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90_SB1048ham001
LRB9005120JSgcam05
1 AMENDMENT TO SENATE BILL 1048
2 AMENDMENT NO. . Amend Senate Bill 1048 by replacing
3 the title with the following:
4 "AN ACT concerning health coverage for treatment of
5 diabetes, amending named Acts."; and
6 by replacing everything after the enacting clause with the
7 following:
8 "Section 5. The Illinois Insurance Code is amended by
9 adding Sections 356t, 370s, and 511.114 as follows:
10 (215 ILCS 5/356t new)
11 Sec. 356t. Diabetes self-management training and
12 education.
13 (a) A group policy of accident and health insurance that
14 is amended, delivered, issued, or renewed after the effective
15 date of this amendatory Act of 1997 shall provide coverage
16 for outpatient self-management training and education,
17 equipment, and supplies, as set forth in this Section, for
18 the treatment of diabetes.
19 (b) As used in this Section, "diabetes self-management
20 training" means instruction in an outpatient setting which
21 enables diabetic patients to understand the diabetes
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1 management process and daily management of diabetic therapy
2 as a means of avoiding frequent hospitalizations and
3 complications. Diabetes self-management training shall
4 include, but shall not be limited to, medical nutrition
5 therapy.
6 As used in this Section, "attending physician" means a
7 physician licensed to practice medicine in all of its
8 branches providing care to the individual. The attending
9 physician for an individual enrolled in a health maintenance
10 organization shall be the individual's primary care
11 physician.
12 (c) Coverage under this Section for diabetes
13 self-management training, including medical nutrition
14 education, shall be limited to the following:
15 (1) Up to 6 medically necessary visits upon initial
16 diagnosis of diabetes by the patient's attending
17 physician, which are provided by the attending physician
18 or on the referral of the attending physician by a
19 physician licensed to practice medicine in all of its
20 branches, or on the referral of the attending physician
21 by a certified, registered, or licensed health care
22 professional with expertise in diabetes management.
23 (2) Up to 6 medically necessary visits, upon a
24 diagnosis by a patient's attending physician that
25 represents a significant change in the patient's symptoms
26 or condition, which are provided by the attending
27 physician or on the referral of the attending physician
28 by a physician licensed to practice medicine in all of
29 its branches, or on the referral of the attending
30 physician by a certified, registered or licensed health
31 care professional with expertise in diabetes management.
32 (3) One visit when reeducation or refresher
33 training is medically necessary as prescribed by a
34 physician.
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1 Payment for the coverage required for diabetes
2 self-mangement training pursuant to the provisions of this
3 Section shall be required only upon certification by the
4 health care provider providing the training that the patient
5 has successfully completed diabetes self-mangement training.
6 (d) Coverage shall be provided for medically necessary
7 regular foot care exams.
8 (e) Coverage shall be provided for medically necessary
9 FDA approved oral agents that are for controlling blood
10 sugar, if an individual's policy of accident and health
11 insurance contains a drug benefit.
12 (f) Coverage shall be provided for the following
13 equipment, supplies, and related services for insulin-using
14 diabetics:
15 (1) blood glucose monitors;
16 (2) blood glucose monitors for the legally blind;
17 (3) cartridges for the legally blind;
18 (4) insulin, if an individual's policy of accident
19 and health insurance contains a drug benefit;
20 (5) insulin infusion devices that are authorized by
21 the attending physician;
22 (6) oral agents for controlling blood sugar;
23 (7) syringes, pen needles, lancets, and lancing
24 devices if an individual's policy of accident and health
25 insurance contains a drug benefit;
26 (8) test strips for glucose monitors; and
27 (9) visual reading and urine testing strips.
28 (215 ILCS 5/370s new)
29 Sec. 370s. Diabetes management training. All insurers
30 and administrators are subject to Section 356t of this Code.
31 (215 ILCS 5/511.114 new)
32 Sec. 511.114. Diabetes management training. All
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1 administrators are subject to Section 356t of this Code.
2 Section 10. 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, 356t, 367i, 401,
10 401.1, 402, 403, 403A, 408, 408.2, and 412, paragraph (c) of
11 subsection (2) of Section 367, and Articles VIII 1/2, XII,
12 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
13 Code.
14 (b) For purposes of the Illinois Insurance Code, except
15 for Articles XIII and XIII 1/2, Health Maintenance
16 Organizations in the following categories are deemed to be
17 "domestic companies":
18 (1) a corporation authorized under the Medical
19 Service Plan Act, the Dental Service Plan Act, the Vision
20 Service Plan Act, the Pharmaceutical Service Plan Act,
21 the Voluntary Health Services Plan Act, or the Nonprofit
22 Health Care Service Plan Act;
23 (2) a corporation organized under the laws of this
24 State; or
25 (3) a corporation organized under the laws of
26 another state, 30% or more of the enrollees of which are
27 residents of this State, except a corporation subject to
28 substantially the same requirements in its state of
29 organization as is a "domestic company" under Article
30 VIII 1/2 of the Illinois Insurance Code.
31 (c) In considering the merger, consolidation, or other
32 acquisition of control of a Health Maintenance Organization
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1 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
2 (1) the Director shall give primary consideration
3 to the continuation of benefits to enrollees and the
4 financial conditions of the acquired Health Maintenance
5 Organization after the merger, consolidation, or other
6 acquisition of control takes effect;
7 (2)(i) the criteria specified in subsection (1)(b)
8 of Section 131.8 of the Illinois Insurance Code shall not
9 apply and (ii) the Director, in making his determination
10 with respect to the merger, consolidation, or other
11 acquisition of control, need not take into account the
12 effect on competition of the merger, consolidation, or
13 other acquisition of control;
14 (3) the Director shall have the power to require
15 the following information:
16 (A) certification by an independent actuary of
17 the adequacy of the reserves of the Health
18 Maintenance Organization sought to be acquired;
19 (B) pro forma financial statements reflecting
20 the combined balance sheets of the acquiring company
21 and the Health Maintenance Organization sought to be
22 acquired as of the end of the preceding year and as
23 of a date 90 days prior to the acquisition, as well
24 as pro forma financial statements reflecting
25 projected combined operation for a period of 2
26 years;
27 (C) a pro forma business plan detailing an
28 acquiring party's plans with respect to the
29 operation of the Health Maintenance Organization
30 sought to be acquired for a period of not less than
31 3 years; and
32 (D) such other information as the Director
33 shall require.
34 (d) The provisions of Article VIII 1/2 of the Illinois
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1 Insurance Code and this Section 5-3 shall apply to the sale
2 by any health maintenance organization of greater than 10% of
3 its enrollee population (including without limitation the
4 health maintenance organization's right, title, and interest
5 in and to its health care certificates).
6 (e) In considering any management contract or service
7 agreement subject to Section 141.1 of the Illinois Insurance
8 Code, the Director (i) shall, in addition to the criteria
9 specified in Section 141.2 of the Illinois Insurance Code,
10 take into account the effect of the management contract or
11 service agreement on the continuation of benefits to
12 enrollees and the financial condition of the health
13 maintenance organization to be managed or serviced, and (ii)
14 need not take into account the effect of the management
15 contract or service agreement on competition.
16 (f) Except for small employer groups as defined in the
17 Small Employer Rating, Renewability and Portability Health
18 Insurance Act and except for medicare supplement policies as
19 defined in Section 363 of the Illinois Insurance Code, a
20 Health Maintenance Organization may by contract agree with a
21 group or other enrollment unit to effect refunds or charge
22 additional premiums under the following terms and conditions:
23 (i) the amount of, and other terms and conditions
24 with respect to, the refund or additional premium are set
25 forth in the group or enrollment unit contract agreed in
26 advance of the period for which a refund is to be paid or
27 additional premium is to be charged (which period shall
28 not be less than one year); and
29 (ii) the amount of the refund or additional premium
30 shall not exceed 20% of the Health Maintenance
31 Organization's profitable or unprofitable experience with
32 respect to the group or other enrollment unit for the
33 period (and, for purposes of a refund or additional
34 premium, the profitable or unprofitable experience shall
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1 be calculated taking into account a pro rata share of the
2 Health Maintenance Organization's administrative and
3 marketing expenses, but shall not include any refund to
4 be made or additional premium to be paid pursuant to this
5 subsection (f)). The Health Maintenance Organization and
6 the group or enrollment unit may agree that the
7 profitable or unprofitable experience may be calculated
8 taking into account the refund period and the immediately
9 preceding 2 plan years.
10 The Health Maintenance Organization shall include a
11 statement in the evidence of coverage issued to each enrollee
12 describing the possibility of a refund or additional premium,
13 and upon request of any group or enrollment unit, provide to
14 the group or enrollment unit a description of the method used
15 to calculate (1) the Health Maintenance Organization's
16 profitable experience with respect to the group or enrollment
17 unit and the resulting refund to the group or enrollment unit
18 or (2) the Health Maintenance Organization's unprofitable
19 experience with respect to the group or enrollment unit and
20 the resulting additional premium to be paid by the group or
21 enrollment unit.
22 In no event shall the Illinois Health Maintenance
23 Organization Guaranty Association be liable to pay any
24 contractual obligation of an insolvent organization to pay
25 any refund authorized under this Section.
26 (Source: P.A. 88-313; 89-90, eff. 6-30-95.)
27 Section 15. The Limited Health Service Organization Act
28 is amended by changing Section 3009 as follows:
29 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
30 Sec. 3009. Point-of-service limited health service
31 contracts.
32 (a) An LHSO that offers a POS contract:
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1 (1) shall include as in-plan covered services all
2 services required by law to be provided by an LHSO;
3 (2) shall provide incentives, which shall include
4 financial incentives, for enrollees to use in-plan
5 covered services;
6 (3) shall not offer services out-of-plan without
7 providing those services on an in-plan basis;
8 (4) may limit or exclude specific types of services
9 from coverage when obtained out-of-plan;
10 (5) may include annual out-of-pocket limits and
11 lifetime maximum benefits allowances for out-of-plan
12 services that are separate from any limits or allowances
13 applied to in-plan services;
14 (6) shall include an annual maximum benefit
15 allowance not to exceed $2,500 per year that is separate
16 from any limits or allowances applied to in-plan
17 services;
18 (7) may limit the groups to which a POS product is
19 offered, however, if a POS product is offered to a group,
20 then it must be offered to all eligible members of that
21 group, when an LHSO provider is available;
22 (8) shall not consider emergency services,
23 authorized referral services, or non-routine services
24 obtained out of the service area to be POS services; and
25 (9) may treat as out-of-plan services those
26 services that an enrollee obtains from a participating
27 provider, but for which the proper authorization was not
28 given by the LHSO.
29 (b) An LHSO offering a POS contract shall be subject to
30 the following limitations:
31 (1) The LHSO shall not expend in any calendar
32 quarter more than 20% of its total limited health
33 services expenditures for all its members for out-of-plan
34 covered services.
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1 (2) If the amount specified in paragraph (1) is
2 exceeded by 2% in a quarter, the LHSO shall effect
3 compliance with paragraph (1) by the end of the following
4 quarter.
5 (3) If compliance with the amount specified in
6 paragraph (1) is not demonstrated in the LHSO's next
7 quarterly report, the LHSO may not offer the POS contract
8 to new groups or include the POS option in the renewal of
9 an existing group until compliance with the amount
10 specified in paragraph (1) is demonstrated or otherwise
11 allowed by the Director.
12 (4) Any LHSO failing, without just cause, to comply
13 with the provisions of this subsection shall be required,
14 after notice and hearing, to pay a penalty of $250 for
15 each day out of compliance, to be recovered by the
16 Director of Insurance. Any penalty recovered shall be
17 paid into the General Revenue Fund. The Director may
18 reduce the penalty if the LHSO demonstrates to the
19 Director that the imposition of the penalty would
20 constitute a financial hardship to the LHSO.
21 (c) Any LHSO that offers a POS product shall:
22 (1) File a quarterly financial statement detailing
23 compliance with the requirements of subsection (b).
24 (2) Track out-of-plan POS utilization separately
25 from in-plan or non-POS out-of-plan emergency care,
26 referral care, and urgent care out of the service area
27 utilization.
28 (3) Record out-of-plan utilization in a manner that
29 will permit such utilization and cost reporting as the
30 Director may, by regulation, require.
31 (4) Demonstrate to the Director's satisfaction that
32 the LHSO has the fiscal, administrative, and marketing
33 capacity to control its POS enrollment, utilization, and
34 costs so as not to jeopardize the financial security of
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1 the LHSO.
2 (5) Maintain the deposit required by subsection (b)
3 of Section 2006 in addition to any other deposit required
4 under this Act.
5 (d) An LHSO shall not issue a POS contract until it has
6 filed and had approved by the Director a plan to comply with
7 the provisions of this Section. The compliance plan shall at
8 a minimum include provisions demonstrating that the LHSO will
9 do all of the following:
10 (1) Design the benefit levels and conditions of
11 coverage for in-plan covered services and out-of-plan
12 covered services as required by this Article.
13 (2) Provide or arrange for the provision of
14 adequate systems to:
15 (A) process and pay claims for all out-of-plan
16 covered services;
17 (B) meet the requirements for a POS contract
18 set forth in this Section and any additional
19 requirements that may be set forth by the Director;
20 and
21 (C) generate accurate data and financial and
22 regulatory reports on a timely basis so that the
23 Department can evaluate the LHSO's experience with
24 the POS contract and monitor compliance with POS
25 contract provisions.
26 (3) Comply initially and on an ongoing basis with
27 the requirements of subsections (b) and (c).
28 (e) A limited health service organization that offers a
29 POS contract must comply with Section 356t of the Illinois
30 Insurance Code.
31 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.)
32 Section 20. The Voluntary Health Services Plans Act is
33 amended by changing Section 10 as follows:
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1 (215 ILCS 165/10) (from Ch. 32, par. 604)
2 Sec. 10. Application of Insurance Code provisions.
3 Health services plan corporations and all persons interested
4 therein or dealing therewith shall be subject to the
5 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
6 143, 143c, 149, 354, 355.2, 356r, 356t, 367.2, 401, 401.1,
7 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
8 (15) of Section 367 of the Illinois Insurance Code.
9 (Source: P.A. 89-514, eff. 7-17-96.)
10 Section 99. Effective date. This Act takes effect upon
11 becoming law.".