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Public Act 095-1005


 

Public Act 1005 95TH GENERAL ASSEMBLY



 


 
Public Act 095-1005
 
SB0934 Enrolled LRB095 05756 KBJ 25846 b

    AN ACT concerning health.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The State Employees Group Insurance Act of 1971
is amended by changing Section 6.11 as follows:
 
    (5 ILCS 375/6.11)
    Sec. 6.11. Required health benefits; Illinois Insurance
Code requirements. The program of health benefits shall provide
the post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t of
the Illinois Insurance Code. The program of health benefits
shall provide the coverage required under Sections 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, and 356z.10,
and 356z.14 of the Illinois Insurance Code. The program of
health benefits must comply with Section 155.37 of the Illinois
Insurance Code.
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
    Section 10. The Counties Code is amended by changing
Section 5-1069.3 as follows:
 
    (55 ILCS 5/5-1069.3)
    Sec. 5-1069.3. Required health benefits. If a county,
including a home rule county, is a self-insurer for purposes of
providing health insurance coverage for its employees, the
coverage shall include coverage for the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t and the coverage required
under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.9, and
356z.10, and 356z.14 of the Illinois Insurance Code. The
requirement that health benefits be covered as provided in this
Section is an exclusive power and function of the State and is
a denial and limitation under Article VII, Section 6,
subsection (h) of the Illinois Constitution. A home rule county
to which this Section applies must comply with every provision
of this Section.
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
    Section 15. The Illinois Municipal Code is amended by
changing Section 10-4-2.3 as follows:
 
    (65 ILCS 5/10-4-2.3)
    Sec. 10-4-2.3. Required health benefits. If a
municipality, including a home rule municipality, is a
self-insurer for purposes of providing health insurance
coverage for its employees, the coverage shall include coverage
for the post-mastectomy care benefits required to be covered by
a policy of accident and health insurance under Section 356t
and the coverage required under Sections 356g.5, 356u, 356w,
356x, 356z.6, 356z.9, and 356z.10, and 356z.14 of the Illinois
Insurance Code. The requirement that health benefits be covered
as provided in this is an exclusive power and function of the
State and is a denial and limitation under Article VII, Section
6, subsection (h) of the Illinois Constitution. A home rule
municipality to which this Section applies must comply with
every provision of this Section.
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
    Section 20. The School Code is amended by changing Section
10-22.3f as follows:
 
    (105 ILCS 5/10-22.3f)
    Sec. 10-22.3f. Required health benefits. Insurance
protection and benefits for employees shall provide the
post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t and
the coverage required under Sections 356g.5, 356u, 356w, 356x,
356z.6, and 356z.9, and 356z.14 of the Illinois Insurance Code.
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
95-876, eff. 8-21-08.)
 
    Section 25. The Illinois Insurance Code is amended by
adding Section 356z.14 as follows:
 
    (215 ILCS 5/356z.14 new)
    Sec. 356z.14. Autism spectrum disorders.
    (a) A group or individual policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed after the effective date of this amendatory Act of the
95th General Assembly must provide individuals under 21 years
of age coverage for the diagnosis of autism spectrum disorders
and for the treatment of autism spectrum disorders to the
extent that the diagnosis and treatment of autism spectrum
disorders are not already covered by the policy of accident and
health insurance or managed care plan.
    (b) Coverage provided under this Section shall be subject
to a maximum benefit of $36,000 per year, but shall not be
subject to any limits on the number of visits to a service
provider. After December 30, 2009, the Director of the Division
of Insurance shall, on an annual basis, adjust the maximum
benefit for inflation using the Medical Care Component of the
United States Department of Labor Consumer Price Index for All
Urban Consumers. Payments made by an insurer on behalf of a
covered individual for any care, treatment, intervention,
service, or item, the provision of which was for the treatment
of a health condition not diagnosed as an autism spectrum
disorder, shall not be applied toward any maximum benefit
established under this subsection.
    (c) Coverage under this Section shall be subject to
copayment, deductible, and coinsurance provisions of a policy
of accident and health insurance or managed care plan to the
extent that other medical services covered by the policy of
accident and health insurance or managed care plan are subject
to these provisions.
    (d) This Section shall not be construed as limiting
benefits that are otherwise available to an individual under a
policy of accident and health insurance or managed care plan
and benefits provided under this Section may not be subject to
dollar limits, deductibles, copayments, or coinsurance
provisions that are less favorable to the insured than the
dollar limits, deductibles, or coinsurance provisions that
apply to physical illness generally.
    (e) An insurer may not deny or refuse to provide otherwise
covered services, or refuse to renew, refuse to reissue, or
otherwise terminate or restrict coverage under an individual
contract to provide services to an individual because the
individual or their dependent is diagnosed with an autism
spectrum disorder or due to the individual utilizing benefits
in this Section.
    (f) Upon request of the reimbursing insurer, a provider of
treatment for autism spectrum disorders shall furnish medical
records, clinical notes, or other necessary data that
substantiate that initial or continued medical treatment is
medically necessary and is resulting in improved clinical
status. When treatment is anticipated to require continued
services to achieve demonstrable progress, the insurer may
request a treatment plan consisting of diagnosis, proposed
treatment by type, frequency, anticipated duration of
treatment, the anticipated outcomes stated as goals, and the
frequency by which the treatment plan will be updated.
    (g) When making a determination of medical necessity for a
treatment modality for autism spectrum disorders, an insurer
must make the determination in a manner that is consistent with
the manner used to make that determination with respect to
other diseases or illnesses covered under the policy, including
an appeals process. During the appeals process, any challenge
to medical necessity must be viewed as reasonable only if the
review includes a physician with expertise in the most current
and effective treatment modalities for autism spectrum
disorders.
    (h) Coverage for medically necessary early intervention
services must be delivered by certified early intervention
specialists, as defined in 89 Ill. Admin. Code 500 and any
subsequent amendments thereto.
    (i) As used in this Section:
    "Autism spectrum disorders" means pervasive developmental
disorders as defined in the most recent edition of the
Diagnostic and Statistical Manual of Mental Disorders,
including autism, Asperger's disorder, and pervasive
developmental disorder not otherwise specified.
    "Diagnosis of autism spectrum disorders" means one or more
tests, evaluations, or assessments to diagnose whether an
individual has autism spectrum disorder that is prescribed,
performed, or ordered by (A) a physician licensed to practice
medicine in all its branches or (B) a licensed clinical
psychologist with expertise in diagnosing autism spectrum
disorders.
    "Medically necessary" means any care, treatment,
intervention, service or item which will or is reasonably
expected to do any of the following: (i) prevent the onset of
an illness, condition, injury, disease or disability; (ii)
reduce or ameliorate the physical, mental or developmental
effects of an illness, condition, injury, disease or
disability; or (iii) assist to achieve or maintain maximum
functional activity in performing daily activities.
    "Treatment for autism spectrum disorders" shall include
the following care prescribed, provided, or ordered for an
individual diagnosed with an autism spectrum disorder by (A) a
physician licensed to practice medicine in all its branches or
(B) a certified, registered, or licensed health care
professional with expertise in treating effects of autism
spectrum disorders when the care is determined to be medically
necessary and ordered by a physician licensed to practice
medicine in all its branches:
        (1) Psychiatric care, meaning direct, consultative, or
    diagnostic services provided by a licensed psychiatrist.
        (2) Psychological care, meaning direct or consultative
    services provided by a licensed psychologist.
        (3) Habilitative or rehabilitative care, meaning
    professional, counseling, and guidance services and
    treatment programs, including applied behavior analysis,
    that are intended to develop, maintain, and restore the
    functioning of an individual. As used in this subsection
    (i), "applied behavior analysis" means the design,
    implementation, and evaluation of environmental
    modifications using behavioral stimuli and consequences to
    produce socially significant improvement in human
    behavior, including the use of direct observation,
    measurement, and functional analysis of the relations
    between environment and behavior.
        (4) Therapeutic care, including behavioral, speech,
    occupational, and physical therapies that provide
    treatment in the following areas: (i) self care and
    feeding, (ii) pragmatic, receptive, and expressive
    language, (iii) cognitive functioning, (iv) applied
    behavior analysis, intervention, and modification, (v)
    motor planning, and (vi) sensory processing.
    (j) Rulemaking authority to implement this amendatory Act
of the 95th General Assembly, if any, is conditioned on the
rules being adopted in accordance with all provisions of the
Illinois Administrative Procedure Act and all rules and
procedures of the Joint Committee on Administrative Rules; any
purported rule not so adopted, for whatever reason, is
unauthorized.
 
    Section 30. The Health Maintenance Organization Act is
amended by changing Section 5-3 as follows:
 
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
    Sec. 5-3. Insurance Code provisions.
    (a) Health Maintenance Organizations shall be subject to
the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
356z.14, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
444, and 444.1, paragraph (c) of subsection (2) of Section 367,
and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
and XXVI of the Illinois Insurance Code.
    (b) For purposes of the Illinois Insurance Code, except for
Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
Maintenance Organizations in the following categories are
deemed to be "domestic companies":
        (1) a corporation authorized under the Dental Service
    Plan Act or the Voluntary Health Services Plans Act;
        (2) a corporation organized under the laws of this
    State; or
        (3) a corporation organized under the laws of another
    state, 30% or more of the enrollees of which are residents
    of this State, except a corporation subject to
    substantially the same requirements in its state of
    organization as is a "domestic company" under Article VIII
    1/2 of the Illinois Insurance Code.
    (c) In considering the merger, consolidation, or other
acquisition of control of a Health Maintenance Organization
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
        (1) the Director shall give primary consideration to
    the continuation of benefits to enrollees and the financial
    conditions of the acquired Health Maintenance Organization
    after the merger, consolidation, or other acquisition of
    control takes effect;
        (2)(i) the criteria specified in subsection (1)(b) of
    Section 131.8 of the Illinois Insurance Code shall not
    apply and (ii) the Director, in making his determination
    with respect to the merger, consolidation, or other
    acquisition of control, need not take into account the
    effect on competition of the merger, consolidation, or
    other acquisition of control;
        (3) the Director shall have the power to require the
    following information:
            (A) certification by an independent actuary of the
        adequacy of the reserves of the Health Maintenance
        Organization sought to be acquired;
            (B) pro forma financial statements reflecting the
        combined balance sheets of the acquiring company and
        the Health Maintenance Organization sought to be
        acquired as of the end of the preceding year and as of
        a date 90 days prior to the acquisition, as well as pro
        forma financial statements reflecting projected
        combined operation for a period of 2 years;
            (C) a pro forma business plan detailing an
        acquiring party's plans with respect to the operation
        of the Health Maintenance Organization sought to be
        acquired for a period of not less than 3 years; and
            (D) such other information as the Director shall
        require.
    (d) The provisions of Article VIII 1/2 of the Illinois
Insurance Code and this Section 5-3 shall apply to the sale by
any health maintenance organization of greater than 10% of its
enrollee population (including without limitation the health
maintenance organization's right, title, and interest in and to
its health care certificates).
    (e) In considering any management contract or service
agreement subject to Section 141.1 of the Illinois Insurance
Code, the Director (i) shall, in addition to the criteria
specified in Section 141.2 of the Illinois Insurance Code, take
into account the effect of the management contract or service
agreement on the continuation of benefits to enrollees and the
financial condition of the health maintenance organization to
be managed or serviced, and (ii) need not take into account the
effect of the management contract or service agreement on
competition.
    (f) Except for small employer groups as defined in the
Small Employer Rating, Renewability and Portability Health
Insurance Act and except for medicare supplement policies as
defined in Section 363 of the Illinois Insurance Code, a Health
Maintenance Organization may by contract agree with a group or
other enrollment unit to effect refunds or charge additional
premiums under the following terms and conditions:
        (i) the amount of, and other terms and conditions with
    respect to, the refund or additional premium are set forth
    in the group or enrollment unit contract agreed in advance
    of the period for which a refund is to be paid or
    additional premium is to be charged (which period shall not
    be less than one year); and
        (ii) the amount of the refund or additional premium
    shall not exceed 20% of the Health Maintenance
    Organization's profitable or unprofitable experience with
    respect to the group or other enrollment unit for the
    period (and, for purposes of a refund or additional
    premium, the profitable or unprofitable experience shall
    be calculated taking into account a pro rata share of the
    Health Maintenance Organization's administrative and
    marketing expenses, but shall not include any refund to be
    made or additional premium to be paid pursuant to this
    subsection (f)). The Health Maintenance Organization and
    the group or enrollment unit may agree that the profitable
    or unprofitable experience may be calculated taking into
    account the refund period and the immediately preceding 2
    plan years.
    The Health Maintenance Organization shall include a
statement in the evidence of coverage issued to each enrollee
describing the possibility of a refund or additional premium,
and upon request of any group or enrollment unit, provide to
the group or enrollment unit a description of the method used
to calculate (1) the Health Maintenance Organization's
profitable experience with respect to the group or enrollment
unit and the resulting refund to the group or enrollment unit
or (2) the Health Maintenance Organization's unprofitable
experience with respect to the group or enrollment unit and the
resulting additional premium to be paid by the group or
enrollment unit.
    In no event shall the Illinois Health Maintenance
Organization Guaranty Association be liable to pay any
contractual obligation of an insolvent organization to pay any
refund authorized under this Section.
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
8-21-08.)
 
    Section 35. The Voluntary Health Services Plans Act is
amended by changing Section 10 as follows:
 
    (215 ILCS 165/10)  (from Ch. 32, par. 604)
    Sec. 10. Application of Insurance Code provisions. Health
services plan corporations and all persons interested therein
or dealing therewith shall be subject to the provisions of
Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
356z.9, 356z.10, 356z.14, 364.01, 367.2, 368a, 401, 401.1, 402,
403, 403A, 408, 408.2, and 412, and paragraphs (7) and (15) of
Section 367 of the Illinois Insurance Code.
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
8-28-07; 95-876, eff. 8-21-08.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 12/12/2008