HB2652 Enrolled LRB096 10389 RPM 20559 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 Illinois Insurance Code is amended by
5 renumbering Section 356z.14 as added by Public Act 95-1005, by
6 changing and renumbering Section 356z.15 as added by Public Act
7 96-639, and by adding Section 356z.18 as follows:
 
8     (215 ILCS 5/356z.15)
9     Sec. 356z.15 356z.14. Habilitative services for children.
10     (a) As used in this Section, "habilitative services" means
11 occupational therapy, physical therapy, speech therapy, and
12 other services prescribed by the insured's treating physician
13 pursuant to a treatment plan to enhance the ability of a child
14 to function with a congenital, genetic, or early acquired
15 disorder. A congenital or genetic disorder includes, but is not
16 limited to, hereditary disorders. An early acquired disorder
17 refers to a disorder resulting from illness, trauma, injury, or
18 some other event or condition suffered by a child prior to that
19 child developing functional life skills such as, but not
20 limited to, walking, talking, or self-help skills. Congenital,
21 genetic, and early acquired disorders may include, but are not
22 limited to, autism or an autism spectrum disorder, cerebral
23 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 (Source: P.A. 95-1049, eff. 1-1-10; revised 10-23-09.)
 
19     (215 ILCS 5/356z.17)
20     Sec. 356z.17 356z.15. Wellness coverage.
21     (a) A group or individual policy of accident and health
22 insurance or managed care plan amended, delivered, issued, or
23 renewed after January 1, 2010 (the effective date of Public Act
24 96-639) this amendatory Act of the 96th General Assembly that
25 provides coverage for hospital or medical treatment on an

 

 

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1 expense incurred basis may offer a reasonably designed program
2 for wellness coverage that allows for a reward, a contribution,
3 a reduction in premiums or reduced medical, prescription drug,
4 or equipment copayments, coinsurance, or deductibles, or a
5 combination of these incentives, for participation in any
6 health behavior wellness, maintenance, or improvement program
7 approved or offered by the insurer or managed care plan. The
8 insured or enrollee may be required to provide evidence of
9 participation in a program. Individuals unable to participate
10 in these incentives due to an adverse health factor shall not
11 be penalized based upon an adverse health status.
12     (b) For purposes of this Section, "wellness coverage" means
13 health care coverage with the primary purpose to engage and
14 motivate the insured or enrollee through: incentives;
15 provision of health education, counseling, and self-management
16 skills; identification of modifiable health risks; and other
17 activities to influence health behavior changes.
18     For the purposes of this Section, "reasonably designed
19 program" means a program of wellness coverage that has a
20 reasonable chance of improving health or preventing disease; is
21 not overly burdensome; does not discriminate based upon factors
22 of health; and is not otherwise contrary to law.
23     (c) Incentives as outlined in this Section are specific and
24 unique to the offering of wellness coverage and have no
25 application to any other required or optional health care
26 benefit.

 

 

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1     (d) Such wellness coverage must satisfy the requirements
2 for an exception from the general prohibition against
3 discrimination based on a health factor under the federal
4 Health Insurance Portability and Accountability Act of 1996
5 (P.L. 104-191; 110 Stat. 1936), including any federal
6 regulations that are adopted pursuant to that Act.
7     (e) A plan offering wellness coverage must do the
8 following:
9         (i) give participants the opportunity to qualify for
10     offered incentives at least once a year;
11         (ii) allow a reasonable alternative to any individual
12     for whom it is unreasonably difficult, due to a medical
13     condition, to satisfy otherwise applicable wellness
14     program standards. Plans may seek physician verification
15     that health factors make it unreasonably difficult or
16     medically inadvisable for the participant to satisfy the
17     standards; and
18         (iii) not provide a total incentive that exceeds 20% of
19     the cost of employee-only coverage. The cost of
20     employee-only coverage includes both employer and employee
21     contributions. For plans offering family coverage, the 20%
22     limitation applies to cost of family coverage and applies
23     to the entire family.
24     (f) A reward, contribution, or reduction established under
25 this Section and included in the policy or certificate does not
26 violate Section 151 of this Code.

 

 

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1 (Source: P.A. 96-639, eff. 1-1-10; revised 10-21-09.)
 
2     (215 ILCS 5/356z.18 new)
3     Sec. 356z.18. Prosthetic and customized orthotic devices.
4     (a) For the purposes of this Section:
5     "Customized orthotic device" means a supportive device for
6 the body or a part of the body, the head, neck, or extremities,
7 and includes the replacement or repair of the device based on
8 the patient's physical condition as medically necessary,
9 excluding foot orthotics defined as an in-shoe device designed
10 to support the structural components of the foot during
11 weight-bearing activities.
12     "Licensed provider" means a prosthetist, orthotist, or
13 pedorthist licensed to practice in this State.
14     "Prosthetic device" means an artificial device to replace,
15 in whole or in part, an arm or leg and includes accessories
16 essential to the effective use of the device and the
17 replacement or repair of the device based on the patient's
18 physical condition as medically necessary.
19     (b) This amendatory Act of the 96th General Assembly shall
20 provide benefits to any person covered thereunder for expenses
21 incurred in obtaining a prosthetic or custom orthotic device
22 from any Illinois licensed prosthetist, licensed orthotist, or
23 licensed pedorthist as required under the Orthotics,
24 Prosthetics, and Pedorthics Practice Act.
25     (c) A group or individual major medical policy of accident

 

 

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1 or health insurance or managed care plan or medical, health, or
2 hospital service corporation contract that provides coverage
3 for prosthetic or custom orthotic care and is amended,
4 delivered, issued, or renewed 6 months after the effective date
5 of this amendatory Act of the 96th General Assembly must
6 provide coverage for prosthetic and orthotic devices in
7 accordance with this subsection (c). The coverage required
8 under this Section shall be subject to the other general
9 exclusions, limitations, and financial requirements of the
10 policy, including coordination of benefits, participating
11 provider requirements, utilization review of health care
12 services, including review of medical necessity, case
13 management, and experimental and investigational treatments,
14 and other managed care provisions under terms and conditions
15 that are no less favorable than the terms and conditions that
16 apply to substantially all medical and surgical benefits
17 provided under the plan or coverage.
18     (d) The policy or plan or contract may require prior
19 authorization for the prosthetic or orthotic devices in the
20 same manner that prior authorization is required for any other
21 covered benefit.
22     (e) Repairs and replacements of prosthetic and orthotic
23 devices are also covered, subject to the co-payments and
24 deductibles, unless necessitated by misuse or loss.
25     (f) A policy or plan or contract may require that, if
26 coverage is provided through a managed care plan, the benefits

 

 

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1 mandated pursuant to this Section shall be covered benefits
2 only if the prosthetic or orthotic devices are provided by a
3 licensed provider employed by a provider service who contracts
4 with or is designated by the carrier, to the extent that the
5 carrier provides in-network and out-of-network service, the
6 coverage for the prosthetic or orthotic device shall be offered
7 no less extensively.
8     (g) The policy or plan or contract shall also meet adequacy
9 requirements as established by the Health Care Reimbursement
10 Reform Act of 1985 of the Illinois Insurance Code.
11     (h) This Section shall not apply to accident only,
12 specified disease, short-term hospital or medical, hospital
13 confinement indemnity, credit, dental, vision, Medicare
14 supplement, long-term care, basic hospital and
15 medical-surgical expense coverage, disability income insurance
16 coverage, coverage issued as a supplement to liability
17 insurance, workers' compensation insurance, or automobile
18 medical payment insurance.
 
19     Section 10. The Health Maintenance Organization Act is
20 amended by changing Section 5-3 as follows:
 
21     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
22     Sec. 5-3. Insurance Code provisions.
23     (a) Health Maintenance Organizations shall be subject to
24 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,

 

 

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1 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
2 154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
3 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
4 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14,
5 356z.17 356z.15, 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a,
6 368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408,
7 408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
8 (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
9 XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
10     (b) For purposes of the Illinois Insurance Code, except for
11 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
12 Maintenance Organizations in the following categories are
13 deemed to be "domestic companies":
14         (1) a corporation authorized under the Dental Service
15     Plan Act or the Voluntary Health Services Plans Act;
16         (2) a corporation organized under the laws of this
17     State; or
18         (3) a corporation organized under the laws of another
19     state, 30% or more of the enrollees of which are residents
20     of this State, except a corporation subject to
21     substantially the same requirements in its state of
22     organization as is a "domestic company" under Article VIII
23     1/2 of the Illinois Insurance Code.
24     (c) In considering the merger, consolidation, or other
25 acquisition of control of a Health Maintenance Organization
26 pursuant to Article VIII 1/2 of the Illinois Insurance Code,

 

 

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

 

 

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

 

 

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

 

 

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1 the group or enrollment unit a description of the method used
2 to calculate (1) the Health Maintenance Organization's
3 profitable experience with respect to the group or enrollment
4 unit and the resulting refund to the group or enrollment unit
5 or (2) the Health Maintenance Organization's unprofitable
6 experience with respect to the group or enrollment unit and the
7 resulting additional premium to be paid by the group or
8 enrollment unit.
9     In no event shall the Illinois Health Maintenance
10 Organization Guaranty Association be liable to pay any
11 contractual obligation of an insolvent organization to pay any
12 refund authorized under this Section.
13     (g) Rulemaking authority to implement Public Act 95-1045
14 this amendatory Act of the 95th General Assembly, if any, is
15 conditioned on the rules being adopted in accordance with all
16 provisions of the Illinois Administrative Procedure Act and all
17 rules and procedures of the Joint Committee on Administrative
18 Rules; any purported rule not so adopted, for whatever reason,
19 is unauthorized.
20 (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
21 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
22 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
23 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised
24 10-23-09.)
 
25     Section 15. The Voluntary Health Services Plans Act is

 

 

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1 amended by changing Section 10 as follows:
 
2     (215 ILCS 165/10)  (from Ch. 32, par. 604)
3     Sec. 10. Application of Insurance Code provisions. Health
4 services plan corporations and all persons interested therein
5 or dealing therewith shall be subject to the provisions of
6 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
7 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
8 356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
9 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
10 356z.14, 356z.15 356z.14, 356z.18, 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     Rulemaking authority to implement Public Act 95-1045 this
14 amendatory Act of the 95th General Assembly, if any, is
15 conditioned on the rules being adopted in accordance with all
16 provisions of the Illinois Administrative Procedure Act and all
17 rules and procedures of the Joint Committee on Administrative
18 Rules; any purported rule not so adopted, for whatever reason,
19 is unauthorized.
20 (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
21 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
22 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
23 eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
24 96-328, eff. 8-11-09; revised 9-25-09.)
 

 

 

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1     Section 95. No acceleration or delay. Where this Act makes
2 changes in a statute that is represented in this Act by text
3 that is not yet or no longer in effect (for example, a Section
4 represented by multiple versions), the use of that text does
5 not accelerate or delay the taking effect of (i) the changes
6 made by this Act or (ii) provisions derived from any other
7 Public Act.