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.