98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB0142

 

Introduced 1/14/2013, by Rep. Mary E. Flowers

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Amends the Illinois Insurance Code to provide that accident and health insurance policies and managed care plans must provide coverage for intravenous feeding, prescription nutritional supplements, and hospital patient assessments. Makes corresponding changes in the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Health Maintenance Organization Act, Voluntary Health Services Plans Act, and Illinois Public Aid Code. Amends the Emergency Medical Treatment Act to provide that every hospital licensed under the Hospital Licensing Act shall comply with the Hospital Emergency Service Act. Amends the Hospital Emergency Service Act in a provision concerning the Department of Public Health's rules regarding hospital emergency services. Repeals the provision concerning long-term acute care hospitals. Amends the Health Carrier External Review Act. Sets forth provisions concerning standard information for application forms; medical underwriting; the requirement to send to the applicant a copy of the health care service plan contract along with a notice; rescission and cancellation; postcontract investigation; and continuation. Makes changes in the provision concerning standard external review. Amends the Medical Patient Rights Act. Provides that each patient has a right to be informed of his or her inpatient or outpatient status. Amends the State Mandates Act to require implementation without reimbursement by the State. Effective immediately.


LRB098 02628 RPM 32633 b

FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, and 356z.17 and 356z.19, 356z.22, 356z.23,
16and 356z.24 of the Illinois Insurance Code. The program of
17health benefits must comply with Sections 155.22a, 155.37, and
18356z.19 of the Illinois Insurance Code.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2(Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09;
396-639, eff. 1-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11;
497-343, eff. 1-1-12; 97-813, eff. 7-13-12.)
 
5    Section 10. The Counties Code is amended by changing
6Section 5-1069.3 as follows:
 
7    (55 ILCS 5/5-1069.3)
8    Sec. 5-1069.3. Required health benefits. If a county,
9including a home rule county, is a self-insurer for purposes of
10providing health insurance coverage for its employees, the
11coverage shall include coverage for the post-mastectomy care
12benefits required to be covered by a policy of accident and
13health insurance under Section 356t and the coverage required
14under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
15356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
16356z.14, and 356z.15, 356z.22, 356z.23, and 356z.24 of the
17Illinois Insurance Code. The coverage shall comply with
18Sections 155.22a and 356z.19 of the Illinois Insurance Code.
19The requirement that health benefits be covered as provided in
20this Section is an exclusive power and function of the State
21and is a denial and limitation under Article VII, Section 6,
22subsection (h) of the Illinois Constitution. A home rule county
23to which this Section applies must comply with every provision
24of this Section.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09;
896-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
997-813, eff. 7-13-12.)
 
10    Section 15. The Illinois Municipal Code is amended by
11changing Section 10-4-2.3 as follows:
 
12    (65 ILCS 5/10-4-2.3)
13    Sec. 10-4-2.3. Required health benefits. If a
14municipality, including a home rule municipality, is a
15self-insurer for purposes of providing health insurance
16coverage for its employees, the coverage shall include coverage
17for the post-mastectomy care benefits required to be covered by
18a policy of accident and health insurance under Section 356t
19and the coverage required under Sections 356g, 356g.5,
20356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
21356z.11, 356z.12, 356z.13, 356z.14, and 356z.15, 356z.22,
22356z.23, and 356z.24 of the Illinois Insurance Code. The
23coverage shall comply with Sections 155.22a and 356z.19 of the
24Illinois Insurance Code. The requirement that health benefits

 

 

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1be covered as provided in this is an exclusive power and
2function of the State and is a denial and limitation under
3Article VII, Section 6, subsection (h) of the Illinois
4Constitution. A home rule municipality to which this Section
5applies must comply with every provision of this Section.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09;
1396-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
1497-813, eff. 7-13-12.)
 
15    Section 20. The School Code is amended by changing Section
1610-22.3f as follows:
 
17    (105 ILCS 5/10-22.3f)
18    Sec. 10-22.3f. Required health benefits. Insurance
19protection and benefits for employees shall provide the
20post-mastectomy care benefits required to be covered by a
21policy of accident and health insurance under Section 356t and
22the coverage required under Sections 356g, 356g.5, 356g.5-1,
23356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
24356z.13, 356z.14, and 356z.15, 356z.22, and 356z.23 of the

 

 

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1Illinois Insurance Code. Insurance policies shall comply with
2Section 356z.19 of the Illinois Insurance Code. The coverage
3shall comply with Section 155.22a of the Illinois Insurance
4Code.
5    Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11(Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09;
1296-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
1397-813, eff. 7-13-12.)
 
14    Section 25. The Emergency Medical Treatment Act is amended
15by changing Section 1 as follows:
 
16    (210 ILCS 70/1)  (from Ch. 111 1/2, par. 6151)
17    Sec. 1. No hospital, physician, dentist or other provider
18of professional health care licensed under the laws of this
19State may refuse to provide needed emergency treatment to any
20person whose life would be threatened in the absence of such
21treatment, because of that person's inability to pay therefor,
22nor because of the source of any payment promised therefor.
23Every hospital licensed under the Hospital Licensing Act shall
24comply with the Hospital Emergency Service Act.

 

 

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1(Source: P.A. 83-723.)
 
2    Section 30. The Hospital Emergency Service Act is amended
3by changing Section 1 as follows:
 
4    (210 ILCS 80/1)  (from Ch. 111 1/2, par. 86)
5    Sec. 1. Every hospital required to be licensed by the
6Department of Public Health pursuant to the Hospital Licensing
7Act which provides general medical and surgical hospital
8services, except long-term acute care hospitals identified in
9Section 1.3 of this Act, shall provide a hospital emergency
10service in accordance with rules and regulations adopted by the
11Department of Public Health which shall be consistent with the
12federal Emergency Medical Treatment and Active Labor Act (42
13U.S.C. 1395dd) and shall furnish such hospital emergency
14services to any applicant who applies for the same in case of
15injury or acute medical condition where the same is liable to
16cause death or severe injury or serious illness. For purposes
17of this Act, "applicant" includes any person who is brought to
18a hospital by ambulance or specialized emergency medical
19services vehicle as defined in the Emergency Medical Services
20(EMS) Systems Act.
21(Source: P.A. 97-667, eff. 1-13-12.)
 
22    Section 35. The Illinois Insurance Code is amended by
23adding Sections 356z.22, 356z.23, and 356z.24 as follows:
 

 

 

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1    (215 ILCS 5/356z.22 new)
2    Sec. 356z.22. Intravenous feeding. A group or individual
3policy of accident and health insurance or managed care plan
4amended, delivered, issued, or renewed after the effective date
5of this amendatory Act of the 98th General Assembly must
6provide coverage for intravenous feeding. The benefits under
7this Section shall be at least as favorable as for other
8coverages under the policy and may be subject to the same
9dollar amount limits, deductibles, and co-insurance
10requirements applicable generally to other coverages under the
11policy.
 
12    (215 ILCS 5/356z.23 new)
13    Sec. 356z.23. Prescription nutritional supplements. A
14group or individual policy of accident and health insurance or
15managed care plan amended, delivered, issued, or renewed after
16the effective date of this amendatory Act of the 98th General
17Assembly that provides coverage for prescription drugs must
18provide coverage for reimbursement for medically appropriate
19prescription nutritional supplements when ordered by a
20physician licensed to practice medicine in all its branches and
21the insured suffers from a condition that prevents him or her
22from taking sufficient oral nourishment to sustain life.
 
23    (215 ILCS 5/356z.24 new)

 

 

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1    Sec. 356z.24. Hospital patient assessments. A group or
2individual policy of accident and health insurance or managed
3care plan amended, delivered, issued, or renewed after the
4effective date of this amendatory Act of the 98th General
5Assembly that provides coverage for hospital care shall include
6in that coverage all services ordered by a physician and
7provided in the hospital that are considered medically
8necessary for the evaluation, assessment, and diagnosis of the
9illness or condition that resulted in the hospital stay of the
10enrollee or recipient. Such services are subject to reasonable
11review and utilization standards required by the policy or plan
12for all hospital services, as defined by the Department of
13Insurance or its successor agency.
 
14    Section 40. The Health Maintenance Organization Act is
15amended by changing Section 5-3 as follows:
 
16    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
17    Sec. 5-3. Insurance Code provisions.
18    (a) Health Maintenance Organizations shall be subject to
19the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
20141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
21154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
22356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4, 356z.5,
23356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
24356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22,

 

 

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1356z.23, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
2368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2,
3409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
4Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
5XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
6    (b) For purposes of the Illinois Insurance Code, except for
7Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
8Maintenance Organizations in the following categories are
9deemed to be "domestic companies":
10        (1) a corporation authorized under the Dental Service
11    Plan Act or the Voluntary Health Services Plans Act;
12        (2) a corporation organized under the laws of this
13    State; or
14        (3) a corporation organized under the laws of another
15    state, 30% or more of the enrollees of which are residents
16    of this State, except a corporation subject to
17    substantially the same requirements in its state of
18    organization as is a "domestic company" under Article VIII
19    1/2 of the Illinois Insurance Code.
20    (c) In considering the merger, consolidation, or other
21acquisition of control of a Health Maintenance Organization
22pursuant to Article VIII 1/2 of the Illinois Insurance Code,
23        (1) the Director shall give primary consideration to
24    the continuation of benefits to enrollees and the financial
25    conditions of the acquired Health Maintenance Organization
26    after the merger, consolidation, or other acquisition of

 

 

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

 

 

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

 

 

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1    of the period for which a refund is to be paid or
2    additional premium is to be charged (which period shall not
3    be less than one year); and
4        (ii) the amount of the refund or additional premium
5    shall not exceed 20% of the Health Maintenance
6    Organization's profitable or unprofitable experience with
7    respect to the group or other enrollment unit for the
8    period (and, for purposes of a refund or additional
9    premium, the profitable or unprofitable experience shall
10    be calculated taking into account a pro rata share of the
11    Health Maintenance Organization's administrative and
12    marketing expenses, but shall not include any refund to be
13    made or additional premium to be paid pursuant to this
14    subsection (f)). The Health Maintenance Organization and
15    the group or enrollment unit may agree that the profitable
16    or unprofitable experience may be calculated taking into
17    account the refund period and the immediately preceding 2
18    plan years.
19    The Health Maintenance Organization shall include a
20statement in the evidence of coverage issued to each enrollee
21describing the possibility of a refund or additional premium,
22and upon request of any group or enrollment unit, provide to
23the group or enrollment unit a description of the method used
24to calculate (1) the Health Maintenance Organization's
25profitable experience with respect to the group or enrollment
26unit and the resulting refund to the group or enrollment unit

 

 

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1or (2) the Health Maintenance Organization's unprofitable
2experience with respect to the group or enrollment unit and the
3resulting additional premium to be paid by the group or
4enrollment unit.
5    In no event shall the Illinois Health Maintenance
6Organization Guaranty Association be liable to pay any
7contractual obligation of an insolvent organization to pay any
8refund authorized under this Section.
9    (g) Rulemaking authority to implement Public Act 95-1045,
10if any, is conditioned on the rules being adopted in accordance
11with all provisions of the Illinois Administrative Procedure
12Act and all rules and procedures of the Joint Committee on
13Administrative Rules; any purported rule not so adopted, for
14whatever reason, is unauthorized.
15(Source: P.A. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10;
1696-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11;
1797-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12;
1897-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, eff.
197-13-12.)
 
20    Section 45. The Voluntary Health Services Plans Act is
21amended by changing Section 10 as follows:
 
22    (215 ILCS 165/10)  (from Ch. 32, par. 604)
23    Sec. 10. Application of Insurance Code provisions. Health
24services plan corporations and all persons interested therein

 

 

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1or dealing therewith shall be subject to the provisions of
2Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
3143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 356g,
4356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
5356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
6356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
7356z.19, 356z.21, 356z.22, 356z.23, 364.01, 367.2, 368a, 401,
8401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
9and (15) of Section 367 of the Illinois Insurance Code.
10    Rulemaking authority to implement Public Act 95-1045, if
11any, is conditioned on the rules being adopted in accordance
12with all provisions of the Illinois Administrative Procedure
13Act and all rules and procedures of the Joint Committee on
14Administrative Rules; any purported rule not so adopted, for
15whatever reason, is unauthorized.
16(Source: P.A. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10;
1796-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
1897-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13;
1997-813, eff. 7-13-12.)
 
20    Section 50. The Health Carrier External Review Act is
21amended by changing Section 35 and by adding Sections 25.1,
2225.2, 25.3, 25.4, 25.5, and 25.6 as follows:
 
23    (215 ILCS 180/25.1 new)
24    Sec. 25.1. Standard information for application forms.

 

 

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1    (a) The Director shall establish standard information and
2health history questions that shall be used by all health care
3service plans for their individual health care coverage
4application forms for individual health plan contracts and
5individual health insurance policies. The health care service
6plan and health insurance application forms for individual
7health plan contracts and health insurance policies may only
8contain questions approved by the Director.
9    (b) The standard information and health history questions
10developed by the Director shall contain clear and unambiguous
11information and questions designed to ascertain the health
12history of the applicant and shall be based on the medical
13information that is reasonable and necessary for medical
14underwriting purposes.
15    (c) The application form shall include a prominently
16displayed notice that shall read: "Illinois law prohibits an
17HIV test from being required or used by health care service
18plans as a condition of obtaining coverage.".
19    (d) No later than 6 months after the adoption of the
20regulation under subsection (a) of this Section, all individual
21health care service plan application forms shall utilize only
22the pool of approved questions and the standardized information
23established pursuant to subsection (a).
24    (e) On and after January 1, 2011, all individual health
25care service plan applications shall be reviewed and approved
26by the Director before they may be used by a health care

 

 

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1service plan.
 
2    (215 ILCS 180/25.2 new)
3    Sec. 25.2. Medical underwriting.
4    (a) "Medical underwriting" means the completion of a
5reasonable investigation of the applicant's health history
6information, which includes, but is not limited to, the
7following:
8        (1) Ensuring that the information submitted on the
9    application form and the material submitted with the
10    application form are complete and accurate.
11        (2) Resolving all reasonable questions arising from
12    the application form or any materials submitted with the
13    application form or any information obtained by the health
14    care service plan as part of its verification of the
15    accuracy and completeness of the application form.
16    (b) A health care service plan shall complete medical
17underwriting prior to issuing an enrollee or subscriber health
18care service plan contract.
19    (c) A health care service plan shall adopt and implement
20written medical underwriting policies and procedures to ensure
21that the health care service plan does all of the following
22with respect to an application for health care coverage:
23        (1) Reviews all of the following:
24            (A) Information on the application and any
25        materials submitted with the application form for

 

 

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1        accuracy and completeness.
2            (B) Claims information about the applicant that is
3        within the health care service plan's own claims
4        information.
5            (C) At least one commercially available
6        prescription drug database for information about the
7        applicant.
8        (2) Identifies and makes inquiries, including
9    contacting the applicant about any questions raised by
10    omissions, ambiguities, or inconsistencies based upon the
11    information collected pursuant to item (1) of this
12    subsection (c).
13    (d) The plan shall document all information collected
14during the underwriting review process.
15    (e) On or before January 1, 2011, a health care service
16plan shall file its medical underwriting policies and
17procedures with the Department.
 
18    (215 ILCS 180/25.3 new)
19    Sec. 25.3. Copies of application and contract; notice.
20    (a) Within 10 business days after issuing a health care
21service plan contract, the health care service plan shall send
22a copy of the completed written application to the applicant
23with a copy of the health care service plan contract issued by
24the health care service plan, along with a notice that states
25all of the following:

 

 

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1        (1) The applicant should review the completed
2    application carefully and notify the health care service
3    plan within 30 days of any inaccuracy in the application.
4        (2) Any intentional material misrepresentation or
5    intentional material omission in the information submitted
6    in the application may result in the cancellation or
7    rescission of the plan contract.
8        (3) The applicant should retain a copy of the completed
9    written application for the applicant's records.
10    (b) If new information is provided by the applicant within
11the 30-day period permitted by subsection (a), then the
12provisions concerning medical underwriting shall apply to the
13new information.
 
14    (215 ILCS 180/25.4 new)
15    Sec. 25.4. Rescission; cancellation.
16    (a) Once a plan has issued an individual health care
17service plan contract, the health care service plan shall not
18rescind or cancel the health care service plan contract unless
19all of the following apply:
20        (1) There was a material misrepresentation or material
21    omission in the information submitted by the applicant in
22    the written application to the health care service plan
23    prior to the issuance of the health care service plan
24    contract that would have prevented the contract from being
25    entered into.

 

 

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1        (2) The health care service plan completed medical
2    underwriting before issuing the plan contract.
3        (3) The health care service plan demonstrates that the
4    applicant intentionally misrepresented or intentionally
5    omitted material information on the application prior to
6    the issuance of the plan contract with the purpose of
7    misrepresenting his or her health history in order to
8    obtain health care coverage.
9        (4) The application form was approved by the
10    Department.
11        (5) The health care service plan sent a copy of the
12    completed written application to the applicant with a copy
13    of the health care service plan contract issued by the
14    health care service plan.
15    (b) Notwithstanding subsection (a) of this Section, an
16enrollment or subscription may be canceled or not renewed for
17failure to pay the fees for that coverage.
 
18    (215 ILCS 180/25.5 new)
19    Sec. 25.5. Postcontract investigation.
20    (a) If a health care service plan obtains information after
21issuing an individual health care service plan contract that
22the subscriber or enrollee may have intentionally omitted or
23intentionally misrepresented material information during the
24application for coverage process, then the health care service
25plan may investigate the potential omissions or

 

 

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1misrepresentations in order to determine whether the
2subscriber's or enrollee's health care service plan contract
3may be rescinded or canceled.
4    (b) The following provisions shall apply to a postcontract
5issuance investigation:
6        (1) Upon initiating a postcontract issuance
7    investigation for potential rescission or cancellation of
8    health care coverage, the plan shall provide a written
9    notice to the enrollee or subscriber by regular and
10    certified mail that it has initiated an investigation of
11    intentional material misrepresentation or intentional
12    material omission on the part of the enrollee or subscriber
13    and that the investigation could lead to the rescission or
14    cancellation of the enrollee's or subscriber's health care
15    service plan contract. The notice shall be provided by the
16    health care service plan within 5 days of the initiation of
17    the investigation.
18        (2) The written notice required under item (1) of this
19    subsection (b) shall include full disclosure of the
20    allegedly intentional material omission or
21    misrepresentation and a clear and concise explanation of
22    why the information has resulted in the health care service
23    plan's initiation of an investigation to determine whether
24    rescission or cancellation is warranted. The notice shall
25    invite the enrollee or subscriber to provide any evidence
26    or information within 45 business days to negate the plan's

 

 

HB0142- 21 -LRB098 02628 RPM 32633 b

1    reasons for initiating the postissuance investigation.
2        (3) The plan shall complete its investigation no later
3    than 90 days after the date that the notice is sent to the
4    enrollee or subscriber pursuant to item (1) of this
5    subsection (b).
6        (4) Upon completion of its postissuance investigation,
7    the plan shall provide written notice by regular and
8    certified mail to the subscriber or enrollee that it has
9    concluded its investigation and has made one of the
10    following determinations:
11            (A) The plan has determined that the enrollee or
12        subscriber did not intentionally misrepresent or
13        intentionally omit material information during the
14        application process and that the subscriber's or
15        enrollee's health care coverage will not be canceled or
16        rescinded.
17            (B) The plan intends to seek approval from the
18        Director to cancel or rescind the enrollee's or
19        subscriber's health care service plan contract for
20        intentional misrepresentation or intentional omission
21        of material information during the application for
22        coverage process.
23        (5) The written notice required under paragraph (B) of
24    item (4) of this subsection (b) shall do all of the
25    following:
26            (A) Include full disclosure of the nature and

 

 

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1        substance of any information that led to the plan's
2        determination that the enrollee or subscriber
3        intentionally misrepresented or intentionally omitted
4        material information on the application form.
5            (B) Provide the enrollee or subscriber with
6        information indicating that the health plan's
7        determination shall not become final until it is
8        reviewed and approved by the Department's independent
9        review process.
10            (C) Provide the enrollee or subscriber with
11        information regarding the Department's independent
12        review process and the right of the enrollee or
13        subscriber to opt out of that review process within 45
14        days of the date upon which an independent review
15        organization receives a request for independent
16        review.
17            (D) Provide a statement that the health care
18        service plan's proposed decision to cancel or rescind
19        the health care service plan contract shall not become
20        effective unless the Department's independent review
21        organization upholds the health care service plan's
22        decision or unless the enrollee or subscriber has opted
23        out of the independent review.
 
24    (215 ILCS 180/25.6 new)
25    Sec. 25.6. Continuation.

 

 

HB0142- 23 -LRB098 02628 RPM 32633 b

1    (a) A health care service plan shall continue to authorize
2and provide all medically necessary health care services
3required to be covered under an enrollee's or subscriber's
4health care service plan contract until the effective date of
5cancellation or rescission.
6    (b) The effective date of the health care service plan's
7cancellation or the date upon which the plan may initiate a
8rescission shall be no earlier than the date that the enrollee
9or subscriber receives notification via regular and certified
10mail that the independent review organization has made a
11determination upholding the health care service plan's
12decision to rescind or cancel.
 
13    (215 ILCS 180/35)
14    Sec. 35. Standard external review.
15    (a) Within 4 months after the date of receipt of a notice
16of an adverse determination or final adverse determination, a
17covered person or the covered person's authorized
18representative may file a request for an external review with
19the Director. Within one business day after the date of receipt
20of a request for external review, the Director shall send a
21copy of the request to the health carrier.
22    (b) Within 5 business days following the date of receipt of
23the external review request, the health carrier shall complete
24a preliminary review of the request to determine whether:
25        (1) the individual is or was a covered person in the

 

 

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1    health benefit plan at the time the health care service was
2    requested or at the time the health care service was
3    provided;
4        (2) the health care service that is the subject of the
5    adverse determination or the final adverse determination
6    is a covered service under the covered person's health
7    benefit plan, but the health carrier has determined that
8    the health care service is not covered;
9        (3) the covered person has exhausted the health
10    carrier's internal appeal process unless the covered
11    person is not required to exhaust the health carrier's
12    internal appeal process pursuant to this Act;
13        (4) (blank); and
14        (5) the covered person has provided all the information
15    and forms required to process an external review, as
16    specified in this Act.
17    (c) Within one business day after completion of the
18preliminary review, the health carrier shall notify the
19Director and covered person and, if applicable, the covered
20person's authorized representative in writing whether the
21request is complete and eligible for external review. If the
22request:
23        (1) is not complete, the health carrier shall inform
24    the Director and covered person and, if applicable, the
25    covered person's authorized representative in writing and
26    include in the notice what information or materials are

 

 

HB0142- 25 -LRB098 02628 RPM 32633 b

1    required by this Act to make the request complete; or
2        (2) is not eligible for external review, the health
3    carrier shall inform the Director and covered person and,
4    if applicable, the covered person's authorized
5    representative in writing and include in the notice the
6    reasons for its ineligibility.
7    The Department may specify the form for the health
8carrier's notice of initial determination under this
9subsection (c) and any supporting information to be included in
10the notice.
11    The notice of initial determination of ineligibility shall
12include a statement informing the covered person and, if
13applicable, the covered person's authorized representative
14that a health carrier's initial determination that the external
15review request is ineligible for review may be appealed to the
16Director by filing a complaint with the Director.
17    Notwithstanding a health carrier's initial determination
18that the request is ineligible for external review, the
19Director may determine that a request is eligible for external
20review and require that it be referred for external review. In
21making such determination, the Director's decision shall be in
22accordance with the terms of the covered person's health
23benefit plan, unless such terms are inconsistent with
24applicable law, and shall be subject to all applicable
25provisions of this Act.
26    (d) Whenever the Director receives notice that a request is

 

 

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1eligible for external review following the preliminary review
2conducted pursuant to this Section, within one business day
3after the date of receipt of the notice, the Director shall:
4        (1) assign an independent review organization from the
5    list of approved independent review organizations compiled
6    and maintained by the Director pursuant to this Act and
7    notify the health carrier of the name of the assigned
8    independent review organization; and
9        (2) notify in writing the covered person and, if
10    applicable, the covered person's authorized representative
11    of the request's eligibility and acceptance for external
12    review and the name of the independent review organization.
13    The Director shall include in the notice provided to the
14covered person and, if applicable, the covered person's
15authorized representative a statement that the covered person
16or the covered person's authorized representative may, within 5
17business days following the date of receipt of the notice
18provided pursuant to item (2) of this subsection (d), submit in
19writing to the assigned independent review organization
20additional information that the independent review
21organization shall consider when conducting the external
22review. The independent review organization is not required to,
23but may, accept and consider additional information submitted
24after 5 business days.
25    (e) The assignment by the Director of an approved
26independent review organization to conduct an external review

 

 

HB0142- 27 -LRB098 02628 RPM 32633 b

1in accordance with this Section shall be done on a random basis
2among those independent review organizations approved by the
3Director pursuant to this Act.
4    (f) Within 5 business days after the date of receipt of the
5notice provided pursuant to item (1) of subsection (d) of this
6Section, the health carrier or its designee utilization review
7organization shall provide to the assigned independent review
8organization the documents and any information considered in
9making the adverse determination or final adverse
10determination; in such cases, the following provisions shall
11apply:
12        (1) Except as provided in item (2) of this subsection
13    (f), failure by the health carrier or its utilization
14    review organization to provide the documents and
15    information within the specified time frame shall not delay
16    the conduct of the external review.
17        (2) If the health carrier or its utilization review
18    organization fails to provide the documents and
19    information within the specified time frame, the assigned
20    independent review organization may terminate the external
21    review and make a decision to reverse the adverse
22    determination or final adverse determination.
23        (3) Within one business day after making the decision
24    to terminate the external review and make a decision to
25    reverse the adverse determination or final adverse
26    determination under item (2) of this subsection (f), the

 

 

HB0142- 28 -LRB098 02628 RPM 32633 b

1    independent review organization shall notify the Director,
2    the health carrier, the covered person and, if applicable,
3    the covered person's authorized representative, of its
4    decision to reverse the adverse determination.
5    (g) Upon receipt of the information from the health carrier
6or its utilization review organization, the assigned
7independent review organization shall review all of the
8information and documents and any other information submitted
9in writing to the independent review organization by the
10covered person and the covered person's authorized
11representative.
12    (h) Upon receipt of any information submitted by the
13covered person or the covered person's authorized
14representative, the independent review organization shall
15forward the information to the health carrier within 1 business
16day.
17        (1) Upon receipt of the information, if any, the health
18    carrier may reconsider its adverse determination or final
19    adverse determination that is the subject of the external
20    review.
21        (2) Reconsideration by the health carrier of its
22    adverse determination or final adverse determination shall
23    not delay or terminate the external review.
24        (3) The external review may only be terminated if the
25    health carrier decides, upon completion of its
26    reconsideration, to reverse its adverse determination or

 

 

HB0142- 29 -LRB098 02628 RPM 32633 b

1    final adverse determination and provide coverage or
2    payment for the health care service that is the subject of
3    the adverse determination or final adverse determination.
4    In such cases, the following provisions shall apply:
5            (A) Within one business day after making the
6        decision to reverse its adverse determination or final
7        adverse determination, the health carrier shall notify
8        the Director, the covered person and, if applicable,
9        the covered person's authorized representative, and
10        the assigned independent review organization in
11        writing of its decision.
12            (B) Upon notice from the health carrier that the
13        health carrier has made a decision to reverse its
14        adverse determination or final adverse determination,
15        the assigned independent review organization shall
16        terminate the external review.
17    (i) In addition to the documents and information provided
18by the health carrier or its utilization review organization
19and the covered person and the covered person's authorized
20representative, if any, the independent review organization,
21to the extent the information or documents are available and
22the independent review organization considers them
23appropriate, shall consider the following in reaching a
24decision:
25        (1) the covered person's pertinent medical records;
26        (2) the covered person's health care provider's

 

 

HB0142- 30 -LRB098 02628 RPM 32633 b

1    recommendation;
2        (3) consulting reports from appropriate health care
3    providers and other documents submitted by the health
4    carrier or its designee utilization review organization,
5    the covered person, the covered person's authorized
6    representative, or the covered person's treating provider;
7        (4) the terms of coverage under the covered person's
8    health benefit plan with the health carrier to ensure that
9    the independent review organization's decision is not
10    contrary to the terms of coverage under the covered
11    person's health benefit plan with the health carrier,
12    unless the terms are inconsistent with applicable law;
13        (5) the most appropriate practice guidelines, which
14    shall include applicable evidence-based standards and may
15    include any other practice guidelines developed by the
16    federal government, national or professional medical
17    societies, boards, and associations;
18        (6) any applicable clinical review criteria developed
19    and used by the health carrier or its designee utilization
20    review organization;
21        (7) the opinion of the independent review
22    organization's clinical reviewer or reviewers after
23    considering items (1) through (6) of this subsection (i) to
24    the extent the information or documents are available and
25    the clinical reviewer or reviewers considers the
26    information or documents appropriate; and

 

 

HB0142- 31 -LRB098 02628 RPM 32633 b

1        (8) (blank).
2    (j) Within 5 days after the date of receipt of all
3necessary information, but in no event more than 45 days after
4the date of receipt of the request for an external review, the
5assigned independent review organization shall provide written
6notice of its decision to uphold or reverse the adverse
7determination or the final adverse determination to the
8Director, the health carrier, the covered person, and, if
9applicable, the covered person's authorized representative. In
10reaching a decision, the assigned independent review
11organization is not bound by any claim determinations reached
12prior to the submission of information to the independent
13review organization. The assigned independent review
14organization shall independently determine if the health care
15services under review are the medically necessary health care
16services that a physician, exercising prudent clinical
17judgment, would provide to a patient for the purpose of
18preventing, evaluating, diagnosing, or treating an illness,
19injury, disease, or its symptoms and are: (i) in accordance
20with generally accepted standards of medical practice; (ii)
21clinically appropriate, in terms of type, frequency, extent,
22site, and duration and considered effective for the patient's
23illness, injury, or disease; and (iii) not primarily for the
24convenience of the patient, physician, or other health care
25provider. For the purposes of this subsection (j), "generally
26accepted standards of medical practice" means standards that

 

 

HB0142- 32 -LRB098 02628 RPM 32633 b

1are based on credible scientific evidence published in
2peer-reviewed medical literature generally recognized by the
3relevant medical community, physician specialty society
4recommendations, and the views of physicians practicing in
5relevant clinical areas and any other relevant factors. In such
6cases, the following provisions shall apply:
7        (1) The independent review organization shall include
8    in the notice:
9            (A) a general description of the reason for the
10        request for external review;
11            (B) the date the independent review organization
12        received the assignment from the Director to conduct
13        the external review;
14            (C) the time period during which the external
15        review was conducted;
16            (D) references to the evidence or documentation,
17        including the evidence-based standards, considered in
18        reaching its decision;
19            (E) the date of its decision;
20            (F) the principal reason or reasons for its
21        decision, including what applicable, if any,
22        evidence-based standards that were a basis for its
23        decision; and
24            (G) the rationale for its decision.
25        (2) (Blank).
26        (3) (Blank).

 

 

HB0142- 33 -LRB098 02628 RPM 32633 b

1        (4) Upon receipt of a notice of a decision reversing
2    the adverse determination or final adverse determination,
3    the health carrier immediately shall approve the coverage
4    that was the subject of the adverse determination or final
5    adverse determination.
6(Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11; 97-574,
7eff. 8-26-11.)
 
8    Section 55. The Illinois Public Aid Code is amended by
9changing Section 5-16.8 as follows:
 
10    (305 ILCS 5/5-16.8)
11    Sec. 5-16.8. Required health benefits. The medical
12assistance program shall (i) provide the post-mastectomy care
13benefits required to be covered by a policy of accident and
14health insurance under Section 356t and the coverage required
15under Sections 356g.5, 356u, 356w, 356x, and 356z.6, and
16356z.24 of the Illinois Insurance Code and (ii) be subject to
17the provisions of Sections 356z.19 and 364.01 of the Illinois
18Insurance Code.
19    On and after July 1, 2012, the Department shall reduce any
20rate of reimbursement for services or other payments or alter
21any methodologies authorized by this Code to reduce any rate of
22reimbursement for services or other payments in accordance with
23Section 5-5e.
24(Source: P.A. 97-282, eff. 8-9-11; 97-689, eff. 6-14-12.)
 

 

 

HB0142- 34 -LRB098 02628 RPM 32633 b

1    Section 60. The Medical Patient Rights Act is amended by
2changing Sections 2.04 and 3 and by adding Section 2.06 as
3follows:
 
4    (410 ILCS 50/2.04)  (from Ch. 111 1/2, par. 5402.04)
5    Sec. 2.04. "Insurance company" means (1) an insurance
6company, fraternal benefit society, and any other insurer
7subject to regulation under the Illinois Insurance Code; or (2)
8a health maintenance organization, a limited health service
9organization under the Limited Health Service Organization
10Act, or a voluntary health services plan under the Voluntary
11Health Services Plans Act.
12(Source: P.A. 85-677; 85-679.)
 
13    (410 ILCS 50/2.06 new)
14    Sec. 2.06. Health insurance policy or health care plan.
15"Health insurance policy or health care plan" means any policy
16of health or accident insurance provided by a health insurance
17company or under the Counties Code, the Municipal Code, the
18State Employees Group Insurance Act or Medical Assistance
19provided under the Public Aid Code.
 
20    (410 ILCS 50/3)  (from Ch. 111 1/2, par. 5403)
21    Sec. 3. The following rights are hereby established:
22    (a) The right of each patient to care consistent with sound

 

 

HB0142- 35 -LRB098 02628 RPM 32633 b

1nursing and medical practices, to be informed of the name of
2the physician responsible for coordinating his or her care, to
3receive information concerning his or her condition and
4proposed treatment, to refuse any treatment to the extent
5permitted by law, and to privacy and confidentiality of records
6except as otherwise provided by law. Each patient has a right
7to be informed of his or her inpatient or outpatient status
8while undergoing evaluation, assessment, diagnosis, treatment,
9or observation in a hospital. The patient must be informed of
10this status and put on notice that this admission status may
11affect coverage by his or her health insurance policy or health
12care plan or his or her personal responsibility for payment.
13    (b) The right of each patient, regardless of source of
14payment, to examine and receive a reasonable explanation of his
15total bill for services rendered by his physician or health
16care provider, including the itemized charges for specific
17services received. Each physician or health care provider shall
18be responsible only for a reasonable explanation of those
19specific services provided by such physician or health care
20provider.
21    (c) In the event an insurance company or health services
22corporation cancels or refuses to renew an individual policy or
23plan, the insured patient shall be entitled to timely, prior
24notice of the termination of such policy or plan.
25    An insurance company or health services corporation that
26requires any insured patient or applicant for new or continued

 

 

HB0142- 36 -LRB098 02628 RPM 32633 b

1insurance or coverage to be tested for infection with human
2immunodeficiency virus (HIV) or any other identified causative
3agent of acquired immunodeficiency syndrome (AIDS) shall (1)
4give the patient or applicant prior written notice of such
5requirement, (2) proceed with such testing only upon the
6written authorization of the applicant or patient, and (3) keep
7the results of such testing confidential. Notice of an adverse
8underwriting or coverage decision may be given to any
9appropriately interested party, but the insurer may only
10disclose the test result itself to a physician designated by
11the applicant or patient, and any such disclosure shall be in a
12manner that assures confidentiality.
13    The Department of Insurance shall enforce the provisions of
14this subsection.
15    (d) The right of each patient to privacy and
16confidentiality in health care. Each physician, health care
17provider, health services corporation and insurance company
18shall refrain from disclosing the nature or details of services
19provided to patients, except that such information may be
20disclosed to the patient, the party making treatment decisions
21if the patient is incapable of making decisions regarding the
22health services provided, those parties directly involved with
23providing treatment to the patient or processing the payment
24for that treatment, those parties responsible for peer review,
25utilization review and quality assurance, and those parties
26required to be notified under the Abused and Neglected Child

 

 

HB0142- 37 -LRB098 02628 RPM 32633 b

1Reporting Act, the Illinois Sexually Transmissible Disease
2Control Act or where otherwise authorized or required by law.
3This right may be waived in writing by the patient or the
4patient's guardian, but a physician or other health care
5provider may not condition the provision of services on the
6patient's or guardian's agreement to sign such a waiver.
7(Source: P.A. 86-895; 86-902; 86-1028; 87-334.)
 
8    Section 90. The State Mandates Act is amended by adding
9Section 8.37 as follows:
 
10    (30 ILCS 805/8.37 new)
11    Sec. 8.37. Exempt mandate. Notwithstanding Sections 6 and 8
12of this Act, no reimbursement by the State is required for the
13implementation of any mandate created by this amendatory Act of
14the 98th General Assembly.
 
15    (210 ILCS 80/1.3 rep.)
16    Section 95. The Hospital Emergency Service Act is amended
17by repealing Section 1.3.
 
18    Section 99. Effective date. This Act takes effect upon
19becoming law.

 

 

HB0142- 38 -LRB098 02628 RPM 32633 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    210 ILCS 70/1from Ch. 111 1/2, par. 6151
8    210 ILCS 80/1from Ch. 111 1/2, par. 86
9    215 ILCS 5/356z.22 new
10    215 ILCS 5/356z.23 new
11    215 ILCS 5/356z.24 new
12    215 ILCS 125/5-3from Ch. 111 1/2, par. 1411.2
13    215 ILCS 165/10from Ch. 32, par. 604
14    215 ILCS 180/25.1 new
15    215 ILCS 180/25.2 new
16    215 ILCS 180/25.3 new
17    215 ILCS 180/25.4 new
18    215 ILCS 180/25.5 new
19    215 ILCS 180/25.6 new
20    215 ILCS 180/35
21    305 ILCS 5/5-16.8
22    410 ILCS 50/2.04from Ch. 111 1/2, par. 5402.04
23    410 ILCS 50/2.06 new
24    410 ILCS 50/3from Ch. 111 1/2, par. 5403
25    30 ILCS 805/8.37 new

 

 

HB0142- 39 -LRB098 02628 RPM 32633 b

1    210 ILCS 80/1.3 rep.