94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB4125

 

Introduced 10/14/05, by Rep. Mary E. Flowers

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/356z.7 new
215 ILCS 5/370c   from Ch. 73, par. 982c
215 ILCS 125/5-3   from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10   from Ch. 32, par. 604
305 ILCS 5/5-16.8

    Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Illinois Insurance Code, the Health Maintenance Organization Act, the Voluntary Health Services Plans Act, and the Illinois Public Aid Code to require coverage for the treatment of pervasive developmental disorders. Amends the Illinois Insurance Code to provide that certain mental health coverages apply to health maintenance organizations and individual policies of accident and health insurance. Effective immediately.


LRB094 13838 LJB 48711 b

FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

HB4125 LRB094 13838 LJB 48711 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 State Employees Group Insurance Act of 1971
5 is amended by changing Section 6.11 as follows:
 
6     (5 ILCS 375/6.11)
7     Sec. 6.11. Required health benefits; Illinois Insurance
8 Code requirements. The program of health benefits shall provide
9 the post-mastectomy care benefits required to be covered by a
10 policy of accident and health insurance under Section 356t of
11 the Illinois Insurance Code. The program of health benefits
12 shall provide the coverage required under Sections 356u, 356w,
13 356x, 356z.2, 356z.4, and 356z.6, and 356z.7 of the Illinois
14 Insurance Code. The program of health benefits must comply with
15 Section 155.37 of the Illinois Insurance Code.
16 (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03;
17 93-102, eff. 1-1-04; 93-853, eff. 1-1-05.)
 
18     Section 10. The Counties Code is amended by changing
19 Section 5-1069.3 as follows:
 
20     (55 ILCS 5/5-1069.3)
21     Sec. 5-1069.3. Required health benefits. If a county,
22 including a home rule county, is a self-insurer for purposes of
23 providing health insurance coverage for its employees, the
24 coverage shall include coverage for the post-mastectomy care
25 benefits required to be covered by a policy of accident and
26 health insurance under Section 356t and the coverage required
27 under Sections 356u, 356w, 356x, and 356z.6, and 356z.7 of the
28 Illinois Insurance Code. The requirement that health benefits
29 be covered as provided in this Section is an exclusive power
30 and function of the State and is a denial and limitation under

 

 

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1 Article VII, Section 6, subsection (h) of the Illinois
2 Constitution. A home rule county to which this Section applies
3 must comply with every provision of this Section.
4 (Source: P.A. 93-853, eff. 1-1-05.)
 
5     Section 15. The Illinois Municipal Code is amended by
6 changing Section 10-4-2.3 as follows:
 
7     (65 ILCS 5/10-4-2.3)
8     Sec. 10-4-2.3. Required health benefits. If a
9 municipality, including a home rule municipality, is a
10 self-insurer for purposes of providing health insurance
11 coverage for its employees, the coverage shall include coverage
12 for the post-mastectomy care benefits required to be covered by
13 a policy of accident and health insurance under Section 356t
14 and the coverage required under Sections 356u, 356w, 356x, and
15 356z.6, and 356z.7 of the Illinois Insurance Code. The
16 requirement that health benefits be covered as provided in this
17 is an exclusive power and function of the State and is a denial
18 and limitation under Article VII, Section 6, subsection (h) of
19 the Illinois Constitution. A home rule municipality to which
20 this Section applies must comply with every provision of this
21 Section.
22 (Source: P.A. 93-853, eff. 1-1-05.)
 
23     Section 20. The School Code is amended by changing Section
24 10-22.3f as follows:
 
25     (105 ILCS 5/10-22.3f)
26     Sec. 10-22.3f. Required health benefits. Insurance
27 protection and benefits for employees shall provide the
28 post-mastectomy care benefits required to be covered by a
29 policy of accident and health insurance under Section 356t and
30 the coverage required under Sections 356u, 356w, 356x, and
31 356z.6, and 356z.7 of the Illinois Insurance Code.
32 (Source: P.A. 93-853, eff. 1-1-05.)
 

 

 

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1     Section 25. The Illinois Insurance Code is amended by
2 adding Section 356z.7 and by changing Section 370c as follows:
 
3     (215 ILCS 5/356z.7 new)
4     Sec. 356z.7. Pervasive developmental disorders.
5     (a) A group or individual policy of accident and health
6 insurance or managed care plan amended, delivered, issued, or
7 renewed after the effective date of this amendatory Act of the
8 94th General Assembly shall provide coverage for the treatment
9 of pervasive developmental disorders. The coverage required by
10 this Section is limited to treatment that is prescribed by the
11 insured's or the insured's immediate family member's treating
12 physician in accordance with a treatment plan. An insurer may
13 not deny or refuse to issue coverage on, refuse to contract
14 with, or refuse to renew, reissue, or otherwise terminate or
15 restrict coverage to an individual under an insurance policy
16 solely because the individual is diagnosed with a pervasive
17 developmental disorder.
18     Coverage required under this Section may not impose any
19 deductible, coinsurance, waiting period, or other cost-sharing
20 or limitation that is greater than that required for any
21 physical illness generally under the insurance policy.
22     (b) As used in this Section:
23     "Immediate family member" means the insured, any children
24 of the insured covered by the insurance policy, including, but
25 not limited to, children by birth, marriage, or adoption, and
26 any spouse of the insured covered by the insurance policy.
27     "Pervasive developmental disorder" means a neurological
28 condition, including, but not limited to, Asperger's Syndrome
29 and autism, as defined in the most recent edition of the
30 Diagnostic and Statistical Manual of Mental Disorders of the
31 American Psychiatric Association.
 
32     (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
33     Sec. 370c. Mental and emotional disorders.

 

 

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1     (a) (1) On and after the effective date of this Section,
2 every insurer and health maintenance organization which
3 delivers, issues for delivery or renews or modifies group or
4 individual A&H policies or health care plans providing coverage
5 for hospital or medical treatment or services for illness on an
6 expense-incurred basis shall offer to the applicant or group
7 policyholder subject to the insurers standards of
8 insurability, coverage for reasonable and necessary treatment
9 and services for mental, emotional or nervous disorders or
10 conditions, other than serious mental illnesses as defined in
11 item (2) of subsection (b), up to the limits provided in the
12 policy for other disorders or conditions, except (i) the
13 insured may be required to pay up to 50% of expenses incurred
14 as a result of the treatment or services, and (ii) the annual
15 benefit limit may be limited to the lesser of $10,000 or 25% of
16 the lifetime policy limit. The changes made to this item (1) by
17 this amendatory Act of the 94th General Assembly apply on and
18 after the effective date of this amendatory Act of the 94th
19 General Assembly.
20     (2) Each insured that is covered for mental, emotional or
21 nervous disorders or conditions shall be free to select the
22 physician licensed to practice medicine in all its branches,
23 licensed clinical psychologist, licensed clinical social
24 worker, or licensed clinical professional counselor of his
25 choice to treat such disorders, and the insurer shall pay the
26 covered charges of such physician licensed to practice medicine
27 in all its branches, licensed clinical psychologist, licensed
28 clinical social worker, or licensed clinical professional
29 counselor up to the limits of coverage, provided (i) the
30 disorder or condition treated is covered by the policy, and
31 (ii) the physician, licensed psychologist, licensed clinical
32 social worker, or licensed clinical professional counselor is
33 authorized to provide said services under the statutes of this
34 State and in accordance with accepted principles of his
35 profession.
36     (3) Insofar as this Section applies solely to licensed

 

 

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1 clinical social workers and licensed clinical professional
2 counselors, those persons who may provide services to
3 individuals shall do so after the licensed clinical social
4 worker or licensed clinical professional counselor has
5 informed the patient of the desirability of the patient
6 conferring with the patient's primary care physician and the
7 licensed clinical social worker or licensed clinical
8 professional counselor has provided written notification to
9 the patient's primary care physician, if any, that services are
10 being provided to the patient. That notification may, however,
11 be waived by the patient on a written form. Those forms shall
12 be retained by the licensed clinical social worker or licensed
13 clinical professional counselor for a period of not less than 5
14 years.
15     (b) (1) An insurer or health maintenance organization that
16 provides coverage for hospital or medical expenses under a
17 group or individual policy of accident and health insurance or
18 health care plan amended, delivered, issued, or renewed after
19 the effective date of this amendatory Act of the 92nd General
20 Assembly shall provide coverage under the policy for treatment
21 of serious mental illness under the same terms and conditions
22 as coverage for hospital or medical expenses related to other
23 illnesses and diseases. The coverage required under this
24 Section must provide for same durational limits, amount limits,
25 deductibles, and co-insurance requirements for serious mental
26 illness as are provided for other illnesses and diseases. This
27 subsection does not apply to coverage provided to employees by
28 employers who have 50 or fewer employees. The changes made to
29 this item (1) by this amendatory Act of the 94th General
30 Assembly apply on and after the effective date of this
31 amendatory Act of the 94th General Assembly.
32     (2) "Serious mental illness" means the following
33 psychiatric illnesses as defined in the most current edition of
34 the Diagnostic and Statistical Manual (DSM) published by the
35 American Psychiatric Association:
36         (A) schizophrenia;

 

 

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1         (B) paranoid and other psychotic disorders;
2         (C) bipolar disorders (hypomanic, manic, depressive,
3     and mixed);
4         (D) major depressive disorders (single episode or
5     recurrent);
6         (E) schizoaffective disorders (bipolar or depressive);
7         (F) pervasive developmental disorders;
8         (G) obsessive-compulsive disorders;
9         (H) depression in childhood and adolescence;
10         (I) panic disorder; and
11         (J) post-traumatic stress disorders (acute, chronic,
12     or with delayed onset).
13     (3) Upon request of the reimbursing insurer, a provider of
14 treatment of serious mental illness shall furnish medical
15 records or other necessary data that substantiate that initial
16 or continued treatment is at all times medically necessary. An
17 insurer shall provide a mechanism for the timely review by a
18 provider holding the same license and practicing in the same
19 specialty as the patient's provider, who is unaffiliated with
20 the insurer, jointly selected by the patient (or the patient's
21 next of kin or legal representative if the patient is unable to
22 act for himself or herself), the patient's provider, and the
23 insurer in the event of a dispute between the insurer and
24 patient's provider regarding the medical necessity of a
25 treatment proposed by a patient's provider. If the reviewing
26 provider determines the treatment to be medically necessary,
27 the insurer shall provide reimbursement for the treatment.
28 Future contractual or employment actions by the insurer
29 regarding the patient's provider may not be based on the
30 provider's participation in this procedure. Nothing prevents
31 the insured from agreeing in writing to continue treatment at
32 his or her expense. When making a determination of the medical
33 necessity for a treatment modality for serous mental illness,
34 an insurer must make the determination in a manner that is
35 consistent with the manner used to make that determination with
36 respect to other diseases or illnesses covered under the

 

 

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1 policy, including an appeals process.
2     (4) A group health benefit plan:
3         (A) shall provide coverage based upon medical
4     necessity for the following treatment of mental illness in
5     each calendar year;
6             (i) 45 days of inpatient treatment; and
7             (ii) 35 visits for outpatient treatment including
8         group and individual outpatient treatment;
9         (B) may not include a lifetime limit on the number of
10     days of inpatient treatment or the number of outpatient
11     visits covered under the plan; and
12         (C) shall include the same amount limits, deductibles,
13     copayments, and coinsurance factors for serious mental
14     illness as for physical illness.
15     (5) An issuer of a group health benefit plan may not count
16 toward the number of outpatient visits required to be covered
17 under this Section an outpatient visit for the purpose of
18 medication management and shall cover the outpatient visits
19 under the same terms and conditions as it covers outpatient
20 visits for the treatment of physical illness.
21     (6) An issuer of a group health benefit plan may provide or
22 offer coverage required under this Section through a managed
23 care plan.
24     (7) This Section shall not be interpreted to require a
25 group health benefit plan to provide coverage for treatment of:
26         (A) an addiction to a controlled substance or cannabis
27     that is used in violation of law; or
28         (B) mental illness resulting from the use of a
29     controlled substance or cannabis in violation of law.
30     (8) (Blank).
31 (Source: P.A. 94-402, eff. 8-2-05; P.A. 94-584, eff. 8-15-05;
32 revised 8-19-05.)
 
33     Section 30. The Health Maintenance Organization Act is
34 amended by changing Section 5-3 as follows:
 

 

 

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1     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
2     Sec. 5-3. Insurance Code provisions.
3     (a) Health Maintenance Organizations shall be subject to
4 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
5 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
6 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
7 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01, 367.2,
8 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 401, 401.1, 402,
9 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c)
10 of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
11 XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
12 Insurance Code.
13     (b) For purposes of the Illinois Insurance Code, except for
14 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
15 Maintenance Organizations in the following categories are
16 deemed to be "domestic companies":
17         (1) a corporation authorized under the Dental Service
18     Plan Act or the Voluntary Health Services Plans Act;
19         (2) a corporation organized under the laws of this
20     State; or
21         (3) a corporation organized under the laws of another
22     state, 30% or more of the enrollees of which are residents
23     of this State, except a corporation subject to
24     substantially the same requirements in its state of
25     organization as is a "domestic company" under Article VIII
26     1/2 of the Illinois Insurance Code.
27     (c) In considering the merger, consolidation, or other
28 acquisition of control of a Health Maintenance Organization
29 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
30         (1) the Director shall give primary consideration to
31     the continuation of benefits to enrollees and the financial
32     conditions of the acquired Health Maintenance Organization
33     after the merger, consolidation, or other acquisition of
34     control takes effect;
35         (2)(i) the criteria specified in subsection (1)(b) of
36     Section 131.8 of the Illinois Insurance Code shall not

 

 

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1     apply and (ii) the Director, in making his determination
2     with respect to the merger, consolidation, or other
3     acquisition of control, need not take into account the
4     effect on competition of the merger, consolidation, or
5     other acquisition of control;
6         (3) the Director shall have the power to require the
7     following information:
8             (A) certification by an independent actuary of the
9         adequacy of the reserves of the Health Maintenance
10         Organization sought to be acquired;
11             (B) pro forma financial statements reflecting the
12         combined balance sheets of the acquiring company and
13         the Health Maintenance Organization sought to be
14         acquired as of the end of the preceding year and as of
15         a date 90 days prior to the acquisition, as well as pro
16         forma financial statements reflecting projected
17         combined operation for a period of 2 years;
18             (C) a pro forma business plan detailing an
19         acquiring party's plans with respect to the operation
20         of the Health Maintenance Organization sought to be
21         acquired for a period of not less than 3 years; and
22             (D) such other information as the Director shall
23         require.
24     (d) The provisions of Article VIII 1/2 of the Illinois
25 Insurance Code and this Section 5-3 shall apply to the sale by
26 any health maintenance organization of greater than 10% of its
27 enrollee population (including without limitation the health
28 maintenance organization's right, title, and interest in and to
29 its health care certificates).
30     (e) In considering any management contract or service
31 agreement subject to Section 141.1 of the Illinois Insurance
32 Code, the Director (i) shall, in addition to the criteria
33 specified in Section 141.2 of the Illinois Insurance Code, take
34 into account the effect of the management contract or service
35 agreement on the continuation of benefits to enrollees and the
36 financial condition of the health maintenance organization to

 

 

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1 be managed or serviced, and (ii) need not take into account the
2 effect of the management contract or service agreement on
3 competition.
4     (f) Except for small employer groups as defined in the
5 Small Employer Rating, Renewability and Portability Health
6 Insurance Act and except for medicare supplement policies as
7 defined in Section 363 of the Illinois Insurance Code, a Health
8 Maintenance Organization may by contract agree with a group or
9 other enrollment unit to effect refunds or charge additional
10 premiums under the following terms and conditions:
11         (i) the amount of, and other terms and conditions with
12     respect to, the refund or additional premium are set forth
13     in the group or enrollment unit contract agreed in advance
14     of the period for which a refund is to be paid or
15     additional premium is to be charged (which period shall not
16     be less than one year); and
17         (ii) the amount of the refund or additional premium
18     shall not exceed 20% of the Health Maintenance
19     Organization's profitable or unprofitable experience with
20     respect to the group or other enrollment unit for the
21     period (and, for purposes of a refund or additional
22     premium, the profitable or unprofitable experience shall
23     be calculated taking into account a pro rata share of the
24     Health Maintenance Organization's administrative and
25     marketing expenses, but shall not include any refund to be
26     made or additional premium to be paid pursuant to this
27     subsection (f)). The Health Maintenance Organization and
28     the group or enrollment unit may agree that the profitable
29     or unprofitable experience may be calculated taking into
30     account the refund period and the immediately preceding 2
31     plan years.
32     The Health Maintenance Organization shall include a
33 statement in the evidence of coverage issued to each enrollee
34 describing the possibility of a refund or additional premium,
35 and upon request of any group or enrollment unit, provide to
36 the group or enrollment unit a description of the method used

 

 

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1 to calculate (1) the Health Maintenance Organization's
2 profitable experience with respect to the group or enrollment
3 unit and the resulting refund to the group or enrollment unit
4 or (2) the Health Maintenance Organization's unprofitable
5 experience with respect to the group or enrollment unit and the
6 resulting additional premium to be paid by the group or
7 enrollment unit.
8     In no event shall the Illinois Health Maintenance
9 Organization Guaranty Association be liable to pay any
10 contractual obligation of an insolvent organization to pay any
11 refund authorized under this Section.
12 (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261,
13 eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; 93-853,
14 eff. 1-1-05; 93-1000, eff. 1-1-05; revised 10-14-04.)
 
15     Section 35. The Voluntary Health Services Plans Act is
16 amended by changing Section 10 as follows:
 
17     (215 ILCS 165/10)  (from Ch. 32, par. 604)
18     Sec. 10. Application of Insurance Code provisions. Health
19 services plan corporations and all persons interested therein
20 or dealing therewith shall be subject to the provisions of
21 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
22 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v, 356w, 356x,
23 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01,
24 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
25 and paragraphs (7) and (15) of Section 367 of the Illinois
26 Insurance Code.
27 (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
28 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04;
29 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; 93-1000, eff.
30 1-1-05; revised 10-14-04.)
 
31     Section 40. The Illinois Public Aid Code is amended by
32 changing Section 5-16.8 as follows:
 

 

 

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1     (305 ILCS 5/5-16.8)
2     Sec. 5-16.8. Required health benefits. The medical
3 assistance program shall (i) provide the post-mastectomy care
4 benefits required to be covered by a policy of accident and
5 health insurance under Section 356t and the coverage required
6 under Sections 356u, 356w, 356x, and 356z.6, and 356z.7 of the
7 Illinois Insurance Code and (ii) be subject to the provisions
8 of Section 364.01 of the Illinois Insurance Code.
9 (Source: P.A. 93-853, eff. 1-1-05; 93-1000, eff. 1-1-05;
10 revised 10-14-04.)
 
11     Section 99. Effective date. This Act takes effect upon
12 becoming law.