Sen. Jacqueline Y. Collins

Filed: 5/29/2008

 

 


 

 


 
09500SB0874sam002 LRB095 05624 MJR 51682 a

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, and 356z.9,
14 and 356z.10 356z.9 of the Illinois Insurance Code. The program
15 of health benefits must comply with Section 155.37 of the
16 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; revised 12-4-07.)
 
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, and
13 356z.9, and 356z.10 356z.9 of the Illinois Insurance Code. The
14 requirement that health benefits be covered as provided in this
15 Section is an exclusive power and function of the State and is
16 a denial and limitation under Article VII, Section 6,
17 subsection (h) of the Illinois Constitution. A home rule county
18 to which this Section applies must comply with every provision
19 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; revised 12-4-07.)
 
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, and 356z.9, and 356z.10 356z.9 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; revised 12-4-07.)
 
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 of the Illinois Insurance Code.
4 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
5 revised 12-4-07.)
 
6     Section 25. The Illinois Insurance Code is amended by
7 adding Section 356f.1 as follows:
 
8     (215 ILCS 5/356f.1 new)
9     Sec. 356f.1. External review appeals process.
10     (a) A policy of accident or health insurance or managed
11 care plan shall maintain an external review appeals process for
12 member or member representative requests to reverse or modify
13 adverse determinations made by the insurer or managed care
14 plan. For the purposes of this Section, "adverse determination"
15 means a determination by a health insurer, managed care plan,
16 or its designee utilization review organization that an
17 admission, course of treatment, continued stay, or other heath
18 care service that is not excluded explicitly by applicable
19 benefit language, including determinations that a health
20 service is experimental or investigational, does not meet the
21 insurer's or managed care plan's requirements for medical
22 necessity, appropriateness, health care setting, level of
23 care, or effectiveness and the requested payment for the
24 service is therefore denied, reduced, or terminated.

 

 

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1     (b) An insurer or managed care plan shall comply with
2 subsection (a) of this Section by providing an external review
3 appeals program that meets or exceeds the Health Utilization
4 Management independent review process standards established by
5 URAC, whether or not the appeal relates to adverse
6 determinations related to utilization management review.
7     (c) An insurer or managed care plan may comply with this
8 Section by:
9         (1) registering its utilization review program,
10     including appeals, with the Division of Insurance, as
11     provided in Section 85 of the Managed Care and Patients
12     Rights Act, and certifying compliance with the external
13     review standards of the Health Utilization Management
14     Standards of URAC sufficient to achieve accreditation from
15     URAC, doing business as the American Accreditation
16     Healthcare Commission, Inc.; or
17         (2) submitting evidence of accreditation by the
18     American Accreditation Healthcare Commission (URAC) for
19     its Health Utilization Management Standards.
20     Nothing in this Act shall be construed to require an
21 insurer or managed care plan or its subcontractors to become
22 American Accreditation Healthcare Commission (URAC)
23 accredited.
24     (d) The Director of the Division of Insurance, in
25 consultation with the Director of the Department of Public
26 Health, may certify alternative external review standards of

 

 

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1 national accreditation organizations or entities in order for
2 insurers or managed care plans to comply with this Section. Any
3 alternative external review standards shall meet or exceed
4 those standards required under subsection (b) of this Section.
5     (e) This Section does not apply to:
6         (1) persons providing utilization review program
7     services only to the federal government;
8         (2) self-insured health plans under the federal
9     Employee Retirement Income Security Act of 1974; however,
10     this Section does apply to persons conducting a utilization
11     review program on behalf of these health plans;
12         (3) hospitals and medical groups performing
13     utilization review activities for internal purposes unless
14     the utilization review program is conducted for another
15     person; or
16         (4) workers' compensation, short-term travel,
17     accident-only, limited, or specific disease policies.
18     Nothing in this Act prohibits an insurer or managed care
19 plan or other entity from contractually requiring an entity
20 designated in item (3) of this subsection (e) to adhere to the
21 utilization review program requirements of this Act.
22     (f) If the Division of Insurance finds that an external
23 review program is not in compliance with this Section, the
24 Director shall issue a corrective action plan and allow a
25 reasonable amount of time for compliance with the insurer or
26 managed care plan. Before issuing a cease and desist order

 

 

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1 under this Section, the Director shall provide the insurer or
2 managed care plan with a written notice of the reasons for the
3 order and allow a reasonable amount of time to supply
4 additional information demonstrating compliance with
5 requirements of this Section and to request a hearing. The
6 hearing notice shall be sent by certified mail, return receipt
7 requested and the hearing shall be conducted in accordance with
8 the Illinois Administrative Procedure Act.
9     If the insurer's or managed care plan's external review
10 program does not come into compliance with this Section, the
11 Director may issue a cease and desist order.
12     (g) A utilization review program subject to a corrective
13 action may continue to conduct business until a final decision
14 has been issued by the Director.
 
15     Section 30. The Limited Health Service Organization Act is
16 amended by changing Section 4003 as follows:
 
17     (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
18     Sec. 4003. Illinois Insurance Code provisions. Limited
19 health service organizations shall be subject to the provisions
20 of Sections 133, 134, 137, 140, 141.1, 141.2, 141.3, 143, 143c,
21 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6, 154.7, 154.8,
22 155.04, 155.37, 355.2, 356f.1, 356v, 356z.10 356z.9, 368a, 401,
23 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and
24 Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and

 

 

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1 XXVI of the Illinois Insurance Code. For purposes of the
2 Illinois Insurance Code, except for Sections 444 and 444.1 and
3 Articles XIII and XIII 1/2, limited health service
4 organizations in the following categories are deemed to be
5 domestic companies:
6         (1) a corporation under the laws of this State; or
7         (2) a corporation organized under the laws of another
8     state, 30% of more of the enrollees of which are residents
9     of this State, except a corporation subject to
10     substantially the same requirements in its state of
11     organization as is a domestic company under Article VIII
12     1/2 of the Illinois Insurance Code.
13 (Source: P.A. 95-520, eff. 8-28-07; revised 12-5-07.)
 
14     Section 35. The Voluntary Health Services Plans Act is
15 amended by changing Section 10 as follows:
 
16     (215 ILCS 165/10)  (from Ch. 32, par. 604)
17     Sec. 10. Application of Insurance Code provisions. Health
18 services plan corporations and all persons interested therein
19 or dealing therewith shall be subject to the provisions of
20 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
21 149, 155.37, 354, 355.2, 356f.1, 356g.5, 356r, 356t, 356u,
22 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
23 356z.8, 356z.9, 356z.10 356z.9, 364.01, 367.2, 368a, 401,
24 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)

 

 

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1 and (15) of Section 367 of the Illinois Insurance Code.
2 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
3 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
4 8-28-07; revised 12-5-07.)".