95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
SB1900

 

Introduced 1/10/2008, by Sen. James A. DeLeo

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/356z.11 new
215 ILCS 125/5-3   from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003   from Ch. 73, par. 1504-3
215 ILCS 165/10   from Ch. 32, par. 604
305 ILCS 5/5-16.8

    Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Illinois Insurance Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, the Voluntary Health Services Plans Act, and the Illinois Public Aid Code to provide coverage for autism spectrum disorders to the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by the policy or plan. Provides that this coverage shall be subject to a maximum benefit of $36,000 per year, but shall not be subject to any limits on the number of visits to an autism service provider. Makes other changes. Effective immediately.


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FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

SB1900 LRB095 16815 KBJ 42853 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
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 356g.5,
13 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10,
14 and 356z.11 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.
17 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
18 95-520, eff. 8-28-07; revised 12-4-07.)
 
19     Section 10. The Counties Code is amended by changing
20 Section 5-1069.3 as follows:
 
21     (55 ILCS 5/5-1069.3)

 

 

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1     Sec. 5-1069.3. Required health benefits. If a county,
2 including a home rule county, is a self-insurer for purposes of
3 providing health insurance coverage for its employees, the
4 coverage shall include coverage for the post-mastectomy care
5 benefits required to be covered by a policy of accident and
6 health insurance under Section 356t and the coverage required
7 under Sections 356g.5, 356u, 356w, 356x, 356z.6, and 356z.9,
8 356z.10, and 356z.11 356z.9 of the Illinois Insurance Code. The
9 requirement that health benefits be covered as provided in this
10 Section is an exclusive power and function of the State and is
11 a denial and limitation under Article VII, Section 6,
12 subsection (h) of the Illinois Constitution. A home rule county
13 to which this Section applies must comply with every provision
14 of this Section.
15 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
16 95-520, eff. 8-28-07; revised 12-4-07.)
 
17     Section 15. The Illinois Municipal Code is amended by
18 changing Section 10-4-2.3 as follows:
 
19     (65 ILCS 5/10-4-2.3)
20     Sec. 10-4-2.3. Required health benefits. If a
21 municipality, including a home rule municipality, is a
22 self-insurer for purposes of providing health insurance
23 coverage for its employees, the coverage shall include coverage
24 for the post-mastectomy care benefits required to be covered by

 

 

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1 a policy of accident and health insurance under Section 356t
2 and the coverage required under Sections 356g.5, 356u, 356w,
3 356x, 356z.6, and 356z.9, 356z.10, and 356z.11 356z.9 of the
4 Illinois Insurance Code. The requirement that health benefits
5 be covered as provided in this is an exclusive power and
6 function of the State and is a denial and limitation under
7 Article VII, Section 6, subsection (h) of the Illinois
8 Constitution. A home rule municipality to which this Section
9 applies must comply with every provision of this Section.
10 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
11 95-520, eff. 8-28-07; revised 12-4-07.)
 
12     Section 20. The School Code is amended by changing Section
13 10-22.3f as follows:
 
14     (105 ILCS 5/10-22.3f)
15     Sec. 10-22.3f. Required health benefits. Insurance
16 protection and benefits for employees shall provide the
17 post-mastectomy care benefits required to be covered by a
18 policy of accident and health insurance under Section 356t and
19 the coverage required under Sections 356g.5, 356u, 356w, 356x,
20 356z.6, and 356z.9, and 356z.11 of the Illinois Insurance Code.
21 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
22 revised 12-4-07.)
 
23     Section 25. The Illinois Insurance Code is amended by

 

 

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1 adding Section 356z.11 as follows:
 
2     (215 ILCS 5/356z.11 new)
3     Sec. 356z.11. Autism spectrum disorders.
4     (a) A group or individual policy of accident and health
5 insurance or managed care plan amended, delivered, issued, or
6 renewed after the effective date of this amendatory Act of the
7 95th General Assembly must provide individuals under 21 years
8 of age coverage for the diagnosis of autism spectrum disorders
9 and for the treatment of autism spectrum disorders to the
10 extent that the diagnosis and treatment of autism spectrum
11 disorders are not already covered by the policy of accident and
12 health insurance or managed care plan.
13     (b) Coverage provided under this Section shall be subject
14 to a maximum benefit of $36,000 per year, but shall not be
15 subject to any limits on the number of visits to an autism
16 service provider. After December 30, 2009, the Director of the
17 Division of Insurance shall, on an annual basis, adjust the
18 maximum benefit for inflation using the Medical Care Component
19 of the United States Department of Labor Consumer Price Index
20 for All Urban Consumers. Payments made by an insurer on behalf
21 of a covered individual for any care, treatment, intervention,
22 service, or item, the provision of which was for the treatment
23 of a health condition unrelated to the covered individual's
24 autism spectrum disorder, shall not be applied toward any
25 maximum benefit established under this subsection.

 

 

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1     (c) Coverage under this Section shall be subject to
2 co-payment, deductible, and coinsurance provisions of a policy
3 of accident and health insurance or managed care plan to the
4 extent that other medical services covered by the policy of
5 accident and health insurance or managed care plan are subject
6 to these provisions.
7     (d) This Section shall not be construed as limiting
8 benefits which are otherwise available to an individual under a
9 policy of accident and health insurance or managed care plan.
10     (e) As used in this Section:
11     "Autism service provider" means any person, entity, or
12 group that provides treatment of autism spectrum disorders.
13     "Autism spectrum disorders" means any of the pervasive
14 developmental disorders as defined in the most recent edition
15 of the Diagnostic and Statistical Manual of Mental Disorders,
16 including autistic disorder, Asperger's disorder, and
17 pervasive developmental disorder not otherwise specified.
18     "Diagnosis of autism spectrum disorders" means medically
19 necessary assessments, evaluations, or tests in order to
20 diagnose whether an individual has an autism spectrum disorder.
21     "Treatment for autism spectrum disorders" shall include
22 the following care prescribed, provided, or ordered for an
23 individual diagnosed with an autism spectrum disorder by a
24 licensed physician, licensed psychologist, or certified
25 registered nurse practitioner if the care is determined to be
26 medically necessary:

 

 

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1         (i) Psychiatric care.
2         (ii) Psychological care.
3         (iii) Rehabilitative care.
4         (iv) Therapeutic care, including speech, occupational,
5     and physical therapy.
6         (v) Pharmacy care.
7         (vi) Applied behavior analysis therapy.
8         (vii) Any care, treatment, intervention, service or
9     item for individuals with an autism spectrum disorder which
10     is determined by the Department of Health Care and Family
11     Services, based upon its review of best practices or
12     evidenced-based research, to be medically necessary.
 
13     Section 30. The Health Maintenance Organization Act is
14 amended by changing Section 5-3 as follows:
 
15     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
16     Sec. 5-3. Insurance Code provisions.
17     (a) Health Maintenance Organizations shall be subject to
18 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
19 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
20 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
21 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10
22 356z.9, 356z.11, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
23 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2,
24 409, 412, 444, and 444.1, paragraph (c) of subsection (2) of

 

 

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1 Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
2 XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
3     (b) For purposes of the Illinois Insurance Code, except for
4 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
5 Maintenance Organizations in the following categories are
6 deemed to be "domestic companies":
7         (1) a corporation authorized under the Dental Service
8     Plan Act or the Voluntary Health Services Plans Act;
9         (2) a corporation organized under the laws of this
10     State; or
11         (3) a corporation organized under the laws of another
12     state, 30% or more of the enrollees of which are residents
13     of this State, except a corporation subject to
14     substantially the same requirements in its state of
15     organization as is a "domestic company" under Article VIII
16     1/2 of the Illinois Insurance Code.
17     (c) In considering the merger, consolidation, or other
18 acquisition of control of a Health Maintenance Organization
19 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
20         (1) the Director shall give primary consideration to
21     the continuation of benefits to enrollees and the financial
22     conditions of the acquired Health Maintenance Organization
23     after the merger, consolidation, or other acquisition of
24     control takes effect;
25         (2)(i) the criteria specified in subsection (1)(b) of
26     Section 131.8 of the Illinois Insurance Code shall not

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1     state, 30% of more of the enrollees of which are residents
2     of this State, except a corporation subject to
3     substantially the same requirements in its state of
4     organization as is a domestic company under Article VIII
5     1/2 of the Illinois Insurance Code.
6 (Source: P.A. 95-520, eff. 8-28-07; revised 12-5-07.)
 
7     Section 40. The Voluntary Health Services Plans Act is
8 amended by changing Section 10 as follows:
 
9     (215 ILCS 165/10)  (from Ch. 32, par. 604)
10     Sec. 10. Application of Insurance Code provisions. Health
11 services plan corporations and all persons interested therein
12 or dealing therewith shall be subject to the provisions of
13 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
14 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,
15 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
16 356z.9, 356z.10 356z.9, 356z.11, 364.01, 367.2, 368a, 401,
17 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
18 and (15) of Section 367 of the Illinois Insurance Code.
19 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
20 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
21 8-28-07; revised 12-5-07.)
 
22     Section 45. The Illinois Public Aid Code is amended by
23 changing Section 5-16.8 as follows:
 

 

 

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1     (305 ILCS 5/5-16.8)
2     Sec. 5-16.8. Required health benefits. The medical
3 assistance program shall (i) provide the post-mastectomy care
4 benefits required to be covered by a policy of accident and
5 health insurance under Section 356t and the coverage required
6 under Sections 356g.5, 356u, 356w, 356x, and 356z.6, and
7 356z.11 of the Illinois Insurance Code and (ii) be subject to
8 the provisions of Section 364.01 of the Illinois Insurance
9 Code.
10 (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07.)
 
11     Section 99. Effective date. This Act takes effect upon
12 becoming law.