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90_HB3427sam001
LRB9008922JSsbam04
1 AMENDMENT TO HOUSE BILL 3427
2 AMENDMENT NO. . Amend House Bill 3427 by replacing
3 the title with the following:
4 "AN ACT concerning insurance coverages, amending named
5 Acts."; and
6 by replacing everything after the enacting clause with the
7 following:
8 "Section 5. The State Employees Group Insurance Act of
9 1971 is amended by changing and renumbering Section 6.9 added
10 by Public Act 90-7 as follows:
11 (5 ILCS 375/6.11)
12 Sec. 6.11. 6.9. Required health benefits. The program
13 of health benefits shall provide the post-mastectomy care
14 benefits required to be covered by a policy of accident and
15 health insurance under Section 356t of the Illinois Insurance
16 Code. The program of health benefits shall provide the
17 coverage required under Sections Section 356u, 356w, and 356x
18 of the Illinois Insurance Code.
19 (Source: P.A. 90-7, eff. 6-10-97; revised 11-10-97.)
20 Section 10. The State Mandates Act is amended by adding
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1 Section 8.22 as follows:
2 (30 ILCS 805/8.22 new)
3 Sec. 8.22. Exempt mandate. Notwithstanding Sections 6
4 and 8 of this Act, no reimbursement by the State is required
5 for the implementation of any mandate created by this
6 amendatory Act of 1998.
7 Section 15. The Counties Code is amended by changing
8 Section 5-1069.3 as follows:
9 (55 ILCS 5/5-1069.3)
10 Sec. 5-1069.3. Required health benefits. If a county,
11 including a home rule county, is a self-insurer for purposes
12 of providing health insurance coverage for its employees, the
13 coverage shall include coverage for the post-mastectomy care
14 benefits required to be covered by a policy of accident and
15 health insurance under Section 356t and the coverage required
16 under Sections Section 356u, 356w, and 356x of the Illinois
17 Insurance Code. The requirement that health benefits be
18 covered as provided in this Section is an exclusive power and
19 function of the State and is a denial and limitation under
20 Article VII, Section 6, subsection (h) of the Illinois
21 Constitution. A home rule county to which this Section
22 applies must comply with every provision of this Section.
23 (Source: P.A. 90-7, eff. 6-10-97.)
24 Section 20. The Illinois Municipal Code is amended by
25 changing Section 10-4-2.3 as follows:
26 (65 ILCS 5/10-4-2.3)
27 Sec. 10-4-2.3. Required health benefits. If a
28 municipality, including a home rule municipality, is a
29 self-insurer for purposes of providing health insurance
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1 coverage for its employees, the coverage shall include
2 coverage for the post-mastectomy care benefits required to be
3 covered by a policy of accident and health insurance under
4 Section 356t and the coverage required under Sections Section
5 356u, 356w, and 356x of the Illinois Insurance Code. The
6 requirement that health benefits be covered as provided in
7 this is an exclusive power and function of the State and is a
8 denial and limitation under Article VII, Section 6,
9 subsection (h) of the Illinois Constitution. A home rule
10 municipality to which this Section applies must comply with
11 every provision of this Section.
12 (Source: P.A. 90-7, eff. 6-10-97.)
13 Section 25. The School Code is amended by changing
14 Section 10-22.3f as follows:
15 (105 ILCS 5/10-22.3f)
16 Sec. 10-22.3f. Required health benefits. Insurance
17 protection and benefits for employees shall provide the
18 post-mastectomy care benefits required to be covered by a
19 policy of accident and health insurance under Section 356t
20 and the coverage required under Sections Section 356u, 356w,
21 and 356x of the Illinois Insurance Code.
22 (Source: P.A. 90-7, eff. 6-10-97.)
23 Section 30. The Illinois Insurance Code is amended by
24 changing Sections 4 and 356r and adding Sections 356w and
25 356x as follows:
26 (215 ILCS 5/4) (from Ch. 73, par. 616)
27 Sec. 4. Classes of insurance. Insurance and insurance
28 business shall be classified as follows:
29 Class 1. Life, Accident and Health.
30 (a) Life. Insurance on the lives of persons and every
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1 insurance appertaining thereto or connected therewith and
2 granting, purchasing or disposing of annuities. Policies of
3 life or endowment insurance or annuity contracts or contracts
4 supplemental thereto which contain provisions for additional
5 benefits in case of death by accidental means and provisions
6 operating to safeguard such policies or contracts against
7 lapse, to give a special surrender value, or special benefit,
8 or an annuity, in the event, that the insured or annuitant
9 shall become totally and permanently disabled as defined by
10 the policy or contract, or which contain benefits providing
11 acceleration of life or endowment or annuity benefits in
12 advance of the time they would otherwise be payable, as an
13 indemnity for long term care which is certified or ordered by
14 a physician, including but not limited to, professional
15 nursing care, medical care expenses, custodial nursing care,
16 non-nursing custodial care provided in a nursing home or at a
17 residence of the insured, or which contain benefits providing
18 acceleration of life or endowment or annuity benefits in
19 advance of the time they would otherwise be payable, at any
20 time during the insured's lifetime, as an indemnity for a
21 terminal illness shall be deemed to be policies of life or
22 endowment insurance or annuity contracts within the intent of
23 this clause.
24 Also to be deemed as policies of life or endowment
25 insurance or annuity contracts within the intent of this
26 clause shall be those policies or riders that provide for the
27 payment of up to 75% 25% of the face amount of benefits in
28 advance of the time they would otherwise be payable upon a
29 diagnosis by a physician licensed to practice medicine in all
30 of its branches that the insured has incurred a one of the
31 covered condition conditions listed in the policy or rider.
32 Every such policy or rider shall contain a majority of
33 the following "Covered condition", as used in this clause,
34 means conditions: heart attack,; stroke,; coronary artery
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1 surgery,; life threatening cancer,; renal failure,;
2 alzheimer's disease,; paraplegia,; major organ
3 transplantation, total and permanent disability, and any
4 other medical condition that the Department may approve for
5 any particular filing.
6 The Director may issue rules that specify prohibited
7 policy provisions, not otherwise specifically prohibited by
8 law, which in the opinion of the Director are unjust, unfair,
9 or unfairly discriminatory to the policyholder, any person
10 insured under the policy, or beneficiary.
11 (b) Accident and health. Insurance against bodily
12 injury, disablement or death by accident and against
13 disablement resulting from sickness or old age and every
14 insurance appertaining thereto, including stop-loss
15 insurance. Stop-loss insurance is insurance against the risk
16 of economic loss issued to a single employer self-funded
17 employee disability benefit plan or an employee welfare
18 benefit plan as described in 29 U.S.C. 100 et seq.
19 (c) Legal Expense Insurance. Insurance which involves
20 the assumption of a contractual obligation to reimburse the
21 beneficiary against or pay on behalf of the beneficiary, all
22 or a portion of his fees, costs, or expenses related to or
23 arising out of services performed by or under the supervision
24 of an attorney licensed to practice in the jurisdiction
25 wherein the services are performed, regardless of whether the
26 payment is made by the beneficiaries individually or by a
27 third person for them, but does not include the provision of
28 or reimbursement for legal services incidental to other
29 insurance coverages. The insurance laws of this State,
30 including this Act do not apply to:
31 (i) Retainer contracts made by attorneys at law
32 with individual clients with fees based on estimates of
33 the nature and amount of services to be provided to the
34 specific client, and similar contracts made with a group
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1 of clients involved in the same or closely related legal
2 matters;
3 (ii) Plans owned or operated by attorneys who are
4 the providers of legal services to the plan;
5 (iii) Plans providing legal service benefits to
6 groups where such plans are owned or operated by
7 authority of a state, county, local or other bar
8 association;
9 (iv) Any lawyer referral service authorized or
10 operated by a state, county, local or other bar
11 association;
12 (v) The furnishing of legal assistance by labor
13 unions and other employee organizations to their members
14 in matters relating to employment or occupation;
15 (vi) The furnishing of legal assistance to members
16 or dependents, by churches, consumer organizations,
17 cooperatives, educational institutions, credit unions, or
18 organizations of employees, where such organizations
19 contract directly with lawyers or law firms for the
20 provision of legal services, and the administration and
21 marketing of such legal services is wholly conducted by
22 the organization or its subsidiary;
23 (vii) Legal services provided by an employee
24 welfare benefit plan defined by the Employee Retirement
25 Income Security Act of 1974;
26 (viii) Any collectively bargained plan for legal
27 services between a labor union and an employer negotiated
28 pursuant to Section 302 of the Labor Management Relations
29 Act as now or hereafter amended, under which plan legal
30 services will be provided for employees of the employer
31 whether or not payments for such services are funded to
32 or through an insurance company.
33 Class 2. Casualty, Fidelity and Surety.
34 (a) Accident and health. Insurance against bodily
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1 injury, disablement or death by accident and against
2 disablement resulting from sickness or old age and every
3 insurance appertaining thereto, including stop-loss
4 insurance. Stop-loss insurance is insurance against the risk
5 of economic loss issued to a single employer self-funded
6 employee disability benefit plan or an employee welfare
7 benefit plan as described in 29 U.S.C. 1001 et seq.
8 (b) Vehicle. Insurance against any loss or liability
9 resulting from or incident to the ownership, maintenance or
10 use of any vehicle (motor or otherwise), draft animal or
11 aircraft. Any policy insuring against any loss or liability
12 on account of the bodily injury or death of any person may
13 contain a provision for payment of disability benefits to
14 injured persons and death benefits to dependents,
15 beneficiaries or personal representatives of persons who are
16 killed, including the named insured, irrespective of legal
17 liability of the insured, if the injury or death for which
18 benefits are provided is caused by accident and sustained
19 while in or upon or while entering into or alighting from or
20 through being struck by a vehicle (motor or otherwise), draft
21 animal or aircraft, and such provision shall not be deemed to
22 be accident insurance.
23 (c) Liability. Insurance against the liability of the
24 insured for the death, injury or disability of an employee or
25 other person, and insurance against the liability of the
26 insured for damage to or destruction of another person's
27 property.
28 (d) Workers' compensation. Insurance of the obligations
29 accepted by or imposed upon employers under laws for workers'
30 compensation.
31 (e) Burglary and forgery. Insurance against loss or
32 damage by burglary, theft, larceny, robbery, forgery, fraud
33 or otherwise; including all householders' personal property
34 floater risks.
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1 (f) Glass. Insurance against loss or damage to glass
2 including lettering, ornamentation and fittings from any
3 cause.
4 (g) Fidelity and surety. Become surety or guarantor for
5 any person, copartnership or corporation in any position or
6 place of trust or as custodian of money or property, public
7 or private; or, becoming a surety or guarantor for the
8 performance of any person, copartnership or corporation of
9 any lawful obligation, undertaking, agreement or contract of
10 any kind, except contracts or policies of insurance; and
11 underwriting blanket bonds. Such obligations shall be known
12 and treated as suretyship obligations and such business shall
13 be known as surety business.
14 (h) Miscellaneous. Insurance against loss or damage to
15 property and any liability of the insured caused by accidents
16 to boilers, pipes, pressure containers, machinery and
17 apparatus of any kind and any apparatus connected thereto, or
18 used for creating, transmitting or applying power, light,
19 heat, steam or refrigeration, making inspection of and
20 issuing certificates of inspection upon elevators, boilers,
21 machinery and apparatus of any kind and all mechanical
22 apparatus and appliances appertaining thereto; insurance
23 against loss or damage by water entering through leaks or
24 openings in buildings, or from the breakage or leakage of a
25 sprinkler, pumps, water pipes, plumbing and all tanks,
26 apparatus, conduits and containers designed to bring water
27 into buildings or for its storage or utilization therein, or
28 caused by the falling of a tank, tank platform or supports,
29 or against loss or damage from any cause (other than causes
30 specifically enumerated under Class 3 of this Section) to
31 such sprinkler, pumps, water pipes, plumbing, tanks,
32 apparatus, conduits or containers; insurance against loss or
33 damage which may result from the failure of debtors to pay
34 their obligations to the insured; and insurance of the
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1 payment of money for personal services under contracts of
2 hiring.
3 (i) Other casualty risks. Insurance against any other
4 casualty risk not otherwise specified under Classes 1 or 3,
5 which may lawfully be the subject of insurance and may
6 properly be classified under Class 2.
7 (j) Contingent losses. Contingent, consequential and
8 indirect coverages wherein the proximate cause of the loss is
9 attributable to any one of the causes enumerated under Class
10 2. Such coverages shall, for the purpose of classification,
11 be included in the specific grouping of the kinds of
12 insurance wherein such cause is specified.
13 (k) Livestock and domestic animals. Insurance against
14 mortality, accident and health of livestock and domestic
15 animals.
16 (l) Legal expense insurance. Insurance against risk
17 resulting from the cost of legal services as defined under
18 Class 1(c).
19 Class 3. Fire and Marine, etc.
20 (a) Fire. Insurance against loss or damage by fire,
21 smoke and smudge, lightning or other electrical disturbances.
22 (b) Elements. Insurance against loss or damage by
23 earthquake, windstorms, cyclone, tornado, tempests, hail,
24 frost, snow, ice, sleet, flood, rain, drought or other
25 weather or climatic conditions including excess or deficiency
26 of moisture, rising of the waters of the ocean or its
27 tributaries.
28 (c) War, riot and explosion. Insurance against loss or
29 damage by bombardment, invasion, insurrection, riot, strikes,
30 civil war or commotion, military or usurped power, or
31 explosion (other than explosion of steam boilers and the
32 breaking of fly wheels on premises owned, controlled,
33 managed, or maintained by the insured.)
34 (d) Marine and transportation. Insurance against loss or
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1 damage to vessels, craft, aircraft, vehicles of every kind,
2 (excluding vehicles operating under their own power or while
3 in storage not incidental to transportation) as well as all
4 goods, freights, cargoes, merchandise, effects,
5 disbursements, profits, moneys, bullion, precious stones,
6 securities, chooses in action, evidences of debt, valuable
7 papers, bottomry and respondentia interests and all other
8 kinds of property and interests therein, in respect to,
9 appertaining to or in connection with any or all risks or
10 perils of navigation, transit, or transportation, including
11 war risks, on or under any seas or other waters, on land or
12 in the air, or while being assembled, packed, crated, baled,
13 compressed or similarly prepared for shipment or while
14 awaiting the same or during any delays, storage,
15 transshipment, or reshipment incident thereto, including
16 marine builder's risks and all personal property floater
17 risks; and for loss or damage to persons or property in
18 connection with or appertaining to marine, inland marine,
19 transit or transportation insurance, including liability for
20 loss of or damage to either arising out of or in connection
21 with the construction, repair, operation, maintenance, or use
22 of the subject matter of such insurance, (but not including
23 life insurance or surety bonds); but, except as herein
24 specified, shall not mean insurances against loss by reason
25 of bodily injury to the person; and insurance against loss or
26 damage to precious stones, jewels, jewelry, gold, silver and
27 other precious metals whether used in business or trade or
28 otherwise and whether the same be in course of transportation
29 or otherwise, which shall include jewelers' block insurance;
30 and insurance against loss or damage to bridges, tunnels and
31 other instrumentalities of transportation and communication
32 (excluding buildings, their furniture and furnishings, fixed
33 contents and supplies held in storage) unless fire, tornado,
34 sprinkler leakage, hail, explosion, earthquake, riot and
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1 civil commotion are the only hazards to be covered; and to
2 piers, wharves, docks and slips, excluding the risks of fire,
3 tornado, sprinkler leakage, hail, explosion, earthquake, riot
4 and civil commotion; and to other aids to navigation and
5 transportation, including dry docks and marine railways,
6 against all risk.
7 (e) Vehicle. Insurance against loss or liability
8 resulting from or incident to the ownership, maintenance or
9 use of any vehicle (motor or otherwise), draft animal or
10 aircraft, excluding the liability of the insured for the
11 death, injury or disability of another person.
12 (f) Property damage, sprinkler leakage and crop.
13 Insurance against the liability of the insured for loss or
14 damage to another person's property or property interests
15 from any cause enumerated in this class; insurance against
16 loss or damage by water entering through leaks or openings in
17 buildings, or from the breakage or leakage of a sprinkler,
18 pumps, water pipes, plumbing and all tanks, apparatus,
19 conduits and containers designed to bring water into
20 buildings or for its storage or utilization therein, or
21 caused by the falling of a tank, tank platform or supports or
22 against loss or damage from any cause to such sprinklers,
23 pumps, water pipes, plumbing, tanks, apparatus, conduits or
24 containers; insurance against loss or damage from insects,
25 diseases or other causes to trees, crops or other products of
26 the soil.
27 (g) Other fire and marine risks. Insurance against any
28 other property risk not otherwise specified under Classes 1
29 or 2, which may lawfully be the subject of insurance and may
30 properly be classified under Class 3.
31 (h) Contingent losses. Contingent, consequential and
32 indirect coverages wherein the proximate cause of the loss is
33 attributable to any of the causes enumerated under Class 3.
34 Such coverages shall, for the purpose of classification, be
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1 included in the specific grouping of the kinds of insurance
2 wherein such cause is specified.
3 (i) Legal expense insurance. Insurance against risk
4 resulting from the cost of legal services as defined under
5 Class 1(c).
6 (Source: P.A. 88-364.)
7 (215 ILCS 5/356r)
8 Sec. 356r. Woman's principal health care provider.
9 (a) An individual or group policy of accident and health
10 insurance or a managed care plan amended, delivered, issued,
11 or renewed in this State after November 14, 1996 that
12 requires an insured or enrollee to designate an individual to
13 coordinate care or to control access to health care services
14 shall also permit a female insured or enrollee to designate a
15 participating woman's principal health care provider, and the
16 insurer or managed care plan shall provide the following
17 written notice to all female insureds or enrollees no later
18 than 120 days after the effective date of this amendatory Act
19 of 1998; to all new enrollees at the time of enrollment; and
20 thereafter to all existing enrollees at least annually, as a
21 part of a regular publication or informational mailing:
22 "NOTICE TO ALL FEMALE PLAN MEMBERS:
23 YOUR RIGHT TO SELECT A WOMAN'S PRINCIPAL
24 HEALTH CARE PROVIDER.
25 Illinois law allows you to select "a woman's
26 principal health care provider" in addition to your
27 selection of a primary care physician. A woman's
28 principal heath care provider is a physician licensed to
29 practice medicine in all its branches specializing in
30 obstetrics or gynecology or specializing in family
31 practice. A woman's principal health care provider may
32 be seen for care without referrals from your primary care
33 physician. If you have not already selected a woman's
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1 principal health care provider, you may do so now or at
2 any other time. You are not required to have or to
3 select a woman's principal health care provider.
4 Your woman's principal health care provider must be
5 a part of your plan. You may get the list of
6 participating obstetricians, gynecologists, and family
7 practice specialists from your employer's employee
8 benefits coordinator, or for your own copy of the current
9 list, you may call [insert plan's toll free number]. The
10 list will be sent to you within 10 days after your call.
11 To designate a woman's principal health care provider
12 from the list, call [insert plan's toll free number] and
13 tell our staff the name of the physician you have
14 selected.".
15 If the insurer or managed care plan exercises the option set
16 forth in subsection (a-5), the notice shall also state:
17 "Your plan requires that your primary care physician
18 and your woman's principal health care provider have a
19 referral arrangement with one another. If the woman's
20 principal health care provider that you select does not
21 have a referral arrangement with your primary care
22 physician, you will have to select a new primary care
23 physician who has a referral arrangement with your
24 woman's principal health care provider or you may select
25 a woman's principal health care provider who has a
26 referral arrangement with your primary care physician.
27 The list of woman's principal health care providers will
28 also have the names of the primary care physicians and
29 their referral arrangements.".
30 No later than 120 days after the effective date of this
31 amendatory Act of 1998, the insurer or managed care plan
32 shall provide each employer who has a policy of insurance or
33 a managed care plan with the insurer or managed care plan
34 with a list of physicians licensed to practice medicine in
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1 all its branches specializing in obstetrics or gynecology or
2 specializing in family practice who have contracted with the
3 plan. At the time of enrollment and thereafter within 10 days
4 after a request by an insured or enrollee, the insurer or
5 managed care plan also shall provide this list directly to
6 the insured or enrollee. The list shall include each
7 physician's address, telephone number, and specialty. No
8 insurer or plan formal or informal policy may restrict a
9 female insured's or enrollee's right to designate a woman's
10 principal health care provider, except as set forth in
11 subsection (a-5). If the female enrollee is an enrollee of a
12 managed care plan under contract with the Department of
13 Public Aid, the physician chosen by the enrollee as her
14 woman's principal health care provider must be a
15 Medicaid-enrolled provider. This requirement does not require
16 a female insured or enrollee to make a selection of a woman's
17 principal health care provider. The female insured or
18 enrollee may designate a physician licensed to practice
19 medicine in all its branches specializing in family practice
20 as her woman's principal health care provider.
21 (a-5) The insured or enrollee may be required by the
22 insurer or managed care plan to select a woman's principal
23 health care provider who has a referral arrangement with the
24 insured's or enrollee's individual who coordinates care or
25 controls access to health care services if such referral
26 arrangement exists or to select a new individual to
27 coordinate care or to control access to health care services
28 who has a referral arrangement with the woman's principal
29 health care provider chosen by the insured or enrollee, if
30 such referral arrangement exists. If an insurer or a managed
31 care plan requires an insured or enrollee to select a new
32 physician under this subsection (a-5), the insurer or managed
33 care plan must provide the insured or enrollee with both
34 options to select a new physician provided in this subsection
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1 (a-5).
2 Notwithstanding a plan's restrictions of the frequency or
3 timing of making designations of primary care providers, a
4 female enrollee or insured who is subject to the selection
5 requirements of this subsection, may, at any time, effect a
6 change in primary care physicians in order to make a
7 selection of a woman's principal health care provider.
8 (a-6) If an insurer or managed care plan exercises the
9 option in subsection (a-5), the list to be provided under
10 subsection (a) shall identify the referral arrangements that
11 exist between the individual who coordinates care or controls
12 access to health care services and the woman's principal
13 health care provider in order to assist the female insured or
14 enrollee to make a selection within the insurer's or managed
15 care plan's requirement.
16 (b) If a female insured or enrollee has designated a
17 woman's principal health care provider, then the insured or
18 enrollee must be given direct access to the woman's principal
19 health care provider for services covered by the policy or
20 plan without the need for a referral or prior approval.
21 Nothing shall prohibit the insurer or managed care plan from
22 requiring prior authorization or approval from either a
23 primary care provider or the woman's principal health care
24 provider for referrals for additional care or services.
25 (c) For the purposes of this Section the following terms
26 are defined:
27 (1) "Woman's principal health care provider" means
28 a physician licensed to practice medicine in all of its
29 branches specializing in obstetrics or gynecology or
30 specializing in family practice.
31 (2) "Managed care entity" means any entity
32 including a licensed insurance company, hospital or
33 medical service plan, health maintenance organization,
34 limited health service organization, preferred provider
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1 organization, third party administrator, an employer or
2 employee organization, or any person or entity that
3 establishes, operates, or maintains a network of
4 participating providers.
5 (3) "Managed care plan" means a plan operated by a
6 managed care entity that provides for the financing of
7 health care services to persons enrolled in the plan
8 through:
9 (A) organizational arrangements for ongoing
10 quality assurance, utilization review programs, or
11 dispute resolution; or
12 (B) financial incentives for persons enrolled
13 in the plan to use the participating providers and
14 procedures covered by the plan.
15 (4) "Participating provider" means a physician who
16 has contracted with an insurer or managed care plan to
17 provide services to insureds or enrollees as defined by
18 the contract.
19 (d) The original provisions of this Section became law
20 on July 17, 1996 and took effect November 14, 1996, which is
21 120 days after becoming law.
22 (Source: P.A. 89-514; 90-14, eff. 7-1-97.)
23 (215 ILCS 5/356w new)
24 Sec. 356w. Diabetes self-management training and
25 education.
26 (a) A group policy of accident and health insurance that
27 is amended, delivered, issued, or renewed after the effective
28 date of this amendatory Act of 1998 shall provide coverage
29 for outpatient self-management training and education,
30 equipment, and supplies, as set forth in this Section, for
31 the treatment of type 1 diabetes, type 2 diabetes, and
32 gestational diabetes mellitus.
33 (b) As used in this Section:
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1 "Diabetes self-management training" means instruction in
2 an outpatient setting which enables a diabetic patient to
3 understand the diabetic management process and daily
4 management of diabetic therapy as a means of avoiding
5 frequent hospitalization and complications. Diabetes
6 self-management training shall include the content areas
7 listed in the National Standards for Diabetes Self-Management
8 Education Programs as published by the American Diabetes
9 Association, including medical nutrition therapy.
10 "Medical nutrition therapy" shall have the meaning
11 ascribed to "medical nutrition care" in the Dietetic and
12 Nutrition Services Practice Act.
13 "Physician" means a physician licensed to practice
14 medicine in all of its branches providing care to the
15 individual.
16 "Qualified provider" for an individual that is enrolled
17 in:
18 (1) a health maintenance organization that uses a
19 primary care physician to control access to specialty
20 care means (A) the individual's primary care physician
21 licensed to practice medicine in all of its branches, (B)
22 a physician licensed to practice medicine in all of its
23 branches to whom the individual has been referred by the
24 primary care physician, or (C) a certified, registered,
25 or licensed network health care professional with
26 expertise in diabetes management to whom the individual
27 has been referred by the primary care physician.
28 (2) an insurance plan means (A) a physician
29 licensed to practice medicine in all of its branches or
30 (B) a certified, registered, or licensed health care
31 professional with expertise in diabetes management to
32 whom the individual has been referred by a physician.
33 (c) Coverage under this Section for diabetes
34 self-management training, including medical nutrition
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1 education, shall be limited to the following:
2 (1) Up to 3 medically necessary visits to a
3 qualified provider upon initial diagnosis of diabetes by
4 the patient's physician or, if diagnosis of diabetes was
5 made within one year prior to the effective date of this
6 amendatory Act of 1998 where the insured was a covered
7 individual, up to 3 medically necessary visits to a
8 qualified provider within one year after that effective
9 date.
10 (2) Up to 2 medically necessary visits to a
11 qualified provider upon a determination by a patient's
12 physician that a significant change in the patient's
13 symptoms or medical condition has occurred. A
14 "significant change" in condition means symptomatic
15 hyperglycemia (greater than 250 mg/dl on repeated
16 occasions), severe hypoglycemia (requiring the assistance
17 of another person), onset or progression of diabetes, or
18 a significant change in medical condition that would
19 require a significantly different treatment regimen.
20 Payment by the insurer or health maintenance
21 organization for the coverage required for diabetes
22 self-management training pursuant to the provisions of this
23 Section is only required to be made for services provided. No
24 coverage is required for additional visits beyond those
25 specified in items (1) and (2) of this subsection.
26 Coverage under this subsection (c) for diabetes
27 self-management training shall be subject to the same
28 deductible, co-payment, and coinsurance provisions that apply
29 to coverage under the policy for other services provided by
30 the same type of provider.
31 (d) Coverage shall be provided for the following
32 equipment when medically necessary and prescribed by a
33 physician licensed to practice medicine in all of its
34 branches. Coverage for the following items shall be subject
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1 to deductible, co-payment and co-insurance provisions
2 provided for under the policy or a durable medical equipment
3 rider to the policy:
4 (1) blood glucose monitors;
5 (2) blood glucose monitors for the legally blind;
6 (3) cartridges for the legally blind; and
7 (4) lancets and lancing devices.
8 This subsection does not apply to a group policy of
9 accident and health insurance that does not provide a durable
10 medical equipment benefit.
11 (e) Coverage shall be provided for the following
12 pharmaceuticals and supplies when medically necessary and
13 prescribed by a physician licensed to practice medicine in
14 all of its branches. Coverage for the following items shall
15 be subject to the same coverage, deductible, co-payment, and
16 co-insurance provisions under the policy or a drug rider to
17 the policy:
18 (1) insulin;
19 (2) syringes and needles;
20 (3) test strips for glucose monitors;
21 (4) FDA approved oral agents used to control blood
22 sugar; and
23 (5) glucagon emergency kits.
24 This subsection does not apply to a group policy of
25 accident and health insurance that does not provide a drug
26 benefit.
27 (f) Coverage shall be provided for regular foot care
28 exams by a physician or by a physician to whom a physician
29 has referred the patient. Coverage for regular foot care
30 exams shall subject to the same deductible, co-payment, and
31 co-insurance provisions that apply under the policy for other
32 services provided by the same type of provider.
33 (g) If authorized by a physician, diabetes
34 self-management training may be provided as a part of an
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1 office visit, group setting, or home visit.
2 (h) This Section shall not apply to agreements,
3 contracts, or policies that provide coverage for a specified
4 diagnosis or other limited benefit coverage.
5 (215 ILCS 5/356x new)
6 Sec. 356x. Coverage for colorectal cancer screening.
7 (a) An insurer shall provide in each group policy,
8 contract, or certificate of accident and health insurance
9 amended, delivered, issued, or renewed covering persons who
10 are residents of this State coverage for colorectal cancer
11 screening with sigmoidoscopy or fecal occult blood testing
12 once every 3 years for persons who are at least 50 years old.
13 (b) For persons who may be classified as high risk for
14 colorectal cancer because the person or a first degree family
15 member of the person has a history of colorectal cancer, the
16 coverage required under subsection (a) shall apply to persons
17 who have attained at least 30 years of age.
18 (c) This Section does not apply to agreements,
19 contracts, or policies that provide coverage for a specified
20 disease or other limited benefit coverage.
21 Section 35. The Health Maintenance Organization Act is
22 amended by changing Section 5-3 as follows:
23 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
24 (Text of Section before amendment by P.A. 90-372)
25 Sec. 5-3. Insurance Code provisions.
26 (a) Health Maintenance Organizations shall be subject to
27 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
28 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
29 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
30 356t, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
31 paragraph (c) of subsection (2) of Section 367, and Articles
-21- LRB9008922JSsbam04
1 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
2 Illinois Insurance Code.
3 (b) For purposes of the Illinois Insurance Code, except
4 for Articles XIII and XIII 1/2, Health Maintenance
5 Organizations in the following categories are deemed to be
6 "domestic companies":
7 (1) a corporation authorized under the Medical
8 Service Plan Act, the Dental Service Plan Act, the
9 Pharmaceutical Service Plan Act, or the Voluntary Health
10 Services Plans Plan Act, or the Nonprofit Health Care
11 Service Plan Act;
12 (2) a corporation organized under the laws of this
13 State; or
14 (3) a corporation organized under the laws of
15 another state, 30% or more of the enrollees of which are
16 residents of this State, except a corporation subject to
17 substantially the same requirements in its state of
18 organization as is a "domestic company" under Article
19 VIII 1/2 of the Illinois Insurance Code.
20 (c) In considering the merger, consolidation, or other
21 acquisition of control of a Health Maintenance Organization
22 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
23 (1) the Director shall give primary consideration
24 to the continuation of benefits to enrollees and the
25 financial conditions of the acquired Health Maintenance
26 Organization after the merger, consolidation, or other
27 acquisition of control takes effect;
28 (2)(i) the criteria specified in subsection (1)(b)
29 of Section 131.8 of the Illinois Insurance Code shall not
30 apply and (ii) the Director, in making his determination
31 with respect to the merger, consolidation, or other
32 acquisition of control, need not take into account the
33 effect on competition of the merger, consolidation, or
34 other acquisition of control;
-22- LRB9008922JSsbam04
1 (3) the Director shall have the power to require
2 the following information:
3 (A) certification by an independent actuary of
4 the adequacy of the reserves of the Health
5 Maintenance Organization sought to be acquired;
6 (B) pro forma financial statements reflecting
7 the combined balance sheets of the acquiring company
8 and the Health Maintenance Organization sought to be
9 acquired as of the end of the preceding year and as
10 of a date 90 days prior to the acquisition, as well
11 as pro forma financial statements reflecting
12 projected combined operation for a period of 2
13 years;
14 (C) a pro forma business plan detailing an
15 acquiring party's plans with respect to the
16 operation of the Health Maintenance Organization
17 sought to be acquired for a period of not less than
18 3 years; and
19 (D) such other information as the Director
20 shall require.
21 (d) The provisions of Article VIII 1/2 of the Illinois
22 Insurance Code and this Section 5-3 shall apply to the sale
23 by any health maintenance organization of greater than 10% of
24 its enrollee population (including without limitation the
25 health maintenance organization's right, title, and interest
26 in and to its health care certificates).
27 (e) In considering any management contract or service
28 agreement subject to Section 141.1 of the Illinois Insurance
29 Code, the Director (i) shall, in addition to the criteria
30 specified in Section 141.2 of the Illinois Insurance Code,
31 take into account the effect of the management contract or
32 service agreement on the continuation of benefits to
33 enrollees and the financial condition of the health
34 maintenance organization to be managed or serviced, and (ii)
-23- LRB9008922JSsbam04
1 need not take into account the effect of the management
2 contract or service agreement on 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
7 Health Maintenance Organization may by contract agree with a
8 group or other enrollment unit to effect refunds or charge
9 additional premiums under the following terms and conditions:
10 (i) the amount of, and other terms and conditions
11 with respect to, the refund or additional premium are set
12 forth in the group or enrollment unit contract agreed in
13 advance of the period for which a refund is to be paid or
14 additional premium is to be charged (which period shall
15 not 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
25 be made or additional premium to be paid pursuant to this
26 subsection (f)). The Health Maintenance Organization and
27 the group or enrollment unit may agree that the
28 profitable or unprofitable experience may be calculated
29 taking into account the refund period and the immediately
30 preceding 2 plan years.
31 The Health Maintenance Organization shall include a
32 statement in the evidence of coverage issued to each enrollee
33 describing the possibility of a refund or additional premium,
34 and upon request of any group or enrollment unit, provide to
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1 the group or enrollment unit a description of the method used
2 to calculate (1) the Health Maintenance Organization's
3 profitable experience with respect to the group or enrollment
4 unit and the resulting refund to the group or enrollment unit
5 or (2) the Health Maintenance Organization's unprofitable
6 experience with respect to the group or enrollment unit and
7 the resulting additional premium to be paid by the group or
8 enrollment unit.
9 In no event shall the Illinois Health Maintenance
10 Organization Guaranty Association be liable to pay any
11 contractual obligation of an insolvent organization to pay
12 any refund authorized under this Section.
13 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
14 90-177, eff. 7-23-97; revised 11-21-97.)
15 (Text of Section after amendment by P.A. 90-372)
16 Sec. 5-3. Insurance Code provisions.
17 (a) Health Maintenance Organizations shall be subject to
18 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
19 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
20 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
21 356t, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
22 paragraph (c) of subsection (2) of Section 367, and Articles
23 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
24 Illinois Insurance Code.
25 (b) For purposes of the Illinois Insurance Code, except
26 for Articles XIII and XIII 1/2, Health Maintenance
27 Organizations in the following categories are deemed to be
28 "domestic companies":
29 (1) a corporation authorized under the Medical
30 Service Plan Act, the Dental Service Plan Act or, the
31 Voluntary Health Services Plans Plan Act, or the
32 Nonprofit Health Care Service Plan Act;
33 (2) a corporation organized under the laws of this
34 State; or
-25- LRB9008922JSsbam04
1 (3) a corporation organized under the laws of
2 another state, 30% or more of the enrollees of which are
3 residents of this State, except a corporation subject to
4 substantially the same requirements in its state of
5 organization as is a "domestic company" under Article
6 VIII 1/2 of the Illinois Insurance Code.
7 (c) In considering the merger, consolidation, or other
8 acquisition of control of a Health Maintenance Organization
9 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
10 (1) the Director shall give primary consideration
11 to the continuation of benefits to enrollees and the
12 financial conditions of the acquired Health Maintenance
13 Organization after the merger, consolidation, or other
14 acquisition of control takes effect;
15 (2)(i) the criteria specified in subsection (1)(b)
16 of Section 131.8 of the Illinois Insurance Code shall not
17 apply and (ii) the Director, in making his determination
18 with respect to the merger, consolidation, or other
19 acquisition of control, need not take into account the
20 effect on competition of the merger, consolidation, or
21 other acquisition of control;
22 (3) the Director shall have the power to require
23 the following information:
24 (A) certification by an independent actuary of
25 the adequacy of the reserves of the Health
26 Maintenance Organization sought to be acquired;
27 (B) pro forma financial statements reflecting
28 the combined balance sheets of the acquiring company
29 and the Health Maintenance Organization sought to be
30 acquired as of the end of the preceding year and as
31 of a date 90 days prior to the acquisition, as well
32 as pro forma financial statements reflecting
33 projected combined operation for a period of 2
34 years;
-26- LRB9008922JSsbam04
1 (C) a pro forma business plan detailing an
2 acquiring party's plans with respect to the
3 operation of the Health Maintenance Organization
4 sought to be acquired for a period of not less than
5 3 years; and
6 (D) such other information as the Director
7 shall require.
8 (d) The provisions of Article VIII 1/2 of the Illinois
9 Insurance Code and this Section 5-3 shall apply to the sale
10 by any health maintenance organization of greater than 10% of
11 its enrollee population (including without limitation the
12 health maintenance organization's right, title, and interest
13 in and to its health care certificates).
14 (e) In considering any management contract or service
15 agreement subject to Section 141.1 of the Illinois Insurance
16 Code, the Director (i) shall, in addition to the criteria
17 specified in Section 141.2 of the Illinois Insurance Code,
18 take into account the effect of the management contract or
19 service agreement on the continuation of benefits to
20 enrollees and the financial condition of the health
21 maintenance organization to be managed or serviced, and (ii)
22 need not take into account the effect of the management
23 contract or service agreement on competition.
24 (f) Except for small employer groups as defined in the
25 Small Employer Rating, Renewability and Portability Health
26 Insurance Act and except for medicare supplement policies as
27 defined in Section 363 of the Illinois Insurance Code, a
28 Health Maintenance Organization may by contract agree with a
29 group or other enrollment unit to effect refunds or charge
30 additional premiums under the following terms and conditions:
31 (i) the amount of, and other terms and conditions
32 with respect to, the refund or additional premium are set
33 forth in the group or enrollment unit contract agreed in
34 advance of the period for which a refund is to be paid or
-27- LRB9008922JSsbam04
1 additional premium is to be charged (which period shall
2 not be less than one year); and
3 (ii) the amount of the refund or additional premium
4 shall not exceed 20% of the Health Maintenance
5 Organization's profitable or unprofitable experience with
6 respect to the group or other enrollment unit for the
7 period (and, for purposes of a refund or additional
8 premium, the profitable or unprofitable experience shall
9 be calculated taking into account a pro rata share of the
10 Health Maintenance Organization's administrative and
11 marketing expenses, but shall not include any refund to
12 be made or additional premium to be paid pursuant to this
13 subsection (f)). The Health Maintenance Organization and
14 the group or enrollment unit may agree that the
15 profitable or unprofitable experience may be calculated
16 taking into account the refund period and the immediately
17 preceding 2 plan years.
18 The Health Maintenance Organization shall include a
19 statement in the evidence of coverage issued to each enrollee
20 describing the possibility of a refund or additional premium,
21 and upon request of any group or enrollment unit, provide to
22 the group or enrollment unit a description of the method used
23 to calculate (1) the Health Maintenance Organization's
24 profitable experience with respect to the group or enrollment
25 unit and the resulting refund to the group or enrollment unit
26 or (2) the Health Maintenance Organization's unprofitable
27 experience with respect to the group or enrollment unit and
28 the resulting additional premium to be paid by the group or
29 enrollment unit.
30 In no event shall the Illinois Health Maintenance
31 Organization Guaranty Association be liable to pay any
32 contractual obligation of an insolvent organization to pay
33 any refund authorized under this Section.
34 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
-28- LRB9008922JSsbam04
1 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; revised 11-21-97.)
2 Section 40. The Limited Health Service Organization Act
3 is amended by changing Section 3009 as follows:
4 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
5 Sec. 3009. Point-of-service limited health service
6 contracts.
7 (a) An LHSO that offers a POS contract:
8 (1) shall include as in-plan covered services all
9 services required by law to be provided by an LHSO;
10 (2) shall provide incentives, which shall include
11 financial incentives, for enrollees to use in-plan
12 covered services;
13 (3) shall not offer services out-of-plan without
14 providing those services on an in-plan basis;
15 (4) may limit or exclude specific types of services
16 from coverage when obtained out-of-plan;
17 (5) may include annual out-of-pocket limits and
18 lifetime maximum benefits allowances for out-of-plan
19 services that are separate from any limits or allowances
20 applied to in-plan services;
21 (6) shall include an annual maximum benefit
22 allowance not to exceed $2,500 per year that is separate
23 from any limits or allowances applied to in-plan
24 services;
25 (7) may limit the groups to which a POS product is
26 offered, however, if a POS product is offered to a group,
27 then it must be offered to all eligible members of that
28 group, when an LHSO provider is available;
29 (8) shall not consider emergency services,
30 authorized referral services, or non-routine services
31 obtained out of the service area to be POS services; and
32 (9) may treat as out-of-plan services those
-29- LRB9008922JSsbam04
1 services that an enrollee obtains from a participating
2 provider, but for which the proper authorization was not
3 given by the LHSO.
4 (b) An LHSO offering a POS contract shall be subject to
5 the following limitations:
6 (1) The LHSO shall not expend in any calendar
7 quarter more than 20% of its total limited health
8 services expenditures for all its members for out-of-plan
9 covered services.
10 (2) If the amount specified in paragraph (1) is
11 exceeded by 2% in a quarter, the LHSO shall effect
12 compliance with paragraph (1) by the end of the following
13 quarter.
14 (3) If compliance with the amount specified in
15 paragraph (1) is not demonstrated in the LHSO's next
16 quarterly report, the LHSO may not offer the POS contract
17 to new groups or include the POS option in the renewal of
18 an existing group until compliance with the amount
19 specified in paragraph (1) is demonstrated or otherwise
20 allowed by the Director.
21 (4) Any LHSO failing, without just cause, to comply
22 with the provisions of this subsection shall be required,
23 after notice and hearing, to pay a penalty of $250 for
24 each day out of compliance, to be recovered by the
25 Director of Insurance. Any penalty recovered shall be
26 paid into the General Revenue Fund. The Director may
27 reduce the penalty if the LHSO demonstrates to the
28 Director that the imposition of the penalty would
29 constitute a financial hardship to the LHSO.
30 (c) Any LHSO that offers a POS product shall:
31 (1) File a quarterly financial statement detailing
32 compliance with the requirements of subsection (b).
33 (2) Track out-of-plan POS utilization separately
34 from in-plan or non-POS out-of-plan emergency care,
-30- LRB9008922JSsbam04
1 referral care, and urgent care out of the service area
2 utilization.
3 (3) Record out-of-plan utilization in a manner that
4 will permit such utilization and cost reporting as the
5 Director may, by regulation, require.
6 (4) Demonstrate to the Director's satisfaction that
7 the LHSO has the fiscal, administrative, and marketing
8 capacity to control its POS enrollment, utilization, and
9 costs so as not to jeopardize the financial security of
10 the LHSO.
11 (5) Maintain the deposit required by subsection (b)
12 of Section 2006 in addition to any other deposit required
13 under this Act.
14 (d) An LHSO shall not issue a POS contract until it has
15 filed and had approved by the Director a plan to comply with
16 the provisions of this Section. The compliance plan shall at
17 a minimum include provisions demonstrating that the LHSO will
18 do all of the following:
19 (1) Design the benefit levels and conditions of
20 coverage for in-plan covered services and out-of-plan
21 covered services as required by this Article.
22 (2) Provide or arrange for the provision of
23 adequate systems to:
24 (A) process and pay claims for all out-of-plan
25 covered services;
26 (B) meet the requirements for a POS contract
27 set forth in this Section and any additional
28 requirements that may be set forth by the Director;
29 and
30 (C) generate accurate data and financial and
31 regulatory reports on a timely basis so that the
32 Department can evaluate the LHSO's experience with
33 the POS contract and monitor compliance with POS
34 contract provisions.
-31- LRB9008922JSsbam04
1 (3) Comply initially and on an ongoing basis with
2 the requirements of subsections (b) and (c).
3 (e) A limited health service organization that offers a
4 POS contract must comply with Sections 356w and 356x of the
5 Illinois Insurance Code.
6 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.)
7 Section 45. The Voluntary Health Services Plans Act is
8 amended by changing Section 10 as follows:
9 (215 ILCS 165/10) (from Ch. 32, par. 604)
10 Sec. 10. Application of Insurance Code provisions.
11 Health services plan corporations and all persons interested
12 therein or dealing therewith shall be subject to the
13 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
14 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
15 356x, 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
16 and paragraphs (7) and (15) of Section 367 of the Illinois
17 Insurance Code.
18 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
19 90-25, eff. 1-1-98; revised 10-14-97.)
20 Section 50. The Illinois Public Aid Code is amended by
21 changing Section 5-16.8 as follows:
22 (305 ILCS 5/5-16.8)
23 Sec. 5-16.8. Required health benefits. The medical
24 assistance program shall provide the post-mastectomy care
25 benefits required to be covered by a policy of accident and
26 health insurance under Section 356t and the coverage required
27 under Sections Section 356u, 356w, and 356x of the Illinois
28 Insurance Code.
29 (Source: P.A. 90-7, eff. 6-10-97.)
-32- LRB9008922JSsbam04
1 Section 95. No acceleration or delay. Where this Act
2 makes changes in a statute that is represented in this Act by
3 text that is not yet or no longer in effect (for example, a
4 Section represented by multiple versions), the use of that
5 text does not accelerate or delay the taking effect of (i)
6 the changes made by this Act or (ii) provisions derived from
7 any other Public Act.
8 Section 99. Effective date. This Section and the
9 provisions of this Act amending Sections 4 and 356r of the
10 Illinois Insurance Code take effect upon becoming law; the
11 remaining provisions of this Act take effect January 1,
12 1999.".