Public Act 096-0833
 
HB2652 Enrolled LRB096 10389 RPM 20559 b

    AN ACT concerning insurance.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Insurance Code is amended by
renumbering Section 356z.14 as added by Public Act 95-1005, by
changing and renumbering Section 356z.15 as added by Public Act
96-639, and by adding Section 356z.18 as follows:
 
    (215 ILCS 5/356z.15)
    Sec. 356z.15 356z.14. Habilitative services for children.
    (a) As used in this Section, "habilitative services" means
occupational therapy, physical therapy, speech therapy, and
other services prescribed by the insured's treating physician
pursuant to a treatment plan to enhance the ability of a child
to function with a congenital, genetic, or early acquired
disorder. A congenital or genetic disorder includes, but is not
limited to, hereditary disorders. An early acquired disorder
refers to a disorder resulting from illness, trauma, injury, or
some other event or condition suffered by a child prior to that
child developing functional life skills such as, but not
limited to, walking, talking, or self-help skills. Congenital,
genetic, and early acquired disorders may include, but are not
limited to, autism or an autism spectrum disorder, cerebral
palsy, and other disorders resulting from early childhood
illness, trauma, or injury.
    (b) A group or individual policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed after the effective date of this amendatory Act of the
95th General Assembly must provide coverage for habilitative
services for children under 19 years of age with a congenital,
genetic, or early acquired disorder so long as all of the
following conditions are met:
        (1) A physician licensed to practice medicine in all
    its branches has diagnosed the child's congenital,
    genetic, or early acquired disorder.
        (2) The treatment is administered by a licensed
    speech-language pathologist, licensed audiologist,
    licensed occupational therapist, licensed physical
    therapist, licensed physician, licensed nurse, licensed
    optometrist, licensed nutritionist, licensed social
    worker, or licensed psychologist upon the referral of a
    physician licensed to practice medicine in all its
    branches.
        (3) The initial or continued treatment must be
    medically necessary and therapeutic and not experimental
    or investigational.
    (c) The coverage required by this Section shall be subject
to other general exclusions and limitations of the policy,
including coordination of benefits, participating provider
requirements, restrictions on services provided by family or
household members, utilization review of health care services,
including review of medical necessity, case management,
experimental, and investigational treatments, and other
managed care provisions.
    (d) Coverage under this Section does not apply to those
services that are solely educational in nature or otherwise
paid under State or federal law for purely educational
services. Nothing in this subsection (d) relieves an insurer or
similar third party from an otherwise valid obligation to
provide or to pay for services provided to a child with a
disability.
    (e) Coverage under this Section for children under age 19
shall not apply to treatment of mental or emotional disorders
or illnesses as covered under Section 370 of this Code as well
as any other benefit based upon a specific diagnosis that may
be otherwise required by law.
    (f) The provisions of this Section do not apply to
short-term travel, accident-only, limited, or specific disease
policies.
    (g) Any denial of care for habilitative services shall be
subject to appeal and external independent review procedures as
provided by Section 45 of the Managed Care Reform and Patient
Rights Act.
    (h) Upon request of the reimbursing insurer, the provider
under whose supervision the habilitative services are being
provided shall furnish medical records, clinical notes, or
other necessary data to allow the insurer to substantiate that
initial or continued medical treatment is medically necessary
and that the patient's condition is clinically improving. When
the treating provider anticipates that continued treatment is
or will be required to permit the patient to achieve
demonstrable progress, the insurer may request that the
provider furnish a treatment plan consisting of diagnosis,
proposed treatment by type, frequency, anticipated duration of
treatment, the anticipated goals of treatment, and how
frequently the treatment plan will be updated.
    (i) Rulemaking authority to implement this amendatory Act
of the 95th General Assembly, if any, is conditioned on the
rules being adopted in accordance with all provisions of the
Illinois Administrative Procedure Act and all rules and
procedures of the Joint Committee on Administrative Rules; any
purported rule not so adopted, for whatever reason, is
unauthorized.
(Source: P.A. 95-1049, eff. 1-1-10; revised 10-23-09.)
 
    (215 ILCS 5/356z.17)
    Sec. 356z.17 356z.15. Wellness coverage.
    (a) A group or individual policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed after January 1, 2010 (the effective date of Public Act
96-639) this amendatory Act of the 96th General Assembly that
provides coverage for hospital or medical treatment on an
expense incurred basis may offer a reasonably designed program
for wellness coverage that allows for a reward, a contribution,
a reduction in premiums or reduced medical, prescription drug,
or equipment copayments, coinsurance, or deductibles, or a
combination of these incentives, for participation in any
health behavior wellness, maintenance, or improvement program
approved or offered by the insurer or managed care plan. The
insured or enrollee may be required to provide evidence of
participation in a program. Individuals unable to participate
in these incentives due to an adverse health factor shall not
be penalized based upon an adverse health status.
    (b) For purposes of this Section, "wellness coverage" means
health care coverage with the primary purpose to engage and
motivate the insured or enrollee through: incentives;
provision of health education, counseling, and self-management
skills; identification of modifiable health risks; and other
activities to influence health behavior changes.
    For the purposes of this Section, "reasonably designed
program" means a program of wellness coverage that has a
reasonable chance of improving health or preventing disease; is
not overly burdensome; does not discriminate based upon factors
of health; and is not otherwise contrary to law.
    (c) Incentives as outlined in this Section are specific and
unique to the offering of wellness coverage and have no
application to any other required or optional health care
benefit.
    (d) Such wellness coverage must satisfy the requirements
for an exception from the general prohibition against
discrimination based on a health factor under the federal
Health Insurance Portability and Accountability Act of 1996
(P.L. 104-191; 110 Stat. 1936), including any federal
regulations that are adopted pursuant to that Act.
    (e) A plan offering wellness coverage must do the
following:
        (i) give participants the opportunity to qualify for
    offered incentives at least once a year;
        (ii) allow a reasonable alternative to any individual
    for whom it is unreasonably difficult, due to a medical
    condition, to satisfy otherwise applicable wellness
    program standards. Plans may seek physician verification
    that health factors make it unreasonably difficult or
    medically inadvisable for the participant to satisfy the
    standards; and
        (iii) not provide a total incentive that exceeds 20% of
    the cost of employee-only coverage. The cost of
    employee-only coverage includes both employer and employee
    contributions. For plans offering family coverage, the 20%
    limitation applies to cost of family coverage and applies
    to the entire family.
    (f) A reward, contribution, or reduction established under
this Section and included in the policy or certificate does not
violate Section 151 of this Code.
(Source: P.A. 96-639, eff. 1-1-10; revised 10-21-09.)
 
    (215 ILCS 5/356z.18 new)
    Sec. 356z.18. Prosthetic and customized orthotic devices.
    (a) For the purposes of this Section:
    "Customized orthotic device" means a supportive device for
the body or a part of the body, the head, neck, or extremities,
and includes the replacement or repair of the device based on
the patient's physical condition as medically necessary,
excluding foot orthotics defined as an in-shoe device designed
to support the structural components of the foot during
weight-bearing activities.
    "Licensed provider" means a prosthetist, orthotist, or
pedorthist licensed to practice in this State.
    "Prosthetic device" means an artificial device to replace,
in whole or in part, an arm or leg and includes accessories
essential to the effective use of the device and the
replacement or repair of the device based on the patient's
physical condition as medically necessary.
    (b) This amendatory Act of the 96th General Assembly shall
provide benefits to any person covered thereunder for expenses
incurred in obtaining a prosthetic or custom orthotic device
from any Illinois licensed prosthetist, licensed orthotist, or
licensed pedorthist as required under the Orthotics,
Prosthetics, and Pedorthics Practice Act.
    (c) A group or individual major medical policy of accident
or health insurance or managed care plan or medical, health, or
hospital service corporation contract that provides coverage
for prosthetic or custom orthotic care and is amended,
delivered, issued, or renewed 6 months after the effective date
of this amendatory Act of the 96th General Assembly must
provide coverage for prosthetic and orthotic devices in
accordance with this subsection (c). The coverage required
under this Section shall be subject to the other general
exclusions, limitations, and financial requirements of the
policy, including coordination of benefits, participating
provider requirements, utilization review of health care
services, including review of medical necessity, case
management, and experimental and investigational treatments,
and other managed care provisions under terms and conditions
that are no less favorable than the terms and conditions that
apply to substantially all medical and surgical benefits
provided under the plan or coverage.
    (d) The policy or plan or contract may require prior
authorization for the prosthetic or orthotic devices in the
same manner that prior authorization is required for any other
covered benefit.
    (e) Repairs and replacements of prosthetic and orthotic
devices are also covered, subject to the co-payments and
deductibles, unless necessitated by misuse or loss.
    (f) A policy or plan or contract may require that, if
coverage is provided through a managed care plan, the benefits
mandated pursuant to this Section shall be covered benefits
only if the prosthetic or orthotic devices are provided by a
licensed provider employed by a provider service who contracts
with or is designated by the carrier, to the extent that the
carrier provides in-network and out-of-network service, the
coverage for the prosthetic or orthotic device shall be offered
no less extensively.
    (g) The policy or plan or contract shall also meet adequacy
requirements as established by the Health Care Reimbursement
Reform Act of 1985 of the Illinois Insurance Code.
    (h) This Section shall not apply to accident only,
specified disease, short-term hospital or medical, hospital
confinement indemnity, credit, dental, vision, Medicare
supplement, long-term care, basic hospital and
medical-surgical expense coverage, disability income insurance
coverage, coverage issued as a supplement to liability
insurance, workers' compensation insurance, or automobile
medical payment insurance.
 
    Section 10. The Health Maintenance Organization Act is
amended by changing Section 5-3 as follows:
 
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
    Sec. 5-3. Insurance Code provisions.
    (a) Health Maintenance Organizations shall be subject to
the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14,
356z.17 356z.15, 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a,
368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408,
408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
    (b) For purposes of the Illinois Insurance Code, except for
Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
Maintenance Organizations in the following categories are
deemed to be "domestic companies":
        (1) a corporation authorized under the Dental Service
    Plan Act or the Voluntary Health Services Plans Act;
        (2) a corporation organized under the laws of this
    State; or
        (3) a corporation organized under the laws of another
    state, 30% or more of the enrollees of which are residents
    of this State, except a corporation subject to
    substantially the same requirements in its state of
    organization as is a "domestic company" under Article VIII
    1/2 of the Illinois Insurance Code.
    (c) In considering the merger, consolidation, or other
acquisition of control of a Health Maintenance Organization
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
        (1) the Director shall give primary consideration to
    the continuation of benefits to enrollees and the financial
    conditions of the acquired Health Maintenance Organization
    after the merger, consolidation, or other acquisition of
    control takes effect;
        (2)(i) the criteria specified in subsection (1)(b) of
    Section 131.8 of the Illinois Insurance Code shall not
    apply and (ii) the Director, in making his determination
    with respect to the merger, consolidation, or other
    acquisition of control, need not take into account the
    effect on competition of the merger, consolidation, or
    other acquisition of control;
        (3) the Director shall have the power to require the
    following information:
            (A) certification by an independent actuary of the
        adequacy of the reserves of the Health Maintenance
        Organization sought to be acquired;
            (B) pro forma financial statements reflecting the
        combined balance sheets of the acquiring company and
        the Health Maintenance Organization sought to be
        acquired as of the end of the preceding year and as of
        a date 90 days prior to the acquisition, as well as pro
        forma financial statements reflecting projected
        combined operation for a period of 2 years;
            (C) a pro forma business plan detailing an
        acquiring party's plans with respect to the operation
        of the Health Maintenance Organization sought to be
        acquired for a period of not less than 3 years; and
            (D) such other information as the Director shall
        require.
    (d) The provisions of Article VIII 1/2 of the Illinois
Insurance Code and this Section 5-3 shall apply to the sale by
any health maintenance organization of greater than 10% of its
enrollee population (including without limitation the health
maintenance organization's right, title, and interest in and to
its health care certificates).
    (e) In considering any management contract or service
agreement subject to Section 141.1 of the Illinois Insurance
Code, the Director (i) shall, in addition to the criteria
specified in Section 141.2 of the Illinois Insurance Code, take
into account the effect of the management contract or service
agreement on the continuation of benefits to enrollees and the
financial condition of the health maintenance organization to
be managed or serviced, and (ii) need not take into account the
effect of the management contract or service agreement on
competition.
    (f) Except for small employer groups as defined in the
Small Employer Rating, Renewability and Portability Health
Insurance Act and except for medicare supplement policies as
defined in Section 363 of the Illinois Insurance Code, a Health
Maintenance Organization may by contract agree with a group or
other enrollment unit to effect refunds or charge additional
premiums under the following terms and conditions:
        (i) the amount of, and other terms and conditions with
    respect to, the refund or additional premium are set forth
    in the group or enrollment unit contract agreed in advance
    of the period for which a refund is to be paid or
    additional premium is to be charged (which period shall not
    be less than one year); and
        (ii) the amount of the refund or additional premium
    shall not exceed 20% of the Health Maintenance
    Organization's profitable or unprofitable experience with
    respect to the group or other enrollment unit for the
    period (and, for purposes of a refund or additional
    premium, the profitable or unprofitable experience shall
    be calculated taking into account a pro rata share of the
    Health Maintenance Organization's administrative and
    marketing expenses, but shall not include any refund to be
    made or additional premium to be paid pursuant to this
    subsection (f)). The Health Maintenance Organization and
    the group or enrollment unit may agree that the profitable
    or unprofitable experience may be calculated taking into
    account the refund period and the immediately preceding 2
    plan years.
    The Health Maintenance Organization shall include a
statement in the evidence of coverage issued to each enrollee
describing the possibility of a refund or additional premium,
and upon request of any group or enrollment unit, provide to
the group or enrollment unit a description of the method used
to calculate (1) the Health Maintenance Organization's
profitable experience with respect to the group or enrollment
unit and the resulting refund to the group or enrollment unit
or (2) the Health Maintenance Organization's unprofitable
experience with respect to the group or enrollment unit and the
resulting additional premium to be paid by the group or
enrollment unit.
    In no event shall the Illinois Health Maintenance
Organization Guaranty Association be liable to pay any
contractual obligation of an insolvent organization to pay any
refund authorized under this Section.
    (g) Rulemaking authority to implement Public Act 95-1045
this amendatory Act of the 95th General Assembly, if any, is
conditioned on the rules being adopted in accordance with all
provisions of the Illinois Administrative Procedure Act and all
rules and procedures of the Joint Committee on Administrative
Rules; any purported rule not so adopted, for whatever reason,
is unauthorized.
(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised
10-23-09.)
 
    Section 15. The Voluntary Health Services Plans Act is
amended by changing Section 10 as follows:
 
    (215 ILCS 165/10)  (from Ch. 32, par. 604)
    Sec. 10. Application of Insurance Code provisions. Health
services plan corporations and all persons interested therein
or dealing therewith shall be subject to the provisions of
Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
356z.14, 356z.15 356z.14, 356z.18, 364.01, 367.2, 368a, 401,
401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
and (15) of Section 367 of the Illinois Insurance Code.
    Rulemaking authority to implement Public Act 95-1045 this
amendatory Act of the 95th General Assembly, if any, is
conditioned on the rules being adopted in accordance with all
provisions of the Illinois Administrative Procedure Act and all
rules and procedures of the Joint Committee on Administrative
Rules; any purported rule not so adopted, for whatever reason,
is unauthorized.
(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
96-328, eff. 8-11-09; revised 9-25-09.)
 
    Section 95. No acceleration or delay. Where this Act makes
changes in a statute that is represented in this Act by text
that is not yet or no longer in effect (for example, a Section
represented by multiple versions), the use of that text does
not accelerate or delay the taking effect of (i) the changes
made by this Act or (ii) provisions derived from any other
Public Act.