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91_HB2774
LRB9102646JSpc
1 AN ACT concerning coverage for health benefits, amending
2 named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Insurance Code is amended by
6 changing Sections 356h, 356v, 364, 367, and 367i as follows:
7 (215 ILCS 5/356h) (from Ch. 73, par. 968h)
8 Sec. 356h. No individual or group policy of accident and
9 health insurance which covers the insured's immediate family
10 or children, as well as covering the insured, shall exclude a
11 child from coverage or limit coverage for a child solely
12 because the child is an adopted child, or solely because the
13 child does not reside with the insured. For purposes of this
14 Section, a child who is in the custody of the insured,
15 pursuant to an interim court order of adoption or, in the
16 case of group insurance, placement of adoption, whichever
17 comes first, vesting temporary care of the child in the
18 insured, is an adopted child, regardless of whether a final
19 order granting adoption is ultimately issued.
20 (Source: P.A. 86-649.)
21 (215 ILCS 5/356v)
22 Sec. 356v. Use of information derived from genetic
23 testing. After the effective date of this amendatory Act of
24 1997, an insurer must comply with the provisions of the
25 Genetic Information Privacy Act in connection with the
26 amendment, delivery, issuance, or renewal of, or claims for
27 or denial of coverage under, an individual or group policy of
28 accident and health insurance. Additionally, genetic
29 information shall not be treated as a condition described in
30 item (1) of subsection (A) of Section 20 of the Illinois
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1 Health Insurance Portability and Accountability Act in the
2 absence of a diagnosis of the condition related to that
3 genetic information.
4 (Source: P.A. 90-25, eff. 1-1-98; 90-655, eff. 7-30-98.)
5 (215 ILCS 5/364) (from Ch. 73, par. 976)
6 Sec. 364. Discrimination prohibited. Discrimination
7 between individuals of the same class of risk in the issuance
8 of its policies or in the amount of premiums or rates charged
9 for any insurance covered by this article, or in the benefits
10 payable thereon, or in any of the terms or conditions of such
11 policy, or in any other manner whatsoever is prohibited.
12 Nothing in this provision shall prohibit an insurer from
13 providing incentives for insureds to utilize the services of
14 a particular hospital or person. It is hereby expressly
15 provided that whenever the terms "physician" or "doctor"
16 appear or are used in any way in any policy of accident or
17 health insurance issued in this state, said terms shall
18 include within their meaning persons licensed to practice
19 dentistry under the Illinois Dental Practice Act with regard
20 to benefits payable for services performed by a person so
21 licensed, which such services are within the coverage
22 provided by the particular policy or contract of insurance
23 and are within the professional services authorized to be
24 performed by such person under and in accordance with the
25 said Act.
26 No company, in any policy of accident or health insurance
27 issued in this State, shall make or permit any distinction or
28 discrimination against individuals solely because of
29 handicaps or disabilities in the amount of payment of
30 premiums or rates charged for policies of insurance, in the
31 amount of any dividends or other benefits payable thereon, or
32 in any other terms and conditions of the contract it makes,
33 except where the distinction or discrimination is based on
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1 sound actuarial principles or is related to actual or
2 reasonably anticipated experience.
3 No company shall refuse to insure, or refuse to continue
4 to insure, or limit the amount or extent or kind of coverage
5 available to an individual, or charge an individual a
6 different rate for the same coverage solely because of
7 blindness or partial blindness. With respect to all other
8 conditions, including the underlying cause of the blindness
9 or partial blindness, persons who are blind or partially
10 blind shall be subject to the same standards of sound
11 actuarial principles or actual or reasonably anticipated
12 experience as are sighted persons. Refusal to insure includes
13 denial by an insurer of disability insurance coverage on the
14 grounds that the policy defines "disability" as being
15 presumed in the event that the insured loses his or her
16 eyesight. However, an insurer may exclude from coverage
17 disabilities consisting solely of blindness or partial
18 blindness when such condition existed at the time the policy
19 was issued.
20 (Source: P.A. 85-1209.)
21 (215 ILCS 5/367) (from Ch. 73, par. 979)
22 Sec. 367. Group accident and health insurance.
23 (1) Group accident and health insurance is hereby
24 declared to be that form of accident and health insurance
25 covering not less than 2 10 employees, members, or employees
26 of members, (except in case of volunteer fire departments the
27 number shall not be less than 5 members) written under a
28 master policy issued to any governmental corporation, unit,
29 agency or department thereof, or to any corporation,
30 copartnership, individual employer, or to any association
31 upon application of an executive officer or trustee of such
32 association having a constitution or bylaws and formed in
33 good faith for purposes other than that of obtaining
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1 insurance, where officers, members, employees, employees of
2 members or classes or department thereof, may be insured for
3 their individual benefit. In addition a group accident and
4 health policy may be written to insure any group which may be
5 insured under a group life insurance policy. The term
6 "employees" shall include the officers, managers and
7 employees of subsidiary or affiliated corporations, and the
8 individual proprietors, partners and employees of affiliated
9 individuals and firms, when the business of such subsidiary
10 or affiliated corporations, firms or individuals, is
11 controlled by a common employer through stock ownership,
12 contract or otherwise.
13 (2) Any insurance company authorized to write accident
14 and health insurance in this State shall have power to issue
15 group accident and health policies. No policy of group
16 accident and health insurance may be issued or delivered in
17 this State unless a copy of the form thereof shall have been
18 filed with the department and approved by it in accordance
19 with Section 355, and it contains in substance those
20 provisions contained in Sections 357.1 through 357.30 as may
21 be applicable to group accident and health insurance and the
22 following provisions:
23 (a) A provision that the policy, the application of
24 the employer, or executive officer or trustee of any
25 association, and the individual applications, if any, of
26 the employees, members or employees of members insured
27 shall constitute the entire contract between the parties,
28 and that all statements made by the employer, or the
29 executive officer or trustee, or by the individual
30 employees, members or employees of members shall (in the
31 absence of fraud) be deemed representations and not
32 warranties, and that no such statement shall be used in
33 defense to a claim under the policy, unless it is
34 contained in a written application.
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1 (b) A provision that the insurer will issue to the
2 employer, or to the executive officer or trustee of the
3 association, for delivery to the employee, member or
4 employee of a member, who is insured under such policy,
5 an individual certificate setting forth a statement as to
6 the insurance protection to which he is entitled and to
7 whom payable.
8 (c) A provision that to the group or class thereof
9 originally insured shall be added from time to time all
10 new employees of the employer, members of the association
11 or employees of members eligible to and applying for
12 insurance in such group or class.
13 (3) Anything in this code to the contrary
14 notwithstanding, any group accident and health policy may
15 provide that all or any portion of any indemnities provided
16 by any such policy on account of hospital, nursing, medical
17 or surgical services, may, at the insurer's option, be paid
18 directly to the hospital or person rendering such services;
19 but the policy may not require that the service be rendered
20 by a particular hospital or person. Payment so made shall
21 discharge the insurer's obligation with respect to the amount
22 of insurance so paid. Nothing in this subsection (3) shall
23 prohibit an insurer from providing incentives for insureds to
24 utilize the services of a particular hospital or person.
25 (4) Special group policies may be issued to school
26 districts providing medical or hospital service, or both, for
27 pupils of the district injured while participating in any
28 athletic activity under the jurisdiction of or sponsored or
29 controlled by the district or the authorities of any school
30 thereof. The provisions of this Section governing the
31 issuance of group accident and health insurance shall,
32 insofar as applicable, control the issuance of such policies
33 issued to schools.
34 (5) No policy of group accident and health insurance may
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1 be issued or delivered in this State unless it provides that
2 upon the death of the insured employee or group member the
3 dependents' coverage, if any, continues for a period of at
4 least 90 days subject to any other policy provisions relating
5 to termination of dependents' coverage.
6 (6) No group hospital policy covering miscellaneous
7 hospital expenses issued or delivered in this State shall
8 contain any exception or exclusion from coverage which would
9 preclude the payment of expenses incurred for the processing
10 and administration of blood and its components.
11 (7) No policy of group accident and health insurance,
12 delivered in this State more than 120 days after the
13 effective day of the Section, which provides inpatient
14 hospital coverage for sicknesses shall exclude from such
15 coverage the treatment of alcoholism. This subsection shall
16 not apply to a policy which covers only specified sicknesses.
17 (8) No policy of group accident and health insurance,
18 which provides benefits for hospital or medical expenses
19 based upon the actual expenses incurred, issued or delivered
20 in this State shall contain any specific exception to
21 coverage which would preclude the payment of actual expenses
22 incurred in the examination and testing of a victim of an
23 offense defined in Sections 12-13 through 12-16 of the
24 Criminal Code of 1961, or an attempt to commit such offense,
25 to establish that sexual contact did occur or did not occur,
26 and to establish the presence or absence of sexually
27 transmitted disease or infection, and examination and
28 treatment of injuries and trauma sustained by the victim of
29 such offense, arising out of the offense. Every group policy
30 of accident and health insurance which specifically provides
31 benefits for routine physical examinations shall provide full
32 coverage for expenses incurred in the examination and testing
33 of a victim of an offense defined in Sections 12-13 through
34 12-16 of the Criminal Code of 1961, or an attempt to commit
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1 such offense, as set forth in this Section. This subsection
2 shall not apply to a policy which covers hospital and medical
3 expenses for specified illnesses and injuries only.
4 (9) For purposes of enabling the recovery of State
5 funds, any insurance carrier subject to this Section shall
6 upon reasonable demand by the Department of Public Health
7 disclose the names and identities of its insureds entitled to
8 benefits under this provision to the Department of Public
9 Health whenever the Department of Public Health has
10 determined that it has paid, or is about to pay, hospital or
11 medical expenses for which an insurance carrier is liable
12 under this Section. All information received by the
13 Department of Public Health under this provision shall be
14 held on a confidential basis and shall not be subject to
15 subpoena and shall not be made public by the Department of
16 Public Health or used for any purpose other than that
17 authorized by this Section.
18 (10) Whenever the Department of Public Health finds that
19 it has paid all or part of any hospital or medical expenses
20 which an insurance carrier is obligated to pay under this
21 Section, the Department of Public Health shall be entitled to
22 receive reimbursement for its payments from such insurance
23 carrier provided that the Department of Public Health has
24 notified the insurance carrier of its claim before the
25 carrier has paid the benefits to its insureds or the
26 insureds' assignees.
27 (11) (a) No group hospital, medical or surgical expense
28 policy shall contain any provision whereby benefits
29 otherwise payable thereunder are subject to reduction
30 solely on account of the existence of similar benefits
31 provided under other group or group-type accident and
32 sickness insurance policies where such reduction would
33 operate to reduce total benefits payable under these
34 policies below an amount equal to 100% of total allowable
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1 expenses provided under these policies.
2 (b) When dependents of insureds are covered under 2
3 policies, both of which contain coordination of benefits
4 provisions, benefits of the policy of the insured whose
5 birthday falls earlier in the year are determined before
6 those of the policy of the insured whose birthday falls
7 later in the year. Birthday, as used herein, refers only
8 to the month and day in a calendar year, not the year in
9 which the person was born. The Department of Insurance
10 shall promulgate rules defining the order of benefit
11 determination pursuant to this paragraph (b).
12 (12) Every group policy under this Section shall be
13 subject to the provisions of Sections 356g and 356n of this
14 Code.
15 (13) No accident and health insurer providing coverage
16 for hospital or medical expenses on an expense incurred basis
17 shall deny reimbursement for an otherwise covered expense
18 incurred for any organ transplantation procedure solely on
19 the basis that such procedure is deemed experimental or
20 investigational unless supported by the determination of the
21 Office of Health Care Technology Assessment within the Agency
22 for Health Care Policy and Research within the federal
23 Department of Health and Human Services that such procedure
24 is either experimental or investigational or that there is
25 insufficient data or experience to determine whether an organ
26 transplantation procedure is clinically acceptable. If an
27 accident and health insurer has made written request, or had
28 one made on its behalf by a national organization, for
29 determination by the Office of Health Care Technology
30 Assessment within the Agency for Health Care Policy and
31 Research within the federal Department of Health and Human
32 Services as to whether a specific organ transplantation
33 procedure is clinically acceptable and said organization
34 fails to respond to such a request within a period of 90
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1 days, the failure to act may be deemed a determination that
2 the procedure is deemed to be experimental or
3 investigational.
4 (14) Whenever a claim for benefits by an insured under a
5 dental prepayment program is denied or reduced, based on the
6 review of x-ray films, such review must be performed by a
7 dentist.
8 (Source: P.A. 89-187, eff. 7-19-95.)
9 (215 ILCS 5/367i) (from Ch. 73, par. 979i)
10 Sec. 367i. Discontinuance and replacement of coverage.
11 Group health insurance policies issued, amended, delivered or
12 renewed on and after the effective date of this amendatory
13 Act of 1989, shall provide a reasonable extension of benefits
14 in the event of total disability on the date the policy is
15 discontinued for any reason.
16 Any applicable extension of benefits or accrued liability
17 shall be described in the policy and group certificate.
18 Benefits payable during any extension of benefits may be
19 subject to the policy's regular benefit limits.
20 Any insurer discontinuing a group health insurance policy
21 shall provide to the policyholder for delivery to covered
22 employees or members a notice as to the date such
23 discontinuation is to be effective and urging them to refer
24 to their group certificates to determine what contract
25 rights, if any, are available to them.
26 In the event a discontinued policy is replaced by another
27 group policy, the prior insurer or plan shall be liable only
28 to the extent of its accrued liabilities and extension of
29 benefits. Persons eligible for coverage under the succeeding
30 insurer's plan or policy shall include all employees and
31 dependents covered under the prior insurer's plan, including
32 disabled individuals covered under the prior plan but absent
33 from work on the effective date and thereafter. The prior
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1 insurer shall provide extension of benefits for an insured's
2 disabling condition when no coverage is available under the
3 succeeding insurer's plan whether due to the absence of
4 coverage in the contract or lack of required creditable
5 coverage for a preexisting condition. be covered by that
6 policy. Persons not eligible for coverage under the
7 succeeding insurer's policy shall, until such time as such
8 person becomes eligible, be covered by the succeeding
9 insurer's policy in such a way as to ensure that such persons
10 shall be treated no less favorably than had the change in
11 insurers not occurred.
12 The Director shall promulgate reasonable rules as
13 necessary to carry out this Section.
14 (Source: P.A. 86-537.)
15 Section 10. The Health Maintenance Organization Act is
16 amended by changing Section 4-9 as follows:
17 (215 ILCS 125/4-9) (from Ch. 111 1/2, par. 1409.2)
18 Sec. 4-9. Adopted children. No contract or evidence of
19 coverage issued by a Health Maintenance Organization which
20 provides for coverage of dependents of the principal
21 enrollees shall exclude a child from coverage or eligibility
22 for coverage or limit coverage for a child solely on the
23 basis that he or she is an adopted child. For purposes of
24 this Section, a child who is in the custody of a principal
25 enrollee, pursuant to an interim court order of adoption or,
26 in the case of group insurance, placement of adoption,
27 whichever comes first, vesting temporary care of the child in
28 the enrollee, is an adopted child, regardless of whether a
29 final order granting adoption is ultimately issued.
30 (Source: P.A. 86-620.)
31 Section 99. Effective date. This Act takes effect upon
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1 becoming law.