99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB1902

 

Introduced 2/20/2015, by Sen. William R. Haine

 

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.10
215 ILCS 5/356z.23 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 Illinois Insurance Code. Removes limitations on coverage for amino acid-based elemental formulas, which restricted coverage to individuals diagnosed with eosinophilic disorders and short bowel syndrome. Provides that group or individual major medical accident and health insurance policies or managed care plans amended, delivered, issued, or renewed after the effective date the Act must provide coverage and reimbursement for enteral feeding services and related medical supplies, including disposable supplies, when a physician licensed to practice medicine in all of its branches determines that enteral feeding is medically necessary and has prescribed enteral feeding for a patient. Defines enteral feeding to mean delivery of nutrients directly into the stomach, duodenum, or jejunum. Makes conforming changes in the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, the Limited Health Services Organization Act, the Voluntary Health Services Plan Act, and the Illinois Public Aid Code.


LRB099 04431 MLM 24459 b

 

 

A BILL FOR

 

SB1902LRB099 04431 MLM 24459 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, 356z.17, and 356z.22, and 356z.23 of the
16Illinois Insurance Code. The program of health benefits must
17comply with Sections 155.22a, 155.37, 355b, and 356z.19 of the
18Illinois Insurance Code.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
3eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
4    Section 10. The Counties Code is amended by changing
5Section 5-1069.3 as follows:
 
6    (55 ILCS 5/5-1069.3)
7    Sec. 5-1069.3. Required health benefits. If a county,
8including a home rule county, is a self-insurer for purposes of
9providing health insurance coverage for its employees, the
10coverage shall include coverage for the post-mastectomy care
11benefits required to be covered by a policy of accident and
12health insurance under Section 356t and the coverage required
13under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, and 356z.22, and 356z.23 of the Illinois
16Insurance Code. The coverage shall comply with Sections
17155.22a, 355b, and 356z.19 of the Illinois Insurance Code. The
18requirement that health benefits be covered as provided in this
19Section is an exclusive power and function of the State and is
20a denial and limitation under Article VII, Section 6,
21subsection (h) of the Illinois Constitution. A home rule county
22to which this Section applies must comply with every provision
23of this Section.
24    Rulemaking authority to implement Public Act 95-1045, if

 

 

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1any, is conditioned on the rules being adopted in accordance
2with all provisions of the Illinois Administrative Procedure
3Act and all rules and procedures of the Joint Committee on
4Administrative Rules; any purported rule not so adopted, for
5whatever reason, is unauthorized.
6(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
7eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
8    Section 15. The Illinois Municipal Code is amended by
9changing Section 10-4-2.3 as follows:
 
10    (65 ILCS 5/10-4-2.3)
11    Sec. 10-4-2.3. Required health benefits. If a
12municipality, including a home rule municipality, is a
13self-insurer for purposes of providing health insurance
14coverage for its employees, the coverage shall include coverage
15for the post-mastectomy care benefits required to be covered by
16a policy of accident and health insurance under Section 356t
17and the coverage required under Sections 356g, 356g.5,
18356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
19356z.11, 356z.12, 356z.13, 356z.14, 356z.15, and 356z.22, and
20356z.23 of the Illinois Insurance Code. The coverage shall
21comply with Sections 155.22a, 355b, and 356z.19 of the Illinois
22Insurance Code. The requirement that health benefits be covered
23as provided in this is an exclusive power and function of the
24State and is a denial and limitation under Article VII, Section

 

 

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16, subsection (h) of the Illinois Constitution. A home rule
2municipality to which this Section applies must comply with
3every provision of this Section.
4    Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
11eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
12    Section 20. The School Code is amended by changing Section
1310-22.3f as follows:
 
14    (105 ILCS 5/10-22.3f)
15    Sec. 10-22.3f. Required health benefits. Insurance
16protection and benefits for employees shall provide the
17post-mastectomy care benefits required to be covered by a
18policy of accident and health insurance under Section 356t and
19the coverage required under Sections 356g, 356g.5, 356g.5-1,
20356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
21356z.12, 356z.13, 356z.14, 356z.15, and 356z.22, and 356z.23 of
22the Illinois Insurance Code. Insurance policies shall comply
23with Section 356z.19 of the Illinois Insurance Code. The
24coverage shall comply with Sections 155.22a and 355b of the

 

 

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1Illinois Insurance Code.
2    Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
9eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
10    Section 25. The Illinois Insurance Code is amended by
11changing Section 356z.10 and by adding Section 356z.23 as
12follows:
 
13    (215 ILCS 5/356z.10)
14    Sec. 356z.10. Amino acid-based elemental formulas. A group
15or individual major medical accident and health insurance
16policy or managed care plan amended, delivered, issued, or
17renewed after the effective date of this amendatory Act of the
1899th General Assembly this amendatory Act of the 95th General
19Assembly must provide coverage and reimbursement for amino
20acid-based elemental formulas, regardless of delivery method,
21for the diagnosis and treatment of (i) eosinophilic disorders
22and (ii) short bowel syndrome when the prescribing physician
23has issued a written order stating that the amino acid-based
24elemental formula is medically necessary.

 

 

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1(Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
2    (215 ILCS 5/356z.23 new)
3    Sec. 356z.23. Coverage for enteral feeding services. A
4group or individual major medical accident and health insurance
5policy or managed care plan amended, delivered, issued, or
6renewed after the effective date of this amendatory Act of the
799th General Assembly must provide coverage and reimbursement
8for enteral feeding services and related medical supplies,
9including disposable supplies, when a physician licensed to
10practice medicine in all of its branches determines that
11enteral feeding is medically necessary and has prescribed
12enteral feeding for a patient. As used in this Section,
13"enteral feeding" means the delivery of nutrients directly into
14the stomach, duodenum, or jejunum. As used in this Section,
15"related medical supplies" means items necessary for enteral
16feeding, including, but not limited to, tubes, catheters,
17pumps, and formulas.
 
18    Section 30. The Health Maintenance Organization Act is
19amended by changing Section 5-3 as follows:
 
20    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
21    Sec. 5-3. Insurance Code provisions.
22    (a) Health Maintenance Organizations shall be subject to
23the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,

 

 

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1141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
2154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
3355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
4356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
5356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
6356z.22, 356z.23, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
7368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
8408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
9subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII,
10XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
11Insurance Code.
12    (b) For purposes of the Illinois Insurance Code, except for
13Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
14Maintenance Organizations in the following categories are
15deemed to be "domestic companies":
16        (1) a corporation authorized under the Dental Service
17    Plan Act or the Voluntary Health Services Plans Act;
18        (2) a corporation organized under the laws of this
19    State; or
20        (3) a corporation organized under the laws of another
21    state, 30% or more of the enrollees of which are residents
22    of this State, except a corporation subject to
23    substantially the same requirements in its state of
24    organization as is a "domestic company" under Article VIII
25    1/2 of the Illinois Insurance Code.
26    (c) In considering the merger, consolidation, or other

 

 

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

 

 

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

 

 

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

 

 

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1describing the possibility of a refund or additional premium,
2and upon request of any group or enrollment unit, provide to
3the group or enrollment unit a description of the method used
4to calculate (1) the Health Maintenance Organization's
5profitable experience with respect to the group or enrollment
6unit and the resulting refund to the group or enrollment unit
7or (2) the Health Maintenance Organization's unprofitable
8experience with respect to the group or enrollment unit and the
9resulting additional premium to be paid by the group or
10enrollment unit.
11    In no event shall the Illinois Health Maintenance
12Organization Guaranty Association be liable to pay any
13contractual obligation of an insolvent organization to pay any
14refund authorized under this Section.
15    (g) Rulemaking authority to implement Public Act 95-1045,
16if any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437,
22eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805,
23eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14;
2498-1091, eff. 1-1-15.)
 
25    Section 35. The Limited Health Service Organization Act is

 

 

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1amended by changing Section 4003 as follows:
 
2    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
3    Sec. 4003. Illinois Insurance Code provisions. Limited
4health service organizations shall be subject to the provisions
5of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
6143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
7154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v,
8356z.10, 356z.21, 356z.22, 356z.23, 368a, 401, 401.1, 402, 403,
9403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles IIA,
10VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the
11Illinois Insurance Code. For purposes of the Illinois Insurance
12Code, except for Sections 444 and 444.1 and Articles XIII and
13XIII 1/2, limited health service organizations in the following
14categories are deemed to be domestic companies:
15        (1) a corporation under the laws of this State; or
16        (2) a corporation organized under the laws of another
17    state, 30% of more of the enrollees of which are residents
18    of this State, except a corporation subject to
19    substantially the same requirements in its state of
20    organization as is a domestic company under Article VIII
21    1/2 of the Illinois Insurance Code.
22(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff.
231-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091,
24eff. 1-1-15.)
 

 

 

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1    Section 40. The Voluntary Health Services Plans Act is
2amended by changing Section 10 as follows:
 
3    (215 ILCS 165/10)  (from Ch. 32, par. 604)
4    Sec. 10. Application of Insurance Code provisions. Health
5services plan corporations and all persons interested therein
6or dealing therewith shall be subject to the provisions of
7Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
8143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
9356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
10356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
11356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
12356z.19, 356z.21, 356z.22, 356z.23, 364.01, 367.2, 368a, 401,
13401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
14and (15) of Section 367 of the Illinois Insurance Code.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486,
22eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813,
23eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
24    Section 45. The Illinois Public Aid Code is amended by

 

 

SB1902- 14 -LRB099 04431 MLM 24459 b

1changing Section 5-16.8 as follows:
 
2    (305 ILCS 5/5-16.8)
3    Sec. 5-16.8. Required health benefits. The medical
4assistance program shall (i) provide the post-mastectomy care
5benefits required to be covered by a policy of accident and
6health insurance under Section 356t and the coverage required
7under Sections 356g.5, 356u, 356w, 356x, and 356z.6, 356z.10,
8and 356z.23 of the Illinois Insurance Code and (ii) be subject
9to the provisions of Sections 356z.19 and 364.01 of the
10Illinois Insurance Code.
11    On and after July 1, 2012, the Department shall reduce any
12rate of reimbursement for services or other payments or alter
13any methodologies authorized by this Code to reduce any rate of
14reimbursement for services or other payments in accordance with
15Section 5-5e.
16(Source: P.A. 97-282, eff. 8-9-11; 97-689, eff. 6-14-12.)