Illinois General Assembly - Full Text of SB0101
Illinois General Assembly

Previous General Assemblies

Full Text of SB0101  95th General Assembly

SB0101enr 95TH GENERAL ASSEMBLY



 


 
SB0101 Enrolled LRB095 03635 BDD 23658 b

1     AN ACT regarding disabled persons.
 
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, 356z.9, and 356z.10,
14 and 356z.14 of the Illinois Insurance Code. The program of
15 health benefits must comply with Section 155.37 of the Illinois
16 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; 95-876, eff. 8-21-08.)
 
19     Section 10. The Counties Code is amended by changing
20 Section 5-1069.3 as follows:
 
21     (55 ILCS 5/5-1069.3)

 

 

SB0101 Enrolled - 2 - LRB095 03635 BDD 23658 b

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, 356z.9, and
8 356z.10, and 356z.14 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; 95-876, eff. 8-21-08.)
 
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

 

 

SB0101 Enrolled - 3 - LRB095 03635 BDD 23658 b

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, 356z.9, and 356z.10, and 356z.14 of the Illinois
4 Insurance Code. The requirement that health benefits be covered
5 as provided in this is an exclusive power and function of the
6 State and is a denial and limitation under Article VII, Section
7 6, subsection (h) of the Illinois Constitution. A home rule
8 municipality to which this Section applies must comply with
9 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; 95-876, eff. 8-21-08.)
 
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.14 of the Illinois Insurance Code.
21 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
22 95-876, eff. 8-21-08.)
 
23     Section 25. The Illinois Insurance Code is amended by

 

 

SB0101 Enrolled - 4 - LRB095 03635 BDD 23658 b

1 changing Section 370c and adding Section 356z.14 as follows:
 
2     (215 ILCS 5/356z.14 new)
3     Sec. 356z.14. Habilitative services for children.
4     (a) As used in this Section, "habilitative services" means
5 occupational therapy, physical therapy, speech therapy, and
6 other services prescribed by the insured's treating physician
7 pursuant to a treatment plan to enhance the ability of a child
8 to function with a congenital, genetic, or early acquired
9 disorder. A congenital or genetic disorder includes, but is not
10 limited to, hereditary disorders. An early acquired disorder
11 refers to a disorder resulting from illness, trauma, injury, or
12 some other event or condition suffered by a child prior to that
13 child developing functional life skills such as, but not
14 limited to, walking, talking, or self-help skills. Congenital,
15 genetic, and early acquired disorders may include, but are not
16 limited to, autism or an autism spectrum disorder, cerebral
17 palsy, and other disorders resulting from early childhood
18 illness, trauma, or injury.
19     (b) A group or individual policy of accident and health
20 insurance or managed care plan amended, delivered, issued, or
21 renewed after the effective date of this amendatory Act of the
22 95th General Assembly must provide coverage for habilitative
23 services for children under 19 years of age with a congenital,
24 genetic, or early acquired disorder so long as all of the
25 following conditions are met:

 

 

SB0101 Enrolled - 5 - LRB095 03635 BDD 23658 b

1         (1) A physician licensed to practice medicine in all
2     its branches has diagnosed the child's congenital,
3     genetic, or early acquired disorder.
4         (2) The treatment is administered by a licensed
5     speech-language pathologist, licensed audiologist,
6     licensed occupational therapist, licensed physical
7     therapist, licensed physician, licensed nurse, licensed
8     optometrist, licensed nutritionist, licensed social
9     worker, or licensed psychologist upon the referral of a
10     physician licensed to practice medicine in all its
11     branches.
12         (3) The initial or continued treatment must be
13     medically necessary and therapeutic and not experimental
14     or investigational.
15     (c) The coverage required by this Section shall be subject
16 to other general exclusions and limitations of the policy,
17 including coordination of benefits, participating provider
18 requirements, restrictions on services provided by family or
19 household members, utilization review of health care services,
20 including review of medical necessity, case management,
21 experimental, and investigational treatments, and other
22 managed care provisions.
23     (d) Coverage under this Section does not apply to those
24 services that are solely educational in nature or otherwise
25 paid under State or federal law for purely educational
26 services. Nothing in this subsection (d) relieves an insurer or

 

 

SB0101 Enrolled - 6 - LRB095 03635 BDD 23658 b

1 similar third party from an otherwise valid obligation to
2 provide or to pay for services provided to a child with a
3 disability.
4     (e) Coverage under this Section for children under age 19
5 shall not apply to treatment of mental or emotional disorders
6 or illnesses as covered under Section 370 of this Code as well
7 as any other benefit based upon a specific diagnosis that may
8 be otherwise required by law.
9     (f) The provisions of this Section do not apply to
10 short-term travel, accident-only, limited, or specific disease
11 policies.
12     (g) Any denial of care for habilitative services shall be
13 subject to appeal and external independent review procedures as
14 provided by Section 45 of the Managed Care Reform and Patient
15 Rights Act.
16     (h) Upon request of the reimbursing insurer, the provider
17 under whose supervision the habilitative services are being
18 provided shall furnish medical records, clinical notes, or
19 other necessary data to allow the insurer to substantiate that
20 initial or continued medical treatment is medically necessary
21 and that the patient's condition is clinically improving. When
22 the treating provider anticipates that continued treatment is
23 or will be required to permit the patient to achieve
24 demonstrable progress, the insurer may request that the
25 provider furnish a treatment plan consisting of diagnosis,
26 proposed treatment by type, frequency, anticipated duration of

 

 

SB0101 Enrolled - 7 - LRB095 03635 BDD 23658 b

1 treatment, the anticipated goals of treatment, and how
2 frequently the treatment plan will be updated.
3     (i) Rulemaking authority to implement this amendatory Act
4 of the 95th General Assembly, if any, is conditioned on the
5 rules being adopted in accordance with all provisions of the
6 Illinois Administrative Procedure Act and all rules and
7 procedures of the Joint Committee on Administrative Rules; any
8 purported rule not so adopted, for whatever reason, is
9 unauthorized.
 
10     (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
11     Sec. 370c. Mental and emotional disorders.
12     (a) (1) On and after the effective date of this Section,
13 every insurer which delivers, issues for delivery or renews or
14 modifies group A&H policies providing coverage for hospital or
15 medical treatment or services for illness on an
16 expense-incurred basis shall offer to the applicant or group
17 policyholder subject to the insurers standards of
18 insurability, coverage for reasonable and necessary treatment
19 and services for mental, emotional or nervous disorders or
20 conditions, other than serious mental illnesses as defined in
21 item (2) of subsection (b), up to the limits provided in the
22 policy for other disorders or conditions, except (i) the
23 insured may be required to pay up to 50% of expenses incurred
24 as a result of the treatment or services, and (ii) the annual
25 benefit limit may be limited to the lesser of $10,000 or 25% of

 

 

SB0101 Enrolled - 8 - LRB095 03635 BDD 23658 b

1 the lifetime policy limit.
2     (2) Each insured that is covered for mental, emotional or
3 nervous disorders or conditions shall be free to select the
4 physician licensed to practice medicine in all its branches,
5 licensed clinical psychologist, licensed clinical social
6 worker, or licensed clinical professional counselor of his
7 choice to treat such disorders, and the insurer shall pay the
8 covered charges of such physician licensed to practice medicine
9 in all its branches, licensed clinical psychologist, licensed
10 clinical social worker, or licensed clinical professional
11 counselor up to the limits of coverage, provided (i) the
12 disorder or condition treated is covered by the policy, and
13 (ii) the physician, licensed psychologist, licensed clinical
14 social worker, or licensed clinical professional counselor is
15 authorized to provide said services under the statutes of this
16 State and in accordance with accepted principles of his
17 profession.
18     (3) Insofar as this Section applies solely to licensed
19 clinical social workers and licensed clinical professional
20 counselors, those persons who may provide services to
21 individuals shall do so after the licensed clinical social
22 worker or licensed clinical professional counselor has
23 informed the patient of the desirability of the patient
24 conferring with the patient's primary care physician and the
25 licensed clinical social worker or licensed clinical
26 professional counselor has provided written notification to

 

 

SB0101 Enrolled - 9 - LRB095 03635 BDD 23658 b

1 the patient's primary care physician, if any, that services are
2 being provided to the patient. That notification may, however,
3 be waived by the patient on a written form. Those forms shall
4 be retained by the licensed clinical social worker or licensed
5 clinical professional counselor for a period of not less than 5
6 years.
7     (b) (1) An insurer that provides coverage for hospital or
8 medical expenses under a group policy of accident and health
9 insurance or health care plan amended, delivered, issued, or
10 renewed after the effective date of this amendatory Act of the
11 92nd General Assembly shall provide coverage under the policy
12 for treatment of serious mental illness under the same terms
13 and conditions as coverage for hospital or medical expenses
14 related to other illnesses and diseases. The coverage required
15 under this Section must provide for same durational limits,
16 amount limits, deductibles, and co-insurance requirements for
17 serious mental illness as are provided for other illnesses and
18 diseases. This subsection does not apply to coverage provided
19 to employees by employers who have 50 or fewer employees.
20     (2) "Serious mental illness" means the following
21 psychiatric illnesses as defined in the most current edition of
22 the Diagnostic and Statistical Manual (DSM) published by the
23 American Psychiatric Association:
24         (A) schizophrenia;
25         (B) paranoid and other psychotic disorders;
26         (C) bipolar disorders (hypomanic, manic, depressive,

 

 

SB0101 Enrolled - 10 - LRB095 03635 BDD 23658 b

1     and mixed);
2         (D) major depressive disorders (single episode or
3     recurrent);
4         (E) schizoaffective disorders (bipolar or depressive);
5         (F) pervasive developmental disorders;
6         (G) obsessive-compulsive disorders;
7         (H) depression in childhood and adolescence;
8         (I) panic disorder; and
9         (J) post-traumatic stress disorders (acute, chronic,
10     or with delayed onset).
11     (3) Upon request of the reimbursing insurer, a provider of
12 treatment of serious mental illness shall furnish medical
13 records or other necessary data that substantiate that initial
14 or continued treatment is at all times medically necessary. An
15 insurer shall provide a mechanism for the timely review by a
16 provider holding the same license and practicing in the same
17 specialty as the patient's provider, who is unaffiliated with
18 the insurer, jointly selected by the patient (or the patient's
19 next of kin or legal representative if the patient is unable to
20 act for himself or herself), the patient's provider, and the
21 insurer in the event of a dispute between the insurer and
22 patient's provider regarding the medical necessity of a
23 treatment proposed by a patient's provider. If the reviewing
24 provider determines the treatment to be medically necessary,
25 the insurer shall provide reimbursement for the treatment.
26 Future contractual or employment actions by the insurer

 

 

SB0101 Enrolled - 11 - LRB095 03635 BDD 23658 b

1 regarding the patient's provider may not be based on the
2 provider's participation in this procedure. Nothing prevents
3 the insured from agreeing in writing to continue treatment at
4 his or her expense. When making a determination of the medical
5 necessity for a treatment modality for serous mental illness,
6 an insurer must make the determination in a manner that is
7 consistent with the manner used to make that determination with
8 respect to other diseases or illnesses covered under the
9 policy, including an appeals process.
10     (4) A group health benefit plan:
11         (A) shall provide coverage based upon medical
12     necessity for the following treatment of mental illness in
13     each calendar year:
14             (i) 45 days of inpatient treatment; and
15             (ii) beginning on June 26, 2006 (the effective date
16         of Public Act 94-921), 60 visits for outpatient
17         treatment including group and individual outpatient
18         treatment; and
19             (iii) for plans or policies delivered, issued for
20         delivery, renewed, or modified after January 1, 2007
21         (the effective date of Public Act 94-906), 20
22         additional outpatient visits for speech therapy for
23         treatment of pervasive developmental disorders that
24         will be in addition to speech therapy provided pursuant
25         to item (ii) of this subparagraph (A);
26         (B) may not include a lifetime limit on the number of

 

 

SB0101 Enrolled - 12 - LRB095 03635 BDD 23658 b

1     days of inpatient treatment or the number of outpatient
2     visits covered under the plan; and
3         (C) shall include the same amount limits, deductibles,
4     copayments, and coinsurance factors for serious mental
5     illness as for physical illness.
6     (5) An issuer of a group health benefit plan may not count
7 toward the number of outpatient visits required to be covered
8 under this Section an outpatient visit for the purpose of
9 medication management and shall cover the outpatient visits
10 under the same terms and conditions as it covers outpatient
11 visits for the treatment of physical illness.
12     (6) An issuer of a group health benefit plan may provide or
13 offer coverage required under this Section through a managed
14 care plan.
15     (7) This Section shall not be interpreted to require a
16 group health benefit plan to provide coverage for treatment of:
17         (A) an addiction to a controlled substance or cannabis
18     that is used in violation of law; or
19         (B) mental illness resulting from the use of a
20     controlled substance or cannabis in violation of law.
21     (8) (Blank).
22     (c) This Section shall not be interpreted to require
23 coverage for speech therapy or other habilitative services for
24 those individuals covered under Section 356z.14 of this Code.
25 (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05;
26 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff.

 

 

SB0101 Enrolled - 13 - LRB095 03635 BDD 23658 b

1 8-21-07.)
 
2     Section 30. The Health Maintenance Organization Act is
3 amended by changing Section 5-3 as follows:
 
4     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
5     Sec. 5-3. Insurance Code provisions.
6     (a) Health Maintenance Organizations shall be subject to
7 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
8 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
9 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
10 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
11 356z.14, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
12 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
13 444, and 444.1, paragraph (c) of subsection (2) of Section 367,
14 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
15 and XXVI of the Illinois Insurance Code.
16     (b) For purposes of the Illinois Insurance Code, except for
17 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
18 Maintenance Organizations in the following categories are
19 deemed to be "domestic companies":
20         (1) a corporation authorized under the Dental Service
21     Plan Act or the Voluntary Health Services Plans Act;
22         (2) a corporation organized under the laws of this
23     State; or
24         (3) a corporation organized under the laws of another

 

 

SB0101 Enrolled - 14 - LRB095 03635 BDD 23658 b

1     state, 30% or 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     (c) In considering the merger, consolidation, or other
7 acquisition of control of a Health Maintenance Organization
8 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
9         (1) the Director shall give primary consideration to
10     the continuation of benefits to enrollees and the financial
11     conditions of the acquired Health Maintenance Organization
12     after the merger, consolidation, or other acquisition of
13     control takes effect;
14         (2)(i) the criteria specified in subsection (1)(b) of
15     Section 131.8 of the Illinois Insurance Code shall not
16     apply and (ii) the Director, in making his determination
17     with respect to the merger, consolidation, or other
18     acquisition of control, need not take into account the
19     effect on competition of the merger, consolidation, or
20     other acquisition of control;
21         (3) the Director shall have the power to require the
22     following information:
23             (A) certification by an independent actuary of the
24         adequacy of the reserves of the Health Maintenance
25         Organization sought to be acquired;
26             (B) pro forma financial statements reflecting the

 

 

SB0101 Enrolled - 15 - LRB095 03635 BDD 23658 b

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

 

 

SB0101 Enrolled - 16 - LRB095 03635 BDD 23658 b

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

 

 

SB0101 Enrolled - 17 - LRB095 03635 BDD 23658 b

1     the group or enrollment unit may agree that the profitable
2     or unprofitable experience may be calculated taking into
3     account the refund period and the immediately preceding 2
4     plan years.
5     The Health Maintenance Organization shall include a
6 statement in the evidence of coverage issued to each enrollee
7 describing the possibility of a refund or additional premium,
8 and upon request of any group or enrollment unit, provide to
9 the group or enrollment unit a description of the method used
10 to calculate (1) the Health Maintenance Organization's
11 profitable experience with respect to the group or enrollment
12 unit and the resulting refund to the group or enrollment unit
13 or (2) the Health Maintenance Organization's unprofitable
14 experience with respect to the group or enrollment unit and the
15 resulting additional premium to be paid by the group or
16 enrollment unit.
17     In no event shall the Illinois Health Maintenance
18 Organization Guaranty Association be liable to pay any
19 contractual obligation of an insolvent organization to pay any
20 refund authorized under this Section.
21 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
22 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
23 8-21-08.)
 
24     Section 35. The Voluntary Health Services Plans Act is
25 amended by changing Section 10 as follows:
 

 

 

SB0101 Enrolled - 18 - LRB095 03635 BDD 23658 b

1     (215 ILCS 165/10)  (from Ch. 32, par. 604)
2     Sec. 10. Application of Insurance Code provisions. Health
3 services plan corporations and all persons interested therein
4 or dealing therewith shall be subject to the provisions of
5 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
6 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,
7 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
8 356z.9, 356z.10, 356z.14, 364.01, 367.2, 368a, 401, 401.1, 402,
9 403, 403A, 408, 408.2, and 412, and paragraphs (7) and (15) of
10 Section 367 of the Illinois Insurance Code.
11 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
12 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
13 8-28-07; 95-876, eff. 8-21-08.)
 
14     Section 90. The State Mandates Act is amended by adding
15 Section 8.32 as follows:
 
16     (30 ILCS 805/8.32 new)
17     Sec. 8.32. Exempt mandate. Notwithstanding Sections 6 and 8
18 of this Act, no reimbursement by the State is required for the
19 implementation of any mandate created by this amendatory Act of
20 the 95th General Assembly.