resulting refund to the group or enrollment unit
26 or (2) the Health Maintenance Organization's unprofitable

 

 

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1 experience with respect to the group or enrollment unit and the
2 resulting additional premium to be paid by the group or
3 enrollment unit.
4     In no event shall the Illinois Health Maintenance
5 Organization Guaranty Association be liable to pay any
6 contractual obligation of an insolvent organization to pay any
7 refund authorized under this Section.
8 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
9 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
10 8-21-08.)
 
11     Section 35. The Limited Health Service Organization Act is
12 amended by changing Section 4003 as follows:
 
13     (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
14     Sec. 4003. Illinois Insurance Code provisions. Limited
15 health service organizations shall be subject to the provisions
16 of Sections 133, 134, 137, 140, 141.1, 141.2, 141.3, 143, 143c,
17 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6, 154.7, 154.8,
18 155.04, 155.37, 355.2, 356f.1, 356v, 356z.10 356z.9, 368a, 401,
19 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and
20 Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and
21 XXVI of the Illinois Insurance Code. For purposes of the
22 Illinois Insurance Code, except for Sections 444 and 444.1 and
23 Articles XIII and XIII 1/2, limited health service
24 organizations in the following categories are deemed to be

 

 

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1 domestic companies:
2         (1) a corporation under the laws of this State; or
3         (2) a corporation organized under the laws of another
4     state, 30% of more of the enrollees of which are residents
5     of this State, except a corporation subject to
6     substantially the same requirements in its state of
7     organization as is a domestic company under Article VIII
8     1/2 of the Illinois Insurance Code.
9 (Source: P.A. 95-520, eff. 8-28-07; revised 12-5-07.)
 
10     Section 40. The Voluntary Health Services Plans Act is
11 amended by changing Section 10 as follows:
 
12     (215 ILCS 165/10)  (from Ch. 32, par. 604)
13     Sec. 10. Application of Insurance Code provisions. Health
14 services plan corporations and all persons interested therein
15 or dealing therewith shall be subject to the provisions of
16 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
17 149, 155.37, 354, 355.2, 356f.1, 356g.5, 356r, 356t, 356u,
18 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
19 356z.8, 356z.9, 356z.10, 356z.14, 364.01, 367.2, 368a, 401,
20 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
21 and (15) of Section 367 of the Illinois Insurance Code.
22 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
23 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
24 8-28-07; 95-876, eff. 8-21-08.)".