100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4844

 

Introduced , by Rep. Deb Conroy

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Amends the Illinois Insurance Code. Provides that, for purposes of treatment in the early stages of a mental health condition, a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed shall provide coverage for the treatment of serious mental illnesses and serious emotional disturbances. Provides that coverage shall include, but not be limited to, certain evidence-based and evidence-informed bundled treatment approaches. Provides that payment for the services performed under the treatment models shall be based on all the components of the treatment model combined, rather than for each separate service. Provides that disability or functional impairment shall not be a precondition to receive treatment under the provisions. Provides that if federal regulations require the State to defray the cost of coverage for serious mental illnesses or serious emotional disturbances, then the provisions are inoperative and the State shall not assume any obligation for the cost of the coverage. Makes conforming changes in the State Employee Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, and the Voluntary Health Services Plans Act. Provides that the amendatory Act may be referred to as the Fair Insurance Coverage for Early Treatment of Serious Mental Health Conditions Act. Effective immediately.


LRB100 18731 SMS 33965 b

FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

HB4844LRB100 18731 SMS 33965 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be referred to as the
5Fair Insurance Coverage for Early Treatment of Serious Mental
6Health Conditions Act.
 
7    Section 5. Legislative findings. The General Assembly
8finds the following:
9        (1) An estimated 60% of Illinoisans have private
10    insurance coverage.
11        (2) Most mental health conditions begin to manifest
12    before the age of 24.
13        (3) On average, it takes 10 years for individuals with
14    a serious mental health condition to receive the right
15    diagnosis and treatment.
16        (4) During the lag time between initial symptom
17    manifestation and when the right treatment is received, an
18    individual often experiences debilitating symptoms that
19    can lead to permanent disability.
20        (5) Early treatment can mean wellness, symptom
21    management, and full recovery.
22        (6) Private insurance does not cover the
23    evidence-based or evidence-informed community-based

 

 

HB4844- 2 -LRB100 18731 SMS 33965 b

1    treatment approaches that the public sector covers that are
2    proven, effective treatments for serious mental illnesses
3    and serious emotional disturbances.
4        (7) Community-based treatment has demonstrated
5    positive mental health outcomes over many decades and
6    enables wellness and supports recovery by providing
7    intensive services through team-based models in a person's
8    natural environment.
9        (8) The 60% of Illinoisans with private insurance
10    coverage do not have access to these evidence-based
11    treatment approaches.
12        (9) If private insurance covered these community-based
13    treatment approaches when an individual is in the early
14    stages of a serious mental health condition, permanent
15    disability and a life of public coverage could be avoided
16    for thousands across Illinois.
 
17    Section 10. The State Employees Group Insurance Act of 1971
18is amended by changing Section 6.11 as follows:
 
19    (5 ILCS 375/6.11)
20    Sec. 6.11. Required health benefits; Illinois Insurance
21Code requirements. The program of health benefits shall provide
22the post-mastectomy care benefits required to be covered by a
23policy of accident and health insurance under Section 356t of
24the Illinois Insurance Code. The program of health benefits

 

 

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1shall provide the coverage required under Sections 356g,
2356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
3356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
4356z.14, 356z.15, 356z.17, 356z.22, and 356z.25, 356z.26, and
5356z.29 of the Illinois Insurance Code. The program of health
6benefits must comply with Sections 155.22a, 155.37, 355b,
7356z.19, 370c, and 370c.1 of the Illinois Insurance Code.
8    Rulemaking authority to implement Public Act 95-1045, if
9any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
14(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
15100-138, eff. 8-18-17; revised 10-3-17.)
 
16    Section 15. The Counties Code is amended by changing
17Section 5-1069.3 as follows:
 
18    (55 ILCS 5/5-1069.3)
19    Sec. 5-1069.3. Required health benefits. If a county,
20including a home rule county, is a self-insurer for purposes of
21providing health insurance coverage for its employees, the
22coverage shall include coverage for the post-mastectomy care
23benefits required to be covered by a policy of accident and
24health insurance under Section 356t and the coverage required

 

 

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1under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
2356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
3356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and 356z.29 of
4the Illinois Insurance Code. The coverage shall comply with
5Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
6Insurance Code. The requirement that health benefits be covered
7as provided in this Section is an exclusive power and function
8of the State and is a denial and limitation under Article VII,
9Section 6, subsection (h) of the Illinois Constitution. A home
10rule county to which this Section applies must comply with
11every provision of this Section.
12    Rulemaking authority to implement Public Act 95-1045, if
13any, is conditioned on the rules being adopted in accordance
14with all provisions of the Illinois Administrative Procedure
15Act and all rules and procedures of the Joint Committee on
16Administrative Rules; any purported rule not so adopted, for
17whatever reason, is unauthorized.
18(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
19100-138, eff. 8-18-17; revised 10-5-17.)
 
20    Section 20. The Illinois Municipal Code is amended by
21changing Section 10-4-2.3 as follows:
 
22    (65 ILCS 5/10-4-2.3)
23    Sec. 10-4-2.3. Required health benefits. If a
24municipality, including a home rule municipality, is a

 

 

HB4844- 5 -LRB100 18731 SMS 33965 b

1self-insurer for purposes of providing health insurance
2coverage for its employees, the coverage shall include coverage
3for the post-mastectomy care benefits required to be covered by
4a policy of accident and health insurance under Section 356t
5and the coverage required under Sections 356g, 356g.5,
6356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
7356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and
8356z.25, 356z.26, and 356z.29 of the Illinois Insurance Code.
9The coverage shall comply with Sections 155.22a, 355b, 356z.19,
10and 370c of the Illinois Insurance Code. The requirement that
11health benefits be covered as provided in this is an exclusive
12power and function of the State and is a denial and limitation
13under Article VII, Section 6, subsection (h) of the Illinois
14Constitution. A home rule municipality to which this Section
15applies must comply with every provision of this Section.
16    Rulemaking authority to implement Public Act 95-1045, if
17any, is conditioned on the rules being adopted in accordance
18with all provisions of the Illinois Administrative Procedure
19Act and all rules and procedures of the Joint Committee on
20Administrative Rules; any purported rule not so adopted, for
21whatever reason, is unauthorized.
22(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
23100-138, eff. 8-18-17; revised 10-5-17.)
 
24    Section 25. The School Code is amended by changing Section
2510-22.3f as follows:
 

 

 

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1    (105 ILCS 5/10-22.3f)
2    Sec. 10-22.3f. Required health benefits. Insurance
3protection and benefits for employees shall provide the
4post-mastectomy care benefits required to be covered by a
5policy of accident and health insurance under Section 356t and
6the coverage required under Sections 356g, 356g.5, 356g.5-1,
7356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
8356z.13, 356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and
9356z.29 of the Illinois Insurance Code. Insurance policies
10shall comply with Section 356z.19 of the Illinois Insurance
11Code. The coverage shall comply with Sections 155.22a and 355b
12of the Illinois Insurance Code.
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
20revised 9-25-17.)
 
21    Section 30. The Illinois Insurance Code is amended by
22adding Section 356z.29 as follows:
 
23    (215 ILCS 5/356z.29 new)

 

 

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1    Sec. 356z.29. Coverage for the early treatment of serious
2mental illnesses and serious emotional disturbances.
3    (a) For purposes of this Section:
4        "Serious emotional disturbance" has the meaning as
5    interpreted by the federal Substance Abuse and Mental
6    Health Services Administration.
7        "Serious mental illness" has the same meaning as in the
8    most recent edition of the Diagnostic and Statistical
9    Manual of Mental Disorders.
10    (b) For purposes of treatment in the early stages of a
11mental health condition, a group or individual policy of
12accident and health insurance or managed care plan that is
13amended, delivered, issued, or renewed after the effective date
14of this amendatory Act of the 100th General Assembly shall
15provide coverage for the treatment of serious mental illnesses
16and serious emotional disturbances, including, but not limited
17to, the following evidence-based and evidence-informed bundled
18treatment approaches:
19        (1) assertive community treatment and community
20    support team treatment, which are both community-based
21    treatment models that are covered for individuals under the
22    Medical Assistance Program under Article V of the Public
23    Aid Code; the covered bundled services for assertive
24    community treatment and community support team treatment
25    shall be comparable in scope to those covered under the
26    treatment models through the Medical Assistance Program;

 

 

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1    and
2        (2) first episode psychosis treatment, covering at a
3    minimum the elements of the coordinated specialty care
4    model applied in the research trials conducted by the
5    National Institute of Mental Health in the Recovery of an
6    Initial Schizophrenia Episode studies.
7    Payment for the services performed under the treatment
8models in paragraphs (1) and (2) shall be based on all the
9components of the treatment model combined, rather than for
10each separate service.
11    (c) For purposes of determining medical necessity for the
12treatment approaches covered by this Section, neither
13disability nor functional impairment shall be a precondition to
14receive the treatment approaches since the goal of coverage
15under this Section is early treatment of a serious mental
16illness or serious emotional disturbance and preventing
17progression of the illness or condition. Medical necessity
18shall be presumed following a psychiatric inpatient
19hospitalization if the treatment approaches are recommended by
20a licensed physician, licensed clinical psychologist, licensed
21professional clinical counselor, or licensed clinical social
22worker. If, at any time, the Secretary of the United States
23Department of Health and Human Services, or its successor
24agency, promulgates rules or regulations to be published in the
25Federal Register or publishes a comment in the Federal Register
26or issues an opinion, guidance, or other action that would

 

 

HB4844- 9 -LRB100 18731 SMS 33965 b

1require the State, pursuant to any provision of the Patient
2Protection and Affordable Care Act, including, but not limited
3to, 42 U.S.C. 18031(d)(3)(b), or any successor provision, to
4defray the cost of any coverage for serious mental illnesses or
5serious emotional disturbances outlined in this Section, then
6the requirement that a group or individual policy of accident
7and health insurance or managed care plan cover the bundled
8treatment approaches outlined in this Section is inoperative
9other than any such coverage authorized under Section 1902 of
10the Social Security Act, 42 U.S.C. 1396a, and the State shall
11not assume any obligation for the cost of the coverage.
 
12    Section 35. The Health Maintenance Organization Act is
13amended by changing Section 5-3 as follows:
 
14    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
15    Sec. 5-3. Insurance Code provisions.
16    (a) Health Maintenance Organizations shall be subject to
17the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
18141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
19154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
20355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
21356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
22356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
23356z.22, 356z.25, 356z.26, 356z.29, 364, 364.01, 367.2,
24367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401,

 

 

HB4844- 10 -LRB100 18731 SMS 33965 b

1401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
2paragraph (c) of subsection (2) of Section 367, and Articles
3IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
4the Illinois Insurance Code.
5    (b) For purposes of the Illinois Insurance Code, except for
6Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
7Maintenance Organizations in the following categories are
8deemed to be "domestic companies":
9        (1) a corporation authorized under the Dental Service
10    Plan Act or the Voluntary Health Services Plans Act;
11        (2) a corporation organized under the laws of this
12    State; or
13        (3) a corporation organized under the laws of another
14    state, 30% or more of the enrollees of which are residents
15    of this State, except a corporation subject to
16    substantially the same requirements in its state of
17    organization as is a "domestic company" under Article VIII
18    1/2 of the Illinois Insurance Code.
19    (c) In considering the merger, consolidation, or other
20acquisition of control of a Health Maintenance Organization
21pursuant to Article VIII 1/2 of the Illinois Insurance Code,
22        (1) the Director shall give primary consideration to
23    the continuation of benefits to enrollees and the financial
24    conditions of the acquired Health Maintenance Organization
25    after the merger, consolidation, or other acquisition of
26    control takes effect;

 

 

HB4844- 11 -LRB100 18731 SMS 33965 b

1        (2)(i) the criteria specified in subsection (1)(b) of
2    Section 131.8 of the Illinois Insurance Code shall not
3    apply and (ii) the Director, in making his determination
4    with respect to the merger, consolidation, or other
5    acquisition of control, need not take into account the
6    effect on competition of the merger, consolidation, or
7    other acquisition of control;
8        (3) the Director shall have the power to require the
9    following information:
10            (A) certification by an independent actuary of the
11        adequacy of the reserves of the Health Maintenance
12        Organization sought to be acquired;
13            (B) pro forma financial statements reflecting the
14        combined balance sheets of the acquiring company and
15        the Health Maintenance Organization sought to be
16        acquired as of the end of the preceding year and as of
17        a date 90 days prior to the acquisition, as well as pro
18        forma financial statements reflecting projected
19        combined operation for a period of 2 years;
20            (C) a pro forma business plan detailing an
21        acquiring party's plans with respect to the operation
22        of the Health Maintenance Organization sought to be
23        acquired for a period of not less than 3 years; and
24            (D) such other information as the Director shall
25        require.
26    (d) The provisions of Article VIII 1/2 of the Illinois

 

 

HB4844- 12 -LRB100 18731 SMS 33965 b

1Insurance Code and this Section 5-3 shall apply to the sale by
2any health maintenance organization of greater than 10% of its
3enrollee population (including without limitation the health
4maintenance organization's right, title, and interest in and to
5its health care certificates).
6    (e) In considering any management contract or service
7agreement subject to Section 141.1 of the Illinois Insurance
8Code, the Director (i) shall, in addition to the criteria
9specified in Section 141.2 of the Illinois Insurance Code, take
10into account the effect of the management contract or service
11agreement on the continuation of benefits to enrollees and the
12financial condition of the health maintenance organization to
13be managed or serviced, and (ii) need not take into account the
14effect of the management contract or service agreement on
15competition.
16    (f) Except for small employer groups as defined in the
17Small Employer Rating, Renewability and Portability Health
18Insurance Act and except for medicare supplement policies as
19defined in Section 363 of the Illinois Insurance Code, a Health
20Maintenance Organization may by contract agree with a group or
21other enrollment unit to effect refunds or charge additional
22premiums under the following terms and conditions:
23        (i) the amount of, and other terms and conditions with
24    respect to, the refund or additional premium are set forth
25    in the group or enrollment unit contract agreed in advance
26    of the period for which a refund is to be paid or

 

 

HB4844- 13 -LRB100 18731 SMS 33965 b

1    additional premium is to be charged (which period shall not
2    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 be
12    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 profitable
15    or unprofitable experience may be calculated taking into
16    account the refund period and the immediately preceding 2
17    plan years.
18    The Health Maintenance Organization shall include a
19statement in the evidence of coverage issued to each enrollee
20describing the possibility of a refund or additional premium,
21and upon request of any group or enrollment unit, provide to
22the group or enrollment unit a description of the method used
23to calculate (1) the Health Maintenance Organization's
24profitable experience with respect to the group or enrollment
25unit and the resulting refund to the group or enrollment unit
26or (2) the Health Maintenance Organization's unprofitable

 

 

HB4844- 14 -LRB100 18731 SMS 33965 b

1experience with respect to the group or enrollment unit and the
2resulting additional premium to be paid by the group or
3enrollment unit.
4    In no event shall the Illinois Health Maintenance
5Organization Guaranty Association be liable to pay any
6contractual obligation of an insolvent organization to pay any
7refund authorized under this Section.
8    (g) Rulemaking authority to implement Public Act 95-1045,
9if any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
14(Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17;
15100-138, eff. 8-18-17; revised 10-5-17.)
 
16    Section 40. The Limited Health Service Organization Act is
17amended by changing Section 4003 as follows:
 
18    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
19    Sec. 4003. Illinois Insurance Code provisions. Limited
20health service organizations shall be subject to the provisions
21of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
22143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
23154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v,
24356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 368a,

 

 

HB4844- 15 -LRB100 18731 SMS 33965 b

1401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and
2444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
3XXV, and XXVI of the Illinois Insurance Code. For purposes of
4the Illinois Insurance Code, except for Sections 444 and 444.1
5and Articles XIII and XIII 1/2, limited health service
6organizations in the following categories are deemed to be
7domestic companies:
8        (1) a corporation under the laws of this State; or
9        (2) a corporation organized under the laws of another
10    state, 30% or more of the enrollees of which are residents
11    of this State, except a corporation subject to
12    substantially the same requirements in its state of
13    organization as is a domestic company under Article VIII
14    1/2 of the Illinois Insurance Code.
15(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
16100-201, eff. 8-18-17; revised 10-5-17.)
 
17    Section 45. The Voluntary Health Services Plans Act is
18amended by changing Section 10 as follows:
 
19    (215 ILCS 165/10)  (from Ch. 32, par. 604)
20    Sec. 10. Application of Insurance Code provisions. Health
21services plan corporations and all persons interested therein
22or dealing therewith shall be subject to the provisions of
23Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
24143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,

 

 

HB4844- 16 -LRB100 18731 SMS 33965 b

1356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
2356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
3356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
4356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 364.01,
5367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
6and paragraphs (7) and (15) of Section 367 of the Illinois
7Insurance Code.
8    Rulemaking authority to implement Public Act 95-1045, if
9any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
14(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
15revised 10-5-17.)
 
16    Section 99. Effective date. This Act takes effect upon
17becoming law.

 

 

HB4844- 17 -LRB100 18731 SMS 33965 b

1 INDEX
2 Statutes amended in order of appearance
3    5 ILCS 375/6.11
4    55 ILCS 5/5-1069.3
5    65 ILCS 5/10-4-2.3
6    105 ILCS 5/10-22.3f
7    215 ILCS 5/356z.29 new
8    215 ILCS 125/5-3from Ch. 111 1/2, par. 1411.2
9    215 ILCS 130/4003from Ch. 73, par. 1504-3
10    215 ILCS 165/10from Ch. 32, par. 604