94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB0835

 

Introduced 02/02/05, by Rep. Kathleen A. Ryg

 

SYNOPSIS AS INTRODUCED:
 
20 ILCS 1405/1405-35 new
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
215 ILCS 5/351B-5   from Ch. 73, par. 963B-5
215 ILCS 5/356z.7 new
215 ILCS 125/5-3   from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10   from Ch. 32, par. 604
30 ILCS 805/8.29 new

     Amends the Department of Insurance Law of the Civil Administrative Code of Illinois to require the Department of Financial and Professional Regulation to conduct an analysis and study of costs and benefits derived from the implementation of coverage for treatment of brain injuries and to report the results of the study to the General Assembly and the Governor. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the Illinois Insurance Code, the Health Maintenance Organization Act, and the Voluntary Health Services Plans Act to require coverage for rehabilitation therapy for brain injuries. Amends the State Mandates Act to require implementation without reimbursement by the State.


LRB094 08458 LJB 38663 b

FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

HB0835 LRB094 08458 LJB 38663 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Department of Insurance Law of the Civil
5 Administrative Code of Illinois is amended by adding Section
6 1405-35 as follows:
 
7     (20 ILCS 1405/1405-35 new)
8     Sec. 1405-35. Brain injury coverage study.
9     (a) The Department of Financial and Professional
10 Regulation shall conduct an analysis and study of costs and
11 benefits derived from the implementation of the coverage
12 requirements for treatment of brain injuries established under
13 Section 356z.7 of the Illinois Insurance Code. The study shall
14 cover the years 2006, 2007, and 2008. The study shall include
15 an analysis of the effect of the coverage requirements on the
16 cost of insurance and health care, the results of the
17 treatments to patients, any improvements in the care of
18 patients, and any improvements in the quality of life of
19 patients.
20     (b) The Department shall report the results of its study to
21 the General Assembly and the Governor on or before March 1,
22 2009.
 
23     Section 10. The State Employees Group Insurance Act of 1971
24 is amended by changing Section 6.11 as follows:
 
25     (5 ILCS 375/6.11)
26     Sec. 6.11. Required health benefits; Illinois Insurance
27 Code requirements. The program of health benefits shall provide
28 the post-mastectomy care benefits required to be covered by a
29 policy of accident and health insurance under Section 356t of
30 the Illinois Insurance Code. The program of health benefits

 

 

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1 shall provide the coverage required under Sections 356u, 356w,
2 356x, 356z.2, 356z.4, and 356z.6, and 356z.7 of the Illinois
3 Insurance Code. The program of health benefits must comply with
4 Section 155.37 of the Illinois Insurance Code.
5 (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03;
6 93-102, eff. 1-1-04; 93-853, eff. 1-1-05.)
 
7     Section 15. The Counties Code is amended by changing
8 Section 5-1069.3 as follows:
 
9     (55 ILCS 5/5-1069.3)
10     Sec. 5-1069.3. Required health benefits. If a county,
11 including a home rule county, is a self-insurer for purposes of
12 providing health insurance coverage for its employees, the
13 coverage shall include coverage for the post-mastectomy care
14 benefits required to be covered by a policy of accident and
15 health insurance under Section 356t and the coverage required
16 under Sections 356u, 356w, 356x, and 356z.6, and 356z.7 of the
17 Illinois Insurance Code. The requirement that health benefits
18 be covered as provided in this Section is an exclusive power
19 and function of the State and is a denial and limitation under
20 Article VII, Section 6, subsection (h) of the Illinois
21 Constitution. A home rule county to which this Section applies
22 must comply with every provision of this Section.
23 (Source: P.A. 93-853, eff. 1-1-05.)
 
24     Section 20. The Illinois Municipal Code is amended by
25 changing Section 10-4-2.3 as follows:
 
26     (65 ILCS 5/10-4-2.3)
27     Sec. 10-4-2.3. Required health benefits. If a
28 municipality, including a home rule municipality, is a
29 self-insurer for purposes of providing health insurance
30 coverage for its employees, the coverage shall include coverage
31 for the post-mastectomy care benefits required to be covered by
32 a policy of accident and health insurance under Section 356t

 

 

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1 and the coverage required under Sections 356u, 356w, 356x, and
2 356z.6, and 356z.7 of the Illinois Insurance Code. The
3 requirement that health benefits be covered as provided in this
4 is an exclusive power and function of the State and is a denial
5 and limitation under Article VII, Section 6, subsection (h) of
6 the Illinois Constitution. A home rule municipality to which
7 this Section applies must comply with every provision of this
8 Section.
9 (Source: P.A. 93-853, eff. 1-1-05.)
 
10     Section 25. The Illinois Insurance Code is amended by
11 changing Section 351B-5 and adding Section 356z.7 as follows:
 
12     (215 ILCS 5/351B-5)  (from Ch. 73, par. 963B-5)
13     Sec. 351B-5. Applicability of other Code provisions. All
14 policies of accident and health insurance issued under this
15 Article shall be subject to the provisions of Sections 356c,
16 subsection (a) of Section 356g, 356h, 356n, 356z.7, 367c, 367d,
17 370, 370a, and 370e of this Code.
18 (Source: P.A. 86-1407; 87-792; 87-1066.)
 
19     (215 ILCS 5/356z.7 new)
20     Sec. 356z.7. Coverage for certain benefits related to brain
21 injury.
22     (a) A group or individual policy of accident and health
23 insurance, a managed care plan, or multiple employer welfare
24 arrangement that is amended, delivered, issued, or renewed
25 after the effective date of this amendatory Act of the 94th
26 General Assembly shall include coverage for cognitive
27 rehabilitation therapy, cognitive communication therapy,
28 neurocognitive therapy and rehabilitation, neurobehavioral,
29 neurophysiological, neuropsychological, and
30 psychophysiological testing or treatment, neurofeedback
31 therapy, remediation, post-acute transition services, or
32 community reintegration services necessary as a result of and
33 related to an acquired brain injury.

 

 

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1     (b) Coverage required under this Section may be subject to
2 deductibles, copayments, coinsurance, or annual or maximum
3 payment limits that are consistent with deductibles,
4 copayments, coinsurance, and annual or maximum payment limits
5 applicable to other similar coverage under the policy.
6     (c) The Department shall adopt rules as necessary to
7 implement this Section.
8     (d) This Section is inoperative after December 31, 2009.
 
9     Section 30. The Health Maintenance Organization Act is
10 amended by changing Section 5-3 as follows:
 
11     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
12     Sec. 5-3. Insurance Code provisions.
13     (a) Health Maintenance Organizations shall be subject to
14 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
15 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
16 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
17 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01, 367.2,
18 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 401, 401.1, 402,
19 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c)
20 of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
21 XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
22 Insurance Code.
23     (b) For purposes of the Illinois Insurance Code, except for
24 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
25 Maintenance Organizations in the following categories are
26 deemed to be "domestic companies":
27         (1) a corporation authorized under the Dental Service
28     Plan Act or the Voluntary Health Services Plans Act;
29         (2) a corporation organized under the laws of this
30     State; or
31         (3) a corporation organized under the laws of another
32     state, 30% or more of the enrollees of which are residents
33     of this State, except a corporation subject to
34     substantially the same requirements in its state of

 

 

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

 

 

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

 

 

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1     marketing expenses, but shall not include any refund to be
2     made or additional premium to be paid pursuant to this
3     subsection (f)). The Health Maintenance Organization and
4     the group or enrollment unit may agree that the profitable
5     or unprofitable experience may be calculated taking into
6     account the refund period and the immediately preceding 2
7     plan years.
8     The Health Maintenance Organization shall include a
9 statement in the evidence of coverage issued to each enrollee
10 describing the possibility of a refund or additional premium,
11 and upon request of any group or enrollment unit, provide to
12 the group or enrollment unit a description of the method used
13 to calculate (1) the Health Maintenance Organization's
14 profitable experience with respect to the group or enrollment
15 unit and the resulting refund to the group or enrollment unit
16 or (2) the Health Maintenance Organization's unprofitable
17 experience with respect to the group or enrollment unit and the
18 resulting additional premium to be paid by the group or
19 enrollment unit.
20     In no event shall the Illinois Health Maintenance
21 Organization Guaranty Association be liable to pay any
22 contractual obligation of an insolvent organization to pay any
23 refund authorized under this Section.
24 (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261,
25 eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; 93-853,
26 eff. 1-1-05; 93-1000, eff. 1-1-05; revised 10-14-04.)
 
27     Section 35. The Voluntary Health Services Plans Act is
28 amended by changing Section 10 as follows:
 
29     (215 ILCS 165/10)  (from Ch. 32, par. 604)
30     Sec. 10. Application of Insurance Code provisions. Health
31 services plan corporations and all persons interested therein
32 or dealing therewith shall be subject to the provisions of
33 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
34 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v, 356w, 356x,

 

 

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1 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01,
2 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
3 and paragraphs (7) and (15) of Section 367 of the Illinois
4 Insurance Code.
5 (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
6 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04;
7 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; 93-1000, eff.
8 1-1-05; revised 10-14-04.)
 
9     Section 90. The State Mandates Act is amended by adding
10 Section 8.29 as follows:
 
11     (30 ILCS 805/8.29 new)
12     Sec. 8.29. Exempt mandate. Notwithstanding Sections 6 and 8
13 of this Act, no reimbursement by the State is required for the
14 implementation of any mandate created by this amendatory Act of
15 the 94th General Assembly.