Sen. Antonio Muņoz

Filed: 10/29/2009

 

 


 

 


 
09600HB2652sam003 LRB096 10389 AMC 30588 a

1
AMENDMENT TO HOUSE BILL 2652

2     AMENDMENT NO. ______. Amend House Bill 2652, AS AMENDED, by
3 replacing everything after the enacting clause with the
4 following:
 
5     "Section 5. The Illinois Insurance Code is amended by
6 renumbering Section 356z.14 as added by Public Act 95-1005, by
7 changing and renumbering Section 356z.15 as added by Public Act
8 96-639, and by adding Section 356z.18 as follows:
 
9     (215 ILCS 5/356z.15)
10     Sec. 356z.15 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

 

 

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1 limited to, hereditary disorders. An early acquired disorder
2 refers to a disorder resulting from illness, trauma, injury, or
3 some other event or condition suffered by a child prior to that
4 child developing functional life skills such as, but not
5 limited to, walking, talking, or self-help skills. Congenital,
6 genetic, and early acquired disorders may include, but are not
7 limited to, autism or an autism spectrum disorder, cerebral
8 palsy, and other disorders resulting from early childhood
9 illness, trauma, or injury.
10     (b) A group or individual policy of accident and health
11 insurance or managed care plan amended, delivered, issued, or
12 renewed after the effective date of this amendatory Act of the
13 95th General Assembly must provide coverage for habilitative
14 services for children under 19 years of age with a congenital,
15 genetic, or early acquired disorder so long as all of the
16 following conditions are met:
17         (1) A physician licensed to practice medicine in all
18     its branches has diagnosed the child's congenital,
19     genetic, or early acquired disorder.
20         (2) The treatment is administered by a licensed
21     speech-language pathologist, licensed audiologist,
22     licensed occupational therapist, licensed physical
23     therapist, licensed physician, licensed nurse, licensed
24     optometrist, licensed nutritionist, licensed social
25     worker, or licensed psychologist upon the referral of a
26     physician licensed to practice medicine in all its

 

 

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1     branches.
2         (3) The initial or continued treatment must be
3     medically necessary and therapeutic and not experimental
4     or investigational.
5     (c) The coverage required by this Section shall be subject
6 to other general exclusions and limitations of the policy,
7 including coordination of benefits, participating provider
8 requirements, restrictions on services provided by family or
9 household members, utilization review of health care services,
10 including review of medical necessity, case management,
11 experimental, and investigational treatments, and other
12 managed care provisions.
13     (d) Coverage under this Section does not apply to those
14 services that are solely educational in nature or otherwise
15 paid under State or federal law for purely educational
16 services. Nothing in this subsection (d) relieves an insurer or
17 similar third party from an otherwise valid obligation to
18 provide or to pay for services provided to a child with a
19 disability.
20     (e) Coverage under this Section for children under age 19
21 shall not apply to treatment of mental or emotional disorders
22 or illnesses as covered under Section 370 of this Code as well
23 as any other benefit based upon a specific diagnosis that may
24 be otherwise required by law.
25     (f) The provisions of this Section do not apply to
26 short-term travel, accident-only, limited, or specific disease

 

 

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1 policies.
2     (g) Any denial of care for habilitative services shall be
3 subject to appeal and external independent review procedures as
4 provided by Section 45 of the Managed Care Reform and Patient
5 Rights Act.
6     (h) Upon request of the reimbursing insurer, the provider
7 under whose supervision the habilitative services are being
8 provided shall furnish medical records, clinical notes, or
9 other necessary data to allow the insurer to substantiate that
10 initial or continued medical treatment is medically necessary
11 and that the patient's condition is clinically improving. When
12 the treating provider anticipates that continued treatment is
13 or will be required to permit the patient to achieve
14 demonstrable progress, the insurer may request that the
15 provider furnish a treatment plan consisting of diagnosis,
16 proposed treatment by type, frequency, anticipated duration of
17 treatment, the anticipated goals of treatment, and how
18 frequently the treatment plan will be updated.
19     (i) Rulemaking authority to implement this amendatory Act
20 of the 95th General Assembly, if any, is conditioned on the
21 rules being adopted in accordance with all provisions of the
22 Illinois Administrative Procedure Act and all rules and
23 procedures of the Joint Committee on Administrative Rules; any
24 purported rule not so adopted, for whatever reason, is
25 unauthorized.
26 (Source: P.A. 95-1049, eff. 1-1-10; revised 10-23-09.)
 

 

 

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1     (215 ILCS 5/356z.17)
2     Sec. 356z.17 356z.15. Wellness coverage.
3     (a) A group or individual policy of accident and health
4 insurance or managed care plan amended, delivered, issued, or
5 renewed after January 1, 2010 (the effective date of Public Act
6 96-639) this amendatory Act of the 96th General Assembly that
7 provides coverage for hospital or medical treatment on an
8 expense incurred basis may offer a reasonably designed program
9 for wellness coverage that allows for a reward, a contribution,
10 a reduction in premiums or reduced medical, prescription drug,
11 or equipment copayments, coinsurance, or deductibles, or a
12 combination of these incentives, for participation in any
13 health behavior wellness, maintenance, or improvement program
14 approved or offered by the insurer or managed care plan. The
15 insured or enrollee may be required to provide evidence of
16 participation in a program. Individuals unable to participate
17 in these incentives due to an adverse health factor shall not
18 be penalized based upon an adverse health status.
19     (b) For purposes of this Section, "wellness coverage" means
20 health care coverage with the primary purpose to engage and
21 motivate the insured or enrollee through: incentives;
22 provision of health education, counseling, and self-management
23 skills; identification of modifiable health risks; and other
24 activities to influence health behavior changes.
25     For the purposes of this Section, "reasonably designed

 

 

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1 program" means a program of wellness coverage that has a
2 reasonable chance of improving health or preventing disease; is
3 not overly burdensome; does not discriminate based upon factors
4 of health; and is not otherwise contrary to law.
5     (c) Incentives as outlined in this Section are specific and
6 unique to the offering of wellness coverage and have no
7 application to any other required or optional health care
8 benefit.
9     (d) Such wellness coverage must satisfy the requirements
10 for an exception from the general prohibition against
11 discrimination based on a health factor under the federal
12 Health Insurance Portability and Accountability Act of 1996
13 (P.L. 104-191; 110 Stat. 1936), including any federal
14 regulations that are adopted pursuant to that Act.
15     (e) A plan offering wellness coverage must do the
16 following:
17         (i) give participants the opportunity to qualify for
18     offered incentives at least once a year;
19         (ii) allow a reasonable alternative to any individual
20     for whom it is unreasonably difficult, due to a medical
21     condition, to satisfy otherwise applicable wellness
22     program standards. Plans may seek physician verification
23     that health factors make it unreasonably difficult or
24     medically inadvisable for the participant to satisfy the
25     standards; and
26         (iii) not provide a total incentive that exceeds 20% of

 

 

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1     the cost of employee-only coverage. The cost of
2     employee-only coverage includes both employer and employee
3     contributions. For plans offering family coverage, the 20%
4     limitation applies to cost of family coverage and applies
5     to the entire family.
6     (f) A reward, contribution, or reduction established under
7 this Section and included in the policy or certificate does not
8 violate Section 151 of this Code.
9 (Source: P.A. 96-639, eff. 1-1-10; revised 10-21-09.)
 
10     (215 ILCS 5/356z.18 new)
11     Sec. 356z.18. Prosthetic and customized orthotic devices.
12     (a) For the purposes of this Section:
13     "Customized orthotic device" means a supportive device for
14 the body or a part of the body, the head, neck, or extremities,
15 and includes the replacement or repair of the device based on
16 the patient's physical condition as medically necessary,
17 excluding foot orthotics defined as an in-shoe device designed
18 to support the structural components of the foot during
19 weight-bearing activities.
20     "Licensed provider" means a prosthetist, orthotist, or
21 pedorthist licensed to practice in this State.
22     "Prosthetic device" means an artificial device to replace,
23 in whole or in part, an arm or leg and includes accessories
24 essential to the effective use of the device and the
25 replacement or repair of the device based on the patient's

 

 

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1 physical condition as medically necessary.
2     (b) This amendatory Act of the 96th General Assembly shall
3 provide benefits to any person covered thereunder for expenses
4 incurred in obtaining a prosthetic or custom orthotic device
5 from any Illinois licensed prosthetist, licensed orthotist, or
6 licensed pedorthist as required under the Orthotics,
7 Prosthetics, and Pedorthics Practice Act.
8     (c) A group or individual major medical policy of accident
9 or health insurance or managed care plan or medical, health, or
10 hospital service corporation contract that provides coverage
11 for prosthetic or custom orthotic care and is amended,
12 delivered, issued, or renewed after July 1, 2010 must provide
13 coverage for prosthetic and orthotic devices under terms and
14 conditions that are no less favorable than the terms and
15 conditions applicable to substantially all medical and
16 surgical benefits provided under the plan or coverage. The
17 coverage required under this Section shall be subject to the
18 other general exclusions, limitations, and financial
19 requirements of the policy, including coordination of
20 benefits, participating provider requirements, utilization
21 review of health care services, including review of medical
22 necessity, case management, and experimental and
23 investigational treatments.
24     (d) The policy or plan or contract may require prior
25 authorization for the prosthetic or orthotic devices in the
26 same manner that prior authorization is required for any other

 

 

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1 covered benefit.
2     (e) Repairs and replacements of prosthetic and orthotic
3 devices are also covered, subject to the co-payments and
4 deductibles, unless necessitated by misuse or loss.
5     (f) A policy or plan or contract may require that, if
6 coverage is provided through a managed care plan, the benefits
7 mandated pursuant to this Section shall be covered benefits
8 only if the prosthetic or orthotic devices are provided by a
9 licensed provider employed by a provider service who contracts
10 with or is designated by the carrier, to the extent that the
11 carrier provides in-network and out of network service, the
12 coverage for the prosthetic or orthotic device shall be offered
13 no less extensively.
14     (g) The policy or plan or contract shall also meet adequacy
15 requirements as established by the Health Care Reimbursement
16 Reform Act of 1985 of the Illinois Insurance Code.
17     (h) This Section shall not apply to accident only,
18 specified disease, short-term hospital or medical, hospital
19 confinement indemnity, credit, dental, vision, Medicare
20 supplement, long-term care, basic hospital and
21 medical-surgical expense coverage, disability income insurance
22 coverage, coverage issued as a supplement to liability
23 insurance, workers' compensation insurance, or automobile
24 medical payment insurance.
 
25     Section 10. The Health Maintenance Organization Act is

 

 

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1 amended by changing Section 5-3 as follows:
 
2     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
3     Sec. 5-3. Insurance Code provisions.
4     (a) Health Maintenance Organizations shall be subject to
5 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
6 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
7 154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
8 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
9 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14,
10 356z.17 356z.15, 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a,
11 368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408,
12 408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
13 (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
14 XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
15     (b) For purposes of the Illinois Insurance Code, except for
16 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
17 Maintenance Organizations in the following categories are
18 deemed to be "domestic companies":
19         (1) a corporation authorized under the Dental Service
20     Plan Act or the Voluntary Health Services Plans Act;
21         (2) a corporation organized under the laws of this
22     State; or
23         (3) a corporation organized under the laws of another
24     state, 30% or more of the enrollees of which are residents
25     of this State, except a corporation subject to

 

 

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1     substantially the same requirements in its state of
2     organization as is a "domestic company" under Article VIII
3     1/2 of the Illinois Insurance Code.
4     (c) In considering the merger, consolidation, or other
5 acquisition of control of a Health Maintenance Organization
6 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
7         (1) the Director shall give primary consideration to
8     the continuation of benefits to enrollees and the financial
9     conditions of the acquired Health Maintenance Organization
10     after the merger, consolidation, or other acquisition of
11     control takes effect;
12         (2)(i) the criteria specified in subsection (1)(b) of
13     Section 131.8 of the Illinois Insurance Code shall not
14     apply and (ii) the Director, in making his determination
15     with respect to the merger, consolidation, or other
16     acquisition of control, need not take into account the
17     effect on competition of the merger, consolidation, or
18     other acquisition of control;
19         (3) the Director shall have the power to require the
20     following information:
21             (A) certification by an independent actuary of the
22         adequacy of the reserves of the Health Maintenance
23         Organization sought to be acquired;
24             (B) pro forma financial statements reflecting the
25         combined balance sheets of the acquiring company and
26         the Health Maintenance Organization sought to be

 

 

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1         acquired as of the end of the preceding year and as of
2         a date 90 days prior to the acquisition, as well as pro
3         forma financial statements reflecting projected
4         combined operation for a period of 2 years;
5             (C) a pro forma business plan detailing an
6         acquiring party's plans with respect to the operation
7         of the Health Maintenance Organization sought to be
8         acquired for a period of not less than 3 years; and
9             (D) such other information as the Director shall
10         require.
11     (d) The provisions of Article VIII 1/2 of the Illinois
12 Insurance Code and this Section 5-3 shall apply to the sale by
13 any health maintenance organization of greater than 10% of its
14 enrollee population (including without limitation the health
15 maintenance organization's right, title, and interest in and to
16 its health care certificates).
17     (e) In considering any management contract or service
18 agreement subject to Section 141.1 of the Illinois Insurance
19 Code, the Director (i) shall, in addition to the criteria
20 specified in Section 141.2 of the Illinois Insurance Code, take
21 into account the effect of the management contract or service
22 agreement on the continuation of benefits to enrollees and the
23 financial condition of the health maintenance organization to
24 be managed or serviced, and (ii) need not take into account the
25 effect of the management contract or service agreement on
26 competition.

 

 

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1     (f) Except for small employer groups as defined in the
2 Small Employer Rating, Renewability and Portability Health
3 Insurance Act and except for medicare supplement policies as
4 defined in Section 363 of the Illinois Insurance Code, a Health
5 Maintenance Organization may by contract agree with a group or
6 other enrollment unit to effect refunds or charge additional
7 premiums under the following terms and conditions:
8         (i) the amount of, and other terms and conditions with
9     respect to, the refund or additional premium are set forth
10     in the group or enrollment unit contract agreed in advance
11     of the period for which a refund is to be paid or
12     additional premium is to be charged (which period shall not
13     be less than one year); and
14         (ii) the amount of the refund or additional premium
15     shall not exceed 20% of the Health Maintenance
16     Organization's profitable or unprofitable experience with
17     respect to the group or other enrollment unit for the
18     period (and, for purposes of a refund or additional
19     premium, the profitable or unprofitable experience shall
20     be calculated taking into account a pro rata share of the
21     Health Maintenance Organization's administrative and
22     marketing expenses, but shall not include any refund to be
23     made or additional premium to be paid pursuant to this
24     subsection (f)). The Health Maintenance Organization and
25     the group or enrollment unit may agree that the profitable
26     or unprofitable experience may be calculated taking into

 

 

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1     account the refund period and the immediately preceding 2
2     plan years.
3     The Health Maintenance Organization shall include a
4 statement in the evidence of coverage issued to each enrollee
5 describing the possibility of a refund or additional premium,
6 and upon request of any group or enrollment unit, provide to
7 the group or enrollment unit a description of the method used
8 to calculate (1) the Health Maintenance Organization's
9 profitable experience with respect to the group or enrollment
10 unit and the resulting refund to the group or enrollment unit
11 or (2) the Health Maintenance Organization's unprofitable
12 experience with respect to the group or enrollment unit and the
13 resulting additional premium to be paid by the group or
14 enrollment unit.
15     In no event shall the Illinois Health Maintenance
16 Organization Guaranty Association be liable to pay any
17 contractual obligation of an insolvent organization to pay any
18 refund authorized under this Section.
19     (g) Rulemaking authority to implement Public Act 95-1045
20 this amendatory Act of the 95th General Assembly, if any, is
21 conditioned on the rules being adopted in accordance with all
22 provisions of the Illinois Administrative Procedure Act and all
23 rules and procedures of the Joint Committee on Administrative
24 Rules; any purported rule not so adopted, for whatever reason,
25 is unauthorized.
26 (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;

 

 

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1 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
2 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
3 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised
4 10-23-09.)
 
5     Section 15. The Voluntary Health Services Plans Act is
6 amended by changing Section 10 as follows:
 
7     (215 ILCS 165/10)  (from Ch. 32, par. 604)
8     Sec. 10. Application of Insurance Code provisions. Health
9 services plan corporations and all persons interested therein
10 or dealing therewith shall be subject to the provisions of
11 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
12 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
13 356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
14 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15 356z.14, 356z.15 356z.14, 356z.18, 364.01, 367.2, 368a, 401,
16 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
17 and (15) of Section 367 of the Illinois Insurance Code.
18     Rulemaking authority to implement Public Act 95-1045 this
19 amendatory Act of the 95th General Assembly, if any, is
20 conditioned on the rules being adopted in accordance with all
21 provisions of the Illinois Administrative Procedure Act and all
22 rules and procedures of the Joint Committee on Administrative
23 Rules; any purported rule not so adopted, for whatever reason,
24 is unauthorized.

 

 

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1 (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
2 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
3 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
4 eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
5 96-328, eff. 8-11-09; revised 9-25-09.)
 
6     Section 95. No acceleration or delay. Where this Act makes
7 changes in a statute that is represented in this Act by text
8 that is not yet or no longer in effect (for example, a Section
9 represented by multiple versions), the use of that text does
10 not accelerate or delay the taking effect of (i) the changes
11 made by this Act or (ii) provisions derived from any other
12 Public Act.
 
13     Section 99. Effective date. This Act takes effect upon
14 becoming law.".