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90_HB2645
215 ILCS 5/356g from Ch. 73, par. 968g
215 ILCS 5/356w new
215 ILCS 125/4-6.1 from Ch. 111 1/2, par. 1408.7
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
Amends the Illinois Insurance Code, the Health
Maintenance Organization Act, the Limited Health Services
Organization Act, and the Voluntary Health Services Plans
Act. Requires coverage for reconstructive surgery and
prosthetic devices for the purpose of achieving or restoring
symmetry after a mastectomy. Requires coverage for
reconstructive surgery for childrens' deformities when the
procedure is medically necessary to return the patient to a
more normal appearance.
LRB9008967JSgc
LRB9008967JSgc
1 AN ACT concerning certain medical procedures relating to
2 reconstructive surgery, amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Insurance Code is amended by
6 changing Section 356g and adding Section 356w as follows:
7 (215 ILCS 5/356g) (from Ch. 73, par. 968g)
8 Sec. 356g. Mammograms; mastectomy.
9 (a) Every insurer shall provide in each group or
10 individual policy, contract, or certificate of insurance
11 issued or renewed for persons who are residents of this
12 State, coverage for screening by low-dose mammography for all
13 women 35 years of age or older for the presence of occult
14 breast cancer within the provisions of the policy, contract,
15 or certificate. The coverage shall be as follows:
16 (1) A baseline mammogram for women 35 to 39 years
17 of age.
18 (2) An annual mammogram for women 40 years of age
19 or older.
20 These benefits shall be at least as favorable as for
21 other radiological examinations and subject to the same
22 dollar limits, deductibles, and co-insurance factors. For
23 purposes of this Section, "low-dose mammography" means the
24 x-ray examination of the breast using equipment dedicated
25 specifically for mammography, including the x-ray tube,
26 filter, compression device, and image receptor, with
27 radiation exposure delivery of less than 1 rad per breast for
28 2 views of an average size breast.
29 (b) No policy of accident or health insurance that
30 provides for the surgical procedure known as a mastectomy
31 shall be issued, amended, delivered or renewed in this State
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1 on or after July 1, 1981, unless coverage is also offered for
2 prosthetic devices or reconstructive surgery incident to the
3 mastectomy, providing that the mastectomy is performed after
4 July 1, 1981. For a policy issued, amended, delivered, or
5 renewed in this State on or after the effective date of this
6 amendatory Act of 1998, that coverage shall include
7 prosthetic devices and reconstructive surgery intended to
8 restore and achieve symmetry for the patient in the manner
9 chosen by the patient and the physician. The offered coverage
10 for prosthetic devices and reconstructive surgery shall be
11 subject to the deductible and coinsurance conditions applied
12 to the mastectomy, and all other terms and conditions
13 applicable to other benefits. When a mastectomy is performed
14 and there is no evidence of malignancy then the offered
15 coverage may be limited to the provision of prosthetic
16 devices and reconstructive surgery to within 2 years after
17 the date of the mastectomy to restore and achieve symmetry.
18 As used in this Section, "mastectomy" means the removal of
19 all or part of the breast for medically necessary reasons, as
20 determined by a licensed physician.
21 (Source: P.A. 90-7, eff. 6-10-97.)
22 (215 ILCS 5/356w new)
23 Sec. 356w. Reconstructive surgery for children's
24 deformities.
25 (a) A group or individual policy of accident and health
26 insurance and a managed care plan, as defined in Section
27 356r, that is amended, delivered, issued, or renewed in this
28 State on or after the effective date of this amendatory Act
29 of 1998 shall include coverage for all outpatient and
30 inpatient diagnosis and treatment of a minor child's
31 congenital or developmental deformity, disease, or injury due
32 to accident or trauma. The coverage shall include treatment
33 that, in the opinion of the treating physician, is medically
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1 necessary to return the patient to a more normal appearance,
2 even if the procedure does not materially affect the function
3 of the body part being treated, including benefits for
4 secondary conditions and follow-up treatment. Benefits shall
5 include, without limitation, coverage of the following:
6 (1) birth abnormalities of the cranium and face,
7 such as cleft lip and palate;
8 (2) musculoskeletal disorders affecting any bone or
9 joint in the face, neck, or head;
10 (3) craniofacial and maxillofacial surgery and
11 prosthetic devices, including restoration of head and
12 facial structures; and
13 (4) restoring facial configuration and functions
14 such as speech, swallowing, and chewing.
15 (b) An insurance policy or managed care plan subject to
16 this Section may not deny coverage for benefits described in
17 subsection (a) as a pre-existing condition if the insured's
18 insurance coverage changes before treatment is either
19 initiated or completed.
20 (c) Any provision in an insurance policy or managed care
21 plan subject to this Section, that is amended, delivered,
22 issued, or renewed after the effective date of this
23 amendatory Act of 1998 that is contrary to this Section
24 shall, to the extent of such conflict, be void, and the
25 provisions shall be construed as to comply with the
26 requirements of this Section.
27 Section 10. The Health Maintenance Organization Act is
28 amended by changing Sections 4-6.1 and 5-3 as follows:
29 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
30 Sec. 4-6.1. Mammograms; mastectomy.
31 (a) Every contract or evidence of coverage issued by a
32 Health Maintenance Organization for persons who are residents
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1 of this State shall contain coverage for screening by
2 low-dose mammography for all women 35 years of age or older
3 for the presence of occult breast cancer. The coverage shall
4 be as follows:
5 (1) A baseline mammogram for women 35 to 39 years
6 of age.
7 (2) An annual mammogram for women 40 years of age
8 or older.
9 These benefits shall be at least as favorable as for
10 other radiological examinations and subject to the same
11 dollar limits, deductibles, and co-insurance factors. For
12 purposes of this Section, "low-dose mammography" means the
13 x-ray examination of the breast using equipment dedicated
14 specifically for mammography, including the x-ray tube,
15 filter, compression device, and image receptor, with
16 radiation exposure delivery of less than 1 rad per breast for
17 2 views of an average size breast.
18 (b) No contract or evidence of coverage that provides
19 for the surgical procedure known as a mastectomy shall be
20 issued, amended, delivered, or renewed in this State on or
21 after the effective date of this amendatory Act of 1998
22 unless coverage is also offered for prosthetic devices or
23 reconstructive surgery incident to the mastectomy, providing
24 that the mastectomy is performed after that date. The
25 coverage shall include prosthetic devices and reconstructive
26 surgery intended to restore and achieve symmetry for the
27 patient in the manner chosen by the patient and the
28 physician. The offered coverage for prosthetic devices and
29 reconstructive surgery shall be subject to the deductible and
30 coinsurance conditions applied to the mastectomy and to all
31 other terms and conditions applicable to other benefits. If
32 a mastectomy is performed and there is no evidence of
33 malignancy, the offered coverage may be limited to the
34 provision of prosthetic devices and reconstructive surgery
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1 within 2 years after the date of the mastectomy to restore
2 and achieve symmetry.
3 As used in this Section, "mastectomy" means the removal
4 of all or part of the breast for medically necessary reasons,
5 as determined by a physician licensed to practice medicine in
6 all its branches.
7 (Source: P.A. 90-7, eff. 6-10-97; revised 7-29-97.)
8 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
9 (Text of Section before amendment by P.A. 90-372)
10 Sec. 5-3. Insurance Code provisions.
11 (a) Health Maintenance Organizations shall be subject to
12 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
13 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
14 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356t,
15 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
16 paragraph (c) of subsection (2) of Section 367, and Articles
17 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
18 Illinois Insurance Code.
19 (b) For purposes of the Illinois Insurance Code, except
20 for Articles XIII and XIII 1/2, Health Maintenance
21 Organizations in the following categories are deemed to be
22 "domestic companies":
23 (1) a corporation authorized under the Medical
24 Service Plan Act, the Dental Service Plan Act, the
25 Pharmaceutical Service Plan Act, or the Voluntary Health
26 Services Plans Plan Act, or the Nonprofit Health Care
27 Service Plan Act;
28 (2) a corporation organized under the laws of this
29 State; or
30 (3) a corporation organized under the laws of
31 another state, 30% or more of the enrollees of which are
32 residents of this State, except a corporation subject to
33 substantially the same requirements in its state of
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1 organization as is a "domestic company" under Article
2 VIII 1/2 of the Illinois Insurance Code.
3 (c) In considering the merger, consolidation, or other
4 acquisition of control of a Health Maintenance Organization
5 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
6 (1) the Director shall give primary consideration
7 to the continuation of benefits to enrollees and the
8 financial conditions of the acquired Health Maintenance
9 Organization after the merger, consolidation, or other
10 acquisition of control takes effect;
11 (2)(i) the criteria specified in subsection (1)(b)
12 of Section 131.8 of the Illinois Insurance Code shall not
13 apply and (ii) the Director, in making his determination
14 with respect to the merger, consolidation, or other
15 acquisition of control, need not take into account the
16 effect on competition of the merger, consolidation, or
17 other acquisition of control;
18 (3) the Director shall have the power to require
19 the following information:
20 (A) certification by an independent actuary of
21 the adequacy of the reserves of the Health
22 Maintenance Organization sought to be acquired;
23 (B) pro forma financial statements reflecting
24 the combined balance sheets of the acquiring company
25 and the Health Maintenance Organization sought to be
26 acquired as of the end of the preceding year and as
27 of a date 90 days prior to the acquisition, as well
28 as pro forma financial statements reflecting
29 projected combined operation for a period of 2
30 years;
31 (C) a pro forma business plan detailing an
32 acquiring party's plans with respect to the
33 operation of the Health Maintenance Organization
34 sought to be acquired for a period of not less than
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1 3 years; and
2 (D) such other information as the Director
3 shall require.
4 (d) The provisions of Article VIII 1/2 of the Illinois
5 Insurance Code and this Section 5-3 shall apply to the sale
6 by any health maintenance organization of greater than 10% of
7 its enrollee population (including without limitation the
8 health maintenance organization's right, title, and interest
9 in and to its health care certificates).
10 (e) In considering any management contract or service
11 agreement subject to Section 141.1 of the Illinois Insurance
12 Code, the Director (i) shall, in addition to the criteria
13 specified in Section 141.2 of the Illinois Insurance Code,
14 take into account the effect of the management contract or
15 service agreement on the continuation of benefits to
16 enrollees and the financial condition of the health
17 maintenance organization to be managed or serviced, and (ii)
18 need not take into account the effect of the management
19 contract or service agreement on competition.
20 (f) Except for small employer groups as defined in the
21 Small Employer Rating, Renewability and Portability Health
22 Insurance Act and except for medicare supplement policies as
23 defined in Section 363 of the Illinois Insurance Code, a
24 Health Maintenance Organization may by contract agree with a
25 group or other enrollment unit to effect refunds or charge
26 additional premiums under the following terms and conditions:
27 (i) the amount of, and other terms and conditions
28 with respect to, the refund or additional premium are set
29 forth in the group or enrollment unit contract agreed in
30 advance of the period for which a refund is to be paid or
31 additional premium is to be charged (which period shall
32 not be less than one year); and
33 (ii) the amount of the refund or additional premium
34 shall not exceed 20% of the Health Maintenance
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1 Organization's profitable or unprofitable experience with
2 respect to the group or other enrollment unit for the
3 period (and, for purposes of a refund or additional
4 premium, the profitable or unprofitable experience shall
5 be calculated taking into account a pro rata share of the
6 Health Maintenance Organization's administrative and
7 marketing expenses, but shall not include any refund to
8 be made or additional premium to be paid pursuant to this
9 subsection (f)). The Health Maintenance Organization and
10 the group or enrollment unit may agree that the
11 profitable or unprofitable experience may be calculated
12 taking into account the refund period and the immediately
13 preceding 2 plan years.
14 The Health Maintenance Organization shall include a
15 statement in the evidence of coverage issued to each enrollee
16 describing the possibility of a refund or additional premium,
17 and upon request of any group or enrollment unit, provide to
18 the group or enrollment unit a description of the method used
19 to calculate (1) the Health Maintenance Organization's
20 profitable experience with respect to the group or enrollment
21 unit and the resulting refund to the group or enrollment unit
22 or (2) the Health Maintenance Organization's unprofitable
23 experience with respect to the group or enrollment unit and
24 the resulting additional premium to be paid by the group or
25 enrollment unit.
26 In no event shall the Illinois Health Maintenance
27 Organization Guaranty Association be liable to pay any
28 contractual obligation of an insolvent organization to pay
29 any refund authorized under this Section.
30 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
31 90-177, eff. 7-23-97; revised 11-21-97.)
32 (Text of Section after amendment by P.A. 90-372)
33 Sec. 5-3. Insurance Code provisions.
34 (a) Health Maintenance Organizations shall be subject to
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1 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
2 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
3 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356t,
4 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
5 paragraph (c) of subsection (2) of Section 367, and Articles
6 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
7 Illinois Insurance Code.
8 (b) For purposes of the Illinois Insurance Code, except
9 for Articles XIII and XIII 1/2, Health Maintenance
10 Organizations in the following categories are deemed to be
11 "domestic companies":
12 (1) a corporation authorized under the Medical
13 Service Plan Act, the Dental Service Plan Act or, the
14 Voluntary Health Services Plans Plan Act, or the
15 Nonprofit Health Care Service Plan Act;
16 (2) a corporation organized under the laws of this
17 State; or
18 (3) a corporation organized under the laws of
19 another state, 30% or more of the enrollees of which are
20 residents 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
23 VIII 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,
27 (1) the Director shall give primary consideration
28 to the continuation of benefits to enrollees and the
29 financial conditions of the acquired Health Maintenance
30 Organization after the merger, consolidation, or other
31 acquisition of control takes effect;
32 (2)(i) the criteria specified in subsection (1)(b)
33 of Section 131.8 of the Illinois Insurance Code shall not
34 apply and (ii) the Director, in making his determination
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1 with respect to the merger, consolidation, or other
2 acquisition of control, need not take into account the
3 effect on competition of the merger, consolidation, or
4 other acquisition of control;
5 (3) the Director shall have the power to require
6 the following information:
7 (A) certification by an independent actuary of
8 the adequacy of the reserves of the Health
9 Maintenance Organization sought to be acquired;
10 (B) pro forma financial statements reflecting
11 the combined balance sheets of the acquiring company
12 and the Health Maintenance Organization sought to be
13 acquired as of the end of the preceding year and as
14 of a date 90 days prior to the acquisition, as well
15 as pro forma financial statements reflecting
16 projected combined operation for a period of 2
17 years;
18 (C) a pro forma business plan detailing an
19 acquiring party's plans with respect to the
20 operation of the Health Maintenance Organization
21 sought to be acquired for a period of not less than
22 3 years; and
23 (D) such other information as the Director
24 shall require.
25 (d) The provisions of Article VIII 1/2 of the Illinois
26 Insurance Code and this Section 5-3 shall apply to the sale
27 by any health maintenance organization of greater than 10% of
28 its enrollee population (including without limitation the
29 health maintenance organization's right, title, and interest
30 in and to its health care certificates).
31 (e) In considering any management contract or service
32 agreement subject to Section 141.1 of the Illinois Insurance
33 Code, the Director (i) shall, in addition to the criteria
34 specified in Section 141.2 of the Illinois Insurance Code,
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1 take into account the effect of the management contract or
2 service agreement on the continuation of benefits to
3 enrollees and the financial condition of the health
4 maintenance organization to be managed or serviced, and (ii)
5 need not take into account the effect of the management
6 contract or service agreement on competition.
7 (f) Except for small employer groups as defined in the
8 Small Employer Rating, Renewability and Portability Health
9 Insurance Act and except for medicare supplement policies as
10 defined in Section 363 of the Illinois Insurance Code, a
11 Health Maintenance Organization may by contract agree with a
12 group or other enrollment unit to effect refunds or charge
13 additional premiums under the following terms and conditions:
14 (i) the amount of, and other terms and conditions
15 with respect to, the refund or additional premium are set
16 forth in the group or enrollment unit contract agreed in
17 advance of the period for which a refund is to be paid or
18 additional premium is to be charged (which period shall
19 not be less than one year); and
20 (ii) the amount of the refund or additional premium
21 shall not exceed 20% of the Health Maintenance
22 Organization's profitable or unprofitable experience with
23 respect to the group or other enrollment unit for the
24 period (and, for purposes of a refund or additional
25 premium, the profitable or unprofitable experience shall
26 be calculated taking into account a pro rata share of the
27 Health Maintenance Organization's administrative and
28 marketing expenses, but shall not include any refund to
29 be made or additional premium to be paid pursuant to this
30 subsection (f)). The Health Maintenance Organization and
31 the group or enrollment unit may agree that the
32 profitable or unprofitable experience may be calculated
33 taking into account the refund period and the immediately
34 preceding 2 plan years.
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1 The Health Maintenance Organization shall include a
2 statement in the evidence of coverage issued to each enrollee
3 describing the possibility of a refund or additional premium,
4 and upon request of any group or enrollment unit, provide to
5 the group or enrollment unit a description of the method used
6 to calculate (1) the Health Maintenance Organization's
7 profitable experience with respect to the group or enrollment
8 unit and the resulting refund to the group or enrollment unit
9 or (2) the Health Maintenance Organization's unprofitable
10 experience with respect to the group or enrollment unit and
11 the resulting additional premium to be paid by the group or
12 enrollment unit.
13 In no event shall the Illinois Health Maintenance
14 Organization Guaranty Association be liable to pay any
15 contractual obligation of an insolvent organization to pay
16 any refund authorized under this Section.
17 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
18 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; revised 11-21-97.)
19 Section 15. The Limited Health Service Organization Act
20 is amended by changing Section 4003 as follows:
21 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
22 Sec. 4003. Illinois Insurance Code provisions. Limited
23 health service organizations shall be subject to the
24 provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
25 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
26 154.6, 154.7, 154.8, 155.04, 355.2, 356v, 356w, 356t, 401,
27 401.1, 402, 403, 403A, 408, 408.2, and 412, and Articles VIII
28 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois
29 Insurance Code. For purposes of the Illinois Insurance Code,
30 except for Articles XIII and XIII 1/2, limited health service
31 organizations in the following categories are deemed to be
32 domestic companies:
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1 (1) a corporation under the laws of this State; or
2 (2) a corporation organized under the laws of
3 another state, 30% of more of the enrollees of which are
4 residents of this State, except a corporation subject to
5 substantially the same requirements in its state of
6 organization as is a domestic company under Article VIII
7 1/2 of the Illinois Insurance Code.
8 (Source: P.A. 90-25, eff. 1-1-98; revised 10-14-97.)
9 Section 20. The Voluntary Health Services Plans Act is
10 amended by changing Section 10 as follows:
11 (215 ILCS 165/10) (from Ch. 32, par. 604)
12 Sec. 10. Application of Insurance Code provisions.
13 Health services plan corporations and all persons interested
14 therein or dealing therewith shall be subject to the
15 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
16 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
17 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and
18 paragraphs (7) and (15) of Section 367 of the Illinois
19 Insurance Code.
20 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
21 90-25, eff. 1-1-98; revised 10-14-97.)
22 Section 95. No acceleration or delay. Where this Act
23 makes changes in a statute that is represented in this Act by
24 text that is not yet or no longer in effect (for example, a
25 Section represented by multiple versions), the use of that
26 text does not accelerate or delay the taking effect of (i)
27 the changes made by this Act or (ii) provisions derived from
28 any other Public Act.