101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB2255

 

Introduced 5/9/2019, by Sen. Laura Fine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.33 new

    Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any service to functionally improve, repair, or restore any body part that is medically necessary to achieve normal body function or appearance, as determined by the treating physician or dentist. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Defines "treatment". Effective immediately.


LRB101 12399 SMS 60462 b

 

 

A BILL FOR

 

SB2255LRB101 12399 SMS 60462 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by adding
5Section 356z.33 as follows:
 
6    (215 ILCS 5/356z.33 new)
7    Sec. 356z.33. Coverage for congenital anomaly or birth
8defect.
9    (a) As used in this Section, "treatment" includes inpatient
10and outpatient care and services performed to improve or
11restore body function, or performed to approximate a normal
12appearance, due to congenital anomaly or birth defect and
13includes treatment to any and all missing or abnormal body
14parts, including teeth, the oral cavity, and their associated
15structures, that would otherwise be provided under the plan or
16coverage for any other injury and sickness, including:
17        (1) inpatient and outpatient care, reconstructive
18    services and procedures, and complications thereof,
19    including prosthetics and appliances;
20        (2) adjunctive dental, orthodontic, or prosthodontic
21    support from birth until the medical or surgical treatment
22    of the defect or anomaly has been completed, including
23    ongoing or subsequent treatment required to maintain

 

 

SB2255- 2 -LRB101 12399 SMS 60462 b

1    function or approximate a normal appearance;
2        (3) procedures that do not materially restore or
3    improve the function of the body part being treated;
4        (4) procedures for secondary conditions and follow-up
5    treatment; and
6        (5) anesthetics provided by a dentist with a permit
7    provided under Section 8.1 of the Illinois Dental Practice
8    Act.
9    "Treatment" does not include cosmetic surgery performed to
10reshape normal structures of the body to improve appearance or
11self-esteem.
12    (b) An individual or group policy of accident and health
13insurance amended, delivered, issued, or renewed after the
14effective date of this amendatory Act of the 101st General
15Assembly shall cover charges incurred and services provided for
16outpatient and inpatient care in conjunction with services that
17are provided to a covered individual related to the diagnosis
18and treatment of a congenital anomaly or birth defect.
19    (c) Coverage required under this Section includes any
20service to functionally improve, repair, or restore any body
21part that is medically necessary to achieve normal body
22function or appearance, as determined by the treating physician
23or dentist. Any coverage provided may be subject to coverage
24limits, such as pre-authorization or pre-certification, as
25required by the plan or issuer that are no more restrictive
26than the predominant treatment limitations applied to

 

 

SB2255- 3 -LRB101 12399 SMS 60462 b

1substantially all medical and surgical benefits covered by the
2plan.
 
3    Section 99. Effective date. This Act takes effect upon
4becoming law.