Public Act 90-0741 of the 90th General Assembly
Public Act 90-0741
HB3427 Enrolled LRB9008922JSgcB
AN ACT concerning insurance coverages, amending named
Acts.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The State Employees Group Insurance Act of
1971 is amended by changing and renumbering Section 6.9 added
by Public Act 90-7 as follows:
(5 ILCS 375/6.11)
Sec. 6.11. 6.9. Required health benefits. The program
of health benefits shall provide the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t of the Illinois Insurance
Code. The program of health benefits shall provide the
coverage required under Sections Section 356u, 356w, and 356x
of the Illinois Insurance Code.
(Source: P.A. 90-7, eff. 6-10-97; revised 11-10-97.)
Section 10. The State Mandates Act is amended by adding
Section 8.22 as follows:
(30 ILCS 805/8.22 new)
Sec. 8.22. Exempt mandate. Notwithstanding Sections 6
and 8 of this Act, no reimbursement by the State is required
for the implementation of any mandate created by this
amendatory Act of 1998.
Section 15. The Counties Code is amended by changing
Section 5-1069.3 as follows:
(55 ILCS 5/5-1069.3)
Sec. 5-1069.3. Required health benefits. If a county,
including a home rule county, is a self-insurer for purposes
of providing health insurance coverage for its employees, the
coverage shall include coverage for the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t and the coverage required
under Sections Section 356u, 356w, and 356x of the Illinois
Insurance Code. The requirement that health benefits be
covered as provided in this Section is an exclusive power and
function of the State and is a denial and limitation under
Article VII, Section 6, subsection (h) of the Illinois
Constitution. A home rule county to which this Section
applies must comply with every provision of this Section.
(Source: P.A. 90-7, eff. 6-10-97.)
Section 20. The Illinois Municipal Code is amended by
changing Section 10-4-2.3 as follows:
(65 ILCS 5/10-4-2.3)
Sec. 10-4-2.3. Required health benefits. If a
municipality, including a home rule municipality, is a
self-insurer for purposes of providing health insurance
coverage for its employees, the coverage shall include
coverage for the post-mastectomy care benefits required to be
covered by a policy of accident and health insurance under
Section 356t and the coverage required under Sections Section
356u, 356w, and 356x of the Illinois Insurance Code. The
requirement that health benefits be covered as provided in
this is an exclusive power and function of the State and is a
denial and limitation under Article VII, Section 6,
subsection (h) of the Illinois Constitution. A home rule
municipality to which this Section applies must comply with
every provision of this Section.
(Source: P.A. 90-7, eff. 6-10-97.)
Section 25. The School Code is amended by changing
Section 10-22.3f as follows:
(105 ILCS 5/10-22.3f)
Sec. 10-22.3f. Required health benefits. Insurance
protection and benefits for employees shall provide the
post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t
and the coverage required under Sections Section 356u, 356w,
and 356x of the Illinois Insurance Code.
(Source: P.A. 90-7, eff. 6-10-97.)
Section 30. The Illinois Insurance Code is amended by
changing Sections 4 and 356r and adding Sections 356w and
356x as follows:
(215 ILCS 5/4) (from Ch. 73, par. 616)
Sec. 4. Classes of insurance. Insurance and insurance
business shall be classified as follows:
Class 1. Life, Accident and Health.
(a) Life. Insurance on the lives of persons and every
insurance appertaining thereto or connected therewith and
granting, purchasing or disposing of annuities. Policies of
life or endowment insurance or annuity contracts or contracts
supplemental thereto which contain provisions for additional
benefits in case of death by accidental means and provisions
operating to safeguard such policies or contracts against
lapse, to give a special surrender value, or special benefit,
or an annuity, in the event, that the insured or annuitant
shall become totally and permanently disabled as defined by
the policy or contract, or which contain benefits providing
acceleration of life or endowment or annuity benefits in
advance of the time they would otherwise be payable, as an
indemnity for long term care which is certified or ordered by
a physician, including but not limited to, professional
nursing care, medical care expenses, custodial nursing care,
non-nursing custodial care provided in a nursing home or at a
residence of the insured, or which contain benefits providing
acceleration of life or endowment or annuity benefits in
advance of the time they would otherwise be payable, at any
time during the insured's lifetime, as an indemnity for a
terminal illness shall be deemed to be policies of life or
endowment insurance or annuity contracts within the intent of
this clause.
Also to be deemed as policies of life or endowment
insurance or annuity contracts within the intent of this
clause shall be those policies or riders that provide for the
payment of up to 75% 25% of the face amount of benefits in
advance of the time they would otherwise be payable upon a
diagnosis by a physician licensed to practice medicine in all
of its branches that the insured has incurred a one of the
covered condition conditions listed in the policy or rider.
Every such policy or rider shall contain a majority of
the following "Covered condition", as used in this clause,
means conditions: heart attack,; stroke,; coronary artery
surgery,; life threatening cancer,; renal failure,;
alzheimer's disease,; paraplegia,; major organ
transplantation, total and permanent disability, and any
other medical condition that the Department may approve for
any particular filing.
The Director may issue rules that specify prohibited
policy provisions, not otherwise specifically prohibited by
law, which in the opinion of the Director are unjust, unfair,
or unfairly discriminatory to the policyholder, any person
insured under the policy, or beneficiary.
(b) Accident and health. Insurance against bodily
injury, disablement or death by accident and against
disablement resulting from sickness or old age and every
insurance appertaining thereto, including stop-loss
insurance. Stop-loss insurance is insurance against the risk
of economic loss issued to a single employer self-funded
employee disability benefit plan or an employee welfare
benefit plan as described in 29 U.S.C. 100 et seq.
(c) Legal Expense Insurance. Insurance which involves
the assumption of a contractual obligation to reimburse the
beneficiary against or pay on behalf of the beneficiary, all
or a portion of his fees, costs, or expenses related to or
arising out of services performed by or under the supervision
of an attorney licensed to practice in the jurisdiction
wherein the services are performed, regardless of whether the
payment is made by the beneficiaries individually or by a
third person for them, but does not include the provision of
or reimbursement for legal services incidental to other
insurance coverages. The insurance laws of this State,
including this Act do not apply to:
(i) Retainer contracts made by attorneys at law
with individual clients with fees based on estimates of
the nature and amount of services to be provided to the
specific client, and similar contracts made with a group
of clients involved in the same or closely related legal
matters;
(ii) Plans owned or operated by attorneys who are
the providers of legal services to the plan;
(iii) Plans providing legal service benefits to
groups where such plans are owned or operated by
authority of a state, county, local or other bar
association;
(iv) Any lawyer referral service authorized or
operated by a state, county, local or other bar
association;
(v) The furnishing of legal assistance by labor
unions and other employee organizations to their members
in matters relating to employment or occupation;
(vi) The furnishing of legal assistance to members
or dependents, by churches, consumer organizations,
cooperatives, educational institutions, credit unions, or
organizations of employees, where such organizations
contract directly with lawyers or law firms for the
provision of legal services, and the administration and
marketing of such legal services is wholly conducted by
the organization or its subsidiary;
(vii) Legal services provided by an employee
welfare benefit plan defined by the Employee Retirement
Income Security Act of 1974;
(viii) Any collectively bargained plan for legal
services between a labor union and an employer negotiated
pursuant to Section 302 of the Labor Management Relations
Act as now or hereafter amended, under which plan legal
services will be provided for employees of the employer
whether or not payments for such services are funded to
or through an insurance company.
Class 2. Casualty, Fidelity and Surety.
(a) Accident and health. Insurance against bodily
injury, disablement or death by accident and against
disablement resulting from sickness or old age and every
insurance appertaining thereto, including stop-loss
insurance. Stop-loss insurance is insurance against the risk
of economic loss issued to a single employer self-funded
employee disability benefit plan or an employee welfare
benefit plan as described in 29 U.S.C. 1001 et seq.
(b) Vehicle. Insurance against any loss or liability
resulting from or incident to the ownership, maintenance or
use of any vehicle (motor or otherwise), draft animal or
aircraft. Any policy insuring against any loss or liability
on account of the bodily injury or death of any person may
contain a provision for payment of disability benefits to
injured persons and death benefits to dependents,
beneficiaries or personal representatives of persons who are
killed, including the named insured, irrespective of legal
liability of the insured, if the injury or death for which
benefits are provided is caused by accident and sustained
while in or upon or while entering into or alighting from or
through being struck by a vehicle (motor or otherwise), draft
animal or aircraft, and such provision shall not be deemed to
be accident insurance.
(c) Liability. Insurance against the liability of the
insured for the death, injury or disability of an employee or
other person, and insurance against the liability of the
insured for damage to or destruction of another person's
property.
(d) Workers' compensation. Insurance of the obligations
accepted by or imposed upon employers under laws for workers'
compensation.
(e) Burglary and forgery. Insurance against loss or
damage by burglary, theft, larceny, robbery, forgery, fraud
or otherwise; including all householders' personal property
floater risks.
(f) Glass. Insurance against loss or damage to glass
including lettering, ornamentation and fittings from any
cause.
(g) Fidelity and surety. Become surety or guarantor for
any person, copartnership or corporation in any position or
place of trust or as custodian of money or property, public
or private; or, becoming a surety or guarantor for the
performance of any person, copartnership or corporation of
any lawful obligation, undertaking, agreement or contract of
any kind, except contracts or policies of insurance; and
underwriting blanket bonds. Such obligations shall be known
and treated as suretyship obligations and such business shall
be known as surety business.
(h) Miscellaneous. Insurance against loss or damage to
property and any liability of the insured caused by accidents
to boilers, pipes, pressure containers, machinery and
apparatus of any kind and any apparatus connected thereto, or
used for creating, transmitting or applying power, light,
heat, steam or refrigeration, making inspection of and
issuing certificates of inspection upon elevators, boilers,
machinery and apparatus of any kind and all mechanical
apparatus and appliances appertaining thereto; insurance
against loss or damage by water entering through leaks or
openings in buildings, or from the breakage or leakage of a
sprinkler, pumps, water pipes, plumbing and all tanks,
apparatus, conduits and containers designed to bring water
into buildings or for its storage or utilization therein, or
caused by the falling of a tank, tank platform or supports,
or against loss or damage from any cause (other than causes
specifically enumerated under Class 3 of this Section) to
such sprinkler, pumps, water pipes, plumbing, tanks,
apparatus, conduits or containers; insurance against loss or
damage which may result from the failure of debtors to pay
their obligations to the insured; and insurance of the
payment of money for personal services under contracts of
hiring.
(i) Other casualty risks. Insurance against any other
casualty risk not otherwise specified under Classes 1 or 3,
which may lawfully be the subject of insurance and may
properly be classified under Class 2.
(j) Contingent losses. Contingent, consequential and
indirect coverages wherein the proximate cause of the loss is
attributable to any one of the causes enumerated under Class
2. Such coverages shall, for the purpose of classification,
be included in the specific grouping of the kinds of
insurance wherein such cause is specified.
(k) Livestock and domestic animals. Insurance against
mortality, accident and health of livestock and domestic
animals.
(l) Legal expense insurance. Insurance against risk
resulting from the cost of legal services as defined under
Class 1(c).
Class 3. Fire and Marine, etc.
(a) Fire. Insurance against loss or damage by fire,
smoke and smudge, lightning or other electrical disturbances.
(b) Elements. Insurance against loss or damage by
earthquake, windstorms, cyclone, tornado, tempests, hail,
frost, snow, ice, sleet, flood, rain, drought or other
weather or climatic conditions including excess or deficiency
of moisture, rising of the waters of the ocean or its
tributaries.
(c) War, riot and explosion. Insurance against loss or
damage by bombardment, invasion, insurrection, riot, strikes,
civil war or commotion, military or usurped power, or
explosion (other than explosion of steam boilers and the
breaking of fly wheels on premises owned, controlled,
managed, or maintained by the insured.)
(d) Marine and transportation. Insurance against loss or
damage to vessels, craft, aircraft, vehicles of every kind,
(excluding vehicles operating under their own power or while
in storage not incidental to transportation) as well as all
goods, freights, cargoes, merchandise, effects,
disbursements, profits, moneys, bullion, precious stones,
securities, chooses in action, evidences of debt, valuable
papers, bottomry and respondentia interests and all other
kinds of property and interests therein, in respect to,
appertaining to or in connection with any or all risks or
perils of navigation, transit, or transportation, including
war risks, on or under any seas or other waters, on land or
in the air, or while being assembled, packed, crated, baled,
compressed or similarly prepared for shipment or while
awaiting the same or during any delays, storage,
transshipment, or reshipment incident thereto, including
marine builder's risks and all personal property floater
risks; and for loss or damage to persons or property in
connection with or appertaining to marine, inland marine,
transit or transportation insurance, including liability for
loss of or damage to either arising out of or in connection
with the construction, repair, operation, maintenance, or use
of the subject matter of such insurance, (but not including
life insurance or surety bonds); but, except as herein
specified, shall not mean insurances against loss by reason
of bodily injury to the person; and insurance against loss or
damage to precious stones, jewels, jewelry, gold, silver and
other precious metals whether used in business or trade or
otherwise and whether the same be in course of transportation
or otherwise, which shall include jewelers' block insurance;
and insurance against loss or damage to bridges, tunnels and
other instrumentalities of transportation and communication
(excluding buildings, their furniture and furnishings, fixed
contents and supplies held in storage) unless fire, tornado,
sprinkler leakage, hail, explosion, earthquake, riot and
civil commotion are the only hazards to be covered; and to
piers, wharves, docks and slips, excluding the risks of fire,
tornado, sprinkler leakage, hail, explosion, earthquake, riot
and civil commotion; and to other aids to navigation and
transportation, including dry docks and marine railways,
against all risk.
(e) Vehicle. Insurance against loss or liability
resulting from or incident to the ownership, maintenance or
use of any vehicle (motor or otherwise), draft animal or
aircraft, excluding the liability of the insured for the
death, injury or disability of another person.
(f) Property damage, sprinkler leakage and crop.
Insurance against the liability of the insured for loss or
damage to another person's property or property interests
from any cause enumerated in this class; insurance against
loss or damage by water entering through leaks or openings in
buildings, or from the breakage or leakage of a sprinkler,
pumps, water pipes, plumbing and all tanks, apparatus,
conduits and containers designed to bring water into
buildings or for its storage or utilization therein, or
caused by the falling of a tank, tank platform or supports or
against loss or damage from any cause to such sprinklers,
pumps, water pipes, plumbing, tanks, apparatus, conduits or
containers; insurance against loss or damage from insects,
diseases or other causes to trees, crops or other products of
the soil.
(g) Other fire and marine risks. Insurance against any
other property risk not otherwise specified under Classes 1
or 2, which may lawfully be the subject of insurance and may
properly be classified under Class 3.
(h) Contingent losses. Contingent, consequential and
indirect coverages wherein the proximate cause of the loss is
attributable to any of the causes enumerated under Class 3.
Such coverages shall, for the purpose of classification, be
included in the specific grouping of the kinds of insurance
wherein such cause is specified.
(i) Legal expense insurance. Insurance against risk
resulting from the cost of legal services as defined under
Class 1(c).
(Source: P.A. 88-364.)
(215 ILCS 5/356r)
Sec. 356r. Woman's principal health care provider.
(a) An individual or group policy of accident and health
insurance or a managed care plan amended, delivered, issued,
or renewed in this State after November 14, 1996 that
requires an insured or enrollee to designate an individual to
coordinate care or to control access to health care services
shall also permit a female insured or enrollee to designate a
participating woman's principal health care provider, and the
insurer or managed care plan shall provide the following
written notice to all female insureds or enrollees no later
than 120 days after the effective date of this amendatory Act
of 1998; to all new enrollees at the time of enrollment; and
thereafter to all existing enrollees at least annually, as a
part of a regular publication or informational mailing:
"NOTICE TO ALL FEMALE PLAN MEMBERS:
YOUR RIGHT TO SELECT A WOMAN'S PRINCIPAL
HEALTH CARE PROVIDER.
Illinois law allows you to select "a woman's
principal health care provider" in addition to your
selection of a primary care physician. A woman's
principal health care provider is a physician licensed to
practice medicine in all its branches specializing in
obstetrics or gynecology or specializing in family
practice. A woman's principal health care provider may
be seen for care without referrals from your primary care
physician. If you have not already selected a woman's
principal health care provider, you may do so now or at
any other time. You are not required to have or to
select a woman's principal health care provider.
Your woman's principal health care provider must be
a part of your plan. You may get the list of
participating obstetricians, gynecologists, and family
practice specialists from your employer's employee
benefits coordinator, or for your own copy of the current
list, you may call [insert plan's toll free number]. The
list will be sent to you within 10 days after your call.
To designate a woman's principal health care provider
from the list, call [insert plan's toll free number] and
tell our staff the name of the physician you have
selected.".
If the insurer or managed care plan exercises the option set
forth in subsection (a-5), the notice shall also state:
"Your plan requires that your primary care physician
and your woman's principal health care provider have a
referral arrangement with one another. If the woman's
principal health care provider that you select does not
have a referral arrangement with your primary care
physician, you will have to select a new primary care
physician who has a referral arrangement with your
woman's principal health care provider or you may select
a woman's principal health care provider who has a
referral arrangement with your primary care physician.
The list of woman's principal health care providers will
also have the names of the primary care physicians and
their referral arrangements.".
No later than 120 days after the effective date of this
amendatory Act of 1998, the insurer or managed care plan
shall provide each employer who has a policy of insurance or
a managed care plan with the insurer or managed care plan
with a list of physicians licensed to practice medicine in
all its branches specializing in obstetrics or gynecology or
specializing in family practice who have contracted with the
plan. At the time of enrollment and thereafter within 10 days
after a request by an insured or enrollee, the insurer or
managed care plan also shall provide this list directly to
the insured or enrollee. The list shall include each
physician's address, telephone number, and specialty. No
insurer or plan formal or informal policy may restrict a
female insured's or enrollee's right to designate a woman's
principal health care provider, except as set forth in
subsection (a-5). If the female enrollee is an enrollee of a
managed care plan under contract with the Department of
Public Aid, the physician chosen by the enrollee as her
woman's principal health care provider must be a
Medicaid-enrolled provider. This requirement does not require
a female insured or enrollee to make a selection of a woman's
principal health care provider. The female insured or
enrollee may designate a physician licensed to practice
medicine in all its branches specializing in family practice
as her woman's principal health care provider.
(a-5) The insured or enrollee may be required by the
insurer or managed care plan to select a woman's principal
health care provider who has a referral arrangement with the
insured's or enrollee's individual who coordinates care or
controls access to health care services if such referral
arrangement exists or to select a new individual to
coordinate care or to control access to health care services
who has a referral arrangement with the woman's principal
health care provider chosen by the insured or enrollee, if
such referral arrangement exists. If an insurer or a managed
care plan requires an insured or enrollee to select a new
physician under this subsection (a-5), the insurer or managed
care plan must provide the insured or enrollee with both
options to select a new physician provided in this subsection
(a-5).
Notwithstanding a plan's restrictions of the frequency or
timing of making designations of primary care providers, a
female enrollee or insured who is subject to the selection
requirements of this subsection, may, at any time, effect a
change in primary care physicians in order to make a
selection of a woman's principal health care provider.
(a-6) If an insurer or managed care plan exercises the
option in subsection (a-5), the list to be provided under
subsection (a) shall identify the referral arrangements that
exist between the individual who coordinates care or controls
access to health care services and the woman's principal
health care provider in order to assist the female insured or
enrollee to make a selection within the insurer's or managed
care plan's requirement.
(b) If a female insured or enrollee has designated a
woman's principal health care provider, then the insured or
enrollee must be given direct access to the woman's principal
health care provider for services covered by the policy or
plan without the need for a referral or prior approval.
Nothing shall prohibit the insurer or managed care plan from
requiring prior authorization or approval from either a
primary care provider or the woman's principal health care
provider for referrals for additional care or services.
(c) For the purposes of this Section the following terms
are defined:
(1) "Woman's principal health care provider" means
a physician licensed to practice medicine in all of its
branches specializing in obstetrics or gynecology or
specializing in family practice.
(2) "Managed care entity" means any entity
including a licensed insurance company, hospital or
medical service plan, health maintenance organization,
limited health service organization, preferred provider
organization, third party administrator, an employer or
employee organization, or any person or entity that
establishes, operates, or maintains a network of
participating providers.
(3) "Managed care plan" means a plan operated by a
managed care entity that provides for the financing of
health care services to persons enrolled in the plan
through:
(A) organizational arrangements for ongoing
quality assurance, utilization review programs, or
dispute resolution; or
(B) financial incentives for persons enrolled
in the plan to use the participating providers and
procedures covered by the plan.
(4) "Participating provider" means a physician who
has contracted with an insurer or managed care plan to
provide services to insureds or enrollees as defined by
the contract.
(d) The original provisions of this Section became law
on July 17, 1996 and took effect November 14, 1996, which is
120 days after becoming law.
(Source: P.A. 89-514; 90-14, eff. 7-1-97.)
(215 ILCS 5/356w new)
Sec. 356w. Diabetes self-management training and
education.
(a) A group policy of accident and health insurance that
is amended, delivered, issued, or renewed after the effective
date of this amendatory Act of 1998 shall provide coverage
for outpatient self-management training and education,
equipment, and supplies, as set forth in this Section, for
the treatment of type 1 diabetes, type 2 diabetes, and
gestational diabetes mellitus.
(b) As used in this Section:
"Diabetes self-management training" means instruction in
an outpatient setting which enables a diabetic patient to
understand the diabetic management process and daily
management of diabetic therapy as a means of avoiding
frequent hospitalization and complications. Diabetes
self-management training shall include the content areas
listed in the National Standards for Diabetes Self-Management
Education Programs as published by the American Diabetes
Association, including medical nutrition therapy.
"Medical nutrition therapy" shall have the meaning
ascribed to "medical nutrition care" in the Dietetic and
Nutrition Services Practice Act.
"Physician" means a physician licensed to practice
medicine in all of its branches providing care to the
individual.
"Qualified provider" for an individual that is enrolled
in:
(1) a health maintenance organization that uses a
primary care physician to control access to specialty
care means (A) the individual's primary care physician
licensed to practice medicine in all of its branches, (B)
a physician licensed to practice medicine in all of its
branches to whom the individual has been referred by the
primary care physician, or (C) a certified, registered,
or licensed network health care professional with
expertise in diabetes management to whom the individual
has been referred by the primary care physician.
(2) an insurance plan means (A) a physician
licensed to practice medicine in all of its branches or
(B) a certified, registered, or licensed health care
professional with expertise in diabetes management to
whom the individual has been referred by a physician.
(c) Coverage under this Section for diabetes
self-management training, including medical nutrition
education, shall be limited to the following:
(1) Up to 3 medically necessary visits to a
qualified provider upon initial diagnosis of diabetes by
the patient's physician or, if diagnosis of diabetes was
made within one year prior to the effective date of this
amendatory Act of 1998 where the insured was a covered
individual, up to 3 medically necessary visits to a
qualified provider within one year after that effective
date.
(2) Up to 2 medically necessary visits to a
qualified provider upon a determination by a patient's
physician that a significant change in the patient's
symptoms or medical condition has occurred. A
"significant change" in condition means symptomatic
hyperglycemia (greater than 250 mg/dl on repeated
occasions), severe hypoglycemia (requiring the assistance
of another person), onset or progression of diabetes, or
a significant change in medical condition that would
require a significantly different treatment regimen.
Payment by the insurer or health maintenance
organization for the coverage required for diabetes
self-management training pursuant to the provisions of this
Section is only required to be made for services provided. No
coverage is required for additional visits beyond those
specified in items (1) and (2) of this subsection.
Coverage under this subsection (c) for diabetes
self-management training shall be subject to the same
deductible, co-payment, and co-insurance provisions that
apply to coverage under the policy for other services
provided by the same type of provider.
(d) Coverage shall be provided for the following
equipment when medically necessary and prescribed by a
physician licensed to practice medicine in all of its
branches. Coverage for the following items shall be subject
to deductible, co-payment and co-insurance provisions
provided for under the policy or a durable medical equipment
rider to the policy:
(1) blood glucose monitors;
(2) blood glucose monitors for the legally blind;
(3) cartridges for the legally blind; and
(4) lancets and lancing devices.
This subsection does not apply to a group policy of
accident and health insurance that does not provide a durable
medical equipment benefit.
(e) Coverage shall be provided for the following
pharmaceuticals and supplies when medically necessary and
prescribed by a physician licensed to practice medicine in
all of its branches. Coverage for the following items shall
be subject to the same coverage, deductible, co-payment, and
co-insurance provisions under the policy or a drug rider to
the policy:
(1) insulin;
(2) syringes and needles;
(3) test strips for glucose monitors;
(4) FDA approved oral agents used to control blood
sugar; and
(5) glucagon emergency kits.
This subsection does not apply to a group policy of
accident and health insurance that does not provide a drug
benefit.
(f) Coverage shall be provided for regular foot care
exams by a physician or by a physician to whom a physician
has referred the patient. Coverage for regular foot care
exams shall be subject to the same deductible, co-payment,
and co-insurance provisions that apply under the policy for
other services provided by the same type of provider.
(g) If authorized by a physician, diabetes
self-management training may be provided as a part of an
office visit, group setting, or home visit.
(h) This Section shall not apply to agreements,
contracts, or policies that provide coverage for a specified
diagnosis or other limited benefit coverage.
(215 ILCS 5/356x new)
Sec. 356x. Coverage for colorectal cancer screening.
(a) An insurer shall provide in each group policy,
contract, or certificate of accident and health insurance
amended, delivered, issued, or renewed covering persons who
are residents of this State coverage for colorectal cancer
screening with sigmoidoscopy or fecal occult blood testing
once every 3 years for persons who are at least 50 years old.
(b) For persons who may be classified as high risk for
colorectal cancer because the person or a first degree family
member of the person has a history of colorectal cancer, the
coverage required under subsection (a) shall apply to persons
who have attained at least 30 years of age.
(c) This Section does not apply to agreements,
contracts, or policies that provide coverage for a specified
disease or other limited benefit coverage.
Section 35. 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)
(Text of Section before amendment by P.A. 90-372)
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, 356m, 356v, 356w, 356x,
356t, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
paragraph (c) of subsection (2) of Section 367, and Articles
VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
Illinois Insurance Code.
(b) For purposes of the Illinois Insurance Code, except
for 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 Medical
Service Plan Act, the Dental Service Plan Act, the
Pharmaceutical Service Plan Act, or the Voluntary Health
Services Plans Plan Act, or the Nonprofit Health Care
Service Plan 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.
(Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
90-177, eff. 7-23-97; revised 11-21-97.)
(Text of Section after amendment by P.A. 90-372)
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, 356m, 356v, 356w, 356x,
356t, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
paragraph (c) of subsection (2) of Section 367, and Articles
VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
Illinois Insurance Code.
(b) For purposes of the Illinois Insurance Code, except
for 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 Medical
Service Plan Act, the Dental Service Plan Act or, the
Voluntary Health Services Plans Plan Act, or the
Nonprofit Health Care Service Plan 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.
(Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
90-177, eff. 7-23-97; 90-372, eff. 7-1-98; revised 11-21-97.)
Section 40. The Limited Health Service Organization Act
is amended by changing Section 3009 as follows:
(215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
Sec. 3009. Point-of-service limited health service
contracts.
(a) An LHSO that offers a POS contract:
(1) shall include as in-plan covered services all
services required by law to be provided by an LHSO;
(2) shall provide incentives, which shall include
financial incentives, for enrollees to use in-plan
covered services;
(3) shall not offer services out-of-plan without
providing those services on an in-plan basis;
(4) may limit or exclude specific types of services
from coverage when obtained out-of-plan;
(5) may include annual out-of-pocket limits and
lifetime maximum benefits allowances for out-of-plan
services that are separate from any limits or allowances
applied to in-plan services;
(6) shall include an annual maximum benefit
allowance not to exceed $2,500 per year that is separate
from any limits or allowances applied to in-plan
services;
(7) may limit the groups to which a POS product is
offered, however, if a POS product is offered to a group,
then it must be offered to all eligible members of that
group, when an LHSO provider is available;
(8) shall not consider emergency services,
authorized referral services, or non-routine services
obtained out of the service area to be POS services; and
(9) may treat as out-of-plan services those
services that an enrollee obtains from a participating
provider, but for which the proper authorization was not
given by the LHSO.
(b) An LHSO offering a POS contract shall be subject to
the following limitations:
(1) The LHSO shall not expend in any calendar
quarter more than 20% of its total limited health
services expenditures for all its members for out-of-plan
covered services.
(2) If the amount specified in paragraph (1) is
exceeded by 2% in a quarter, the LHSO shall effect
compliance with paragraph (1) by the end of the following
quarter.
(3) If compliance with the amount specified in
paragraph (1) is not demonstrated in the LHSO's next
quarterly report, the LHSO may not offer the POS contract
to new groups or include the POS option in the renewal of
an existing group until compliance with the amount
specified in paragraph (1) is demonstrated or otherwise
allowed by the Director.
(4) Any LHSO failing, without just cause, to comply
with the provisions of this subsection shall be required,
after notice and hearing, to pay a penalty of $250 for
each day out of compliance, to be recovered by the
Director of Insurance. Any penalty recovered shall be
paid into the General Revenue Fund. The Director may
reduce the penalty if the LHSO demonstrates to the
Director that the imposition of the penalty would
constitute a financial hardship to the LHSO.
(c) Any LHSO that offers a POS product shall:
(1) File a quarterly financial statement detailing
compliance with the requirements of subsection (b).
(2) Track out-of-plan POS utilization separately
from in-plan or non-POS out-of-plan emergency care,
referral care, and urgent care out of the service area
utilization.
(3) Record out-of-plan utilization in a manner that
will permit such utilization and cost reporting as the
Director may, by regulation, require.
(4) Demonstrate to the Director's satisfaction that
the LHSO has the fiscal, administrative, and marketing
capacity to control its POS enrollment, utilization, and
costs so as not to jeopardize the financial security of
the LHSO.
(5) Maintain the deposit required by subsection (b)
of Section 2006 in addition to any other deposit required
under this Act.
(d) An LHSO shall not issue a POS contract until it has
filed and had approved by the Director a plan to comply with
the provisions of this Section. The compliance plan shall at
a minimum include provisions demonstrating that the LHSO will
do all of the following:
(1) Design the benefit levels and conditions of
coverage for in-plan covered services and out-of-plan
covered services as required by this Article.
(2) Provide or arrange for the provision of
adequate systems to:
(A) process and pay claims for all out-of-plan
covered services;
(B) meet the requirements for a POS contract
set forth in this Section and any additional
requirements that may be set forth by the Director;
and
(C) generate accurate data and financial and
regulatory reports on a timely basis so that the
Department can evaluate the LHSO's experience with
the POS contract and monitor compliance with POS
contract provisions.
(3) Comply initially and on an ongoing basis with
the requirements of subsections (b) and (c).
(e) A limited health service organization that offers a
POS contract must comply with Sections 356w and 356x of the
Illinois Insurance Code.
(Source: P.A. 87-1079; 88-667, eff. 9-16-94.)
Section 45. 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 Article XII 1/2 and Sections 3.1, 133, 140,
143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
356x, 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
and paragraphs (7) and (15) of Section 367 of the Illinois
Insurance Code.
(Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
90-25, eff. 1-1-98; revised 10-14-97.)
Section 50. The Illinois Public Aid Code is amended by
changing Section 5-16.8 as follows:
(305 ILCS 5/5-16.8)
Sec. 5-16.8. Required health benefits. The medical
assistance program shall provide the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t and the coverage required
under Sections Section 356u, 356w, and 356x of the Illinois
Insurance Code.
(Source: P.A. 90-7, eff. 6-10-97.)
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.
Section 99. Effective date. This Section and the
provisions of this Act amending Sections 4 and 356r of the
Illinois Insurance Code take effect upon becoming law; the
remaining provisions of this Act take effect January 1, 1999.